Is your BP monitor any good?

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This article was stimulated by me seeing an article by Dean Piccone and colleagues [1] in the JAMA. I thought that all blood pressure (BP) monitors that are sold in the UK would be equally valid, but apparently not!

Why is measuring BP important? We know that elevated systolic BP is a risk factor for death. It is estimated that 10 million people die globally each year due to high BP [2].  So, identifying patients with elevated blood pressure, therefore, makes sense, so that BP lowering interventions can be made or suggested.

I like to measure my patients BP when I first see them, and annually at their review, if they are attending for regular care. Sometimes it can be very high when I first see a patient, and this might be very relevant, if the patient is complaining of left shoulder pain, for instance. Other times I might notice that it is creeping upwards year-on-year

In-clinic measurements are commonly elevated, giving a false impression of risk, due to ‘white coat syndrome’. [3, 4]. This might result in an inappropriate referral of the patient to their GP for BP meds. We often ask patients to measure their BP at home. These patients will obviously need to have their own BP monitor.

You need to ensure that your BP monitor has been validated. Not all monitors have been validated, because the regulations governing their sale are apparently as much about electrical safety as measurement accuracy. You can check yours at the National Registry  run by the British and Irish Hypertension Society.

You can learn how to reliably measure your own BP an on-line course (yes, really) here which takes about an hour [5]. Most people just follow the instructions that come with the BP equipment that they buy

If you want to learn more, read the article by Piccone and colleagues (link below). Shout out to them for a really useful article. Awesome!

Does too much exercise cause back pain?

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Sometimes you wonder about scientists. Do they want their research to be understood? Or do they want to cloak it in mystery? One study, published quite a number of years ago (2009), sounds like the title of the latest instructions from a piece of drainage kit from Plumbers World: ‘Physical activity and low back pain: a U-shaped relation’ [1], The authors are assuming that the readers are not about to unblock their sink, but are actually epidemiologists with an enthusiasm for descriptions of graphs.What our Dutch researcher friends are attempting to get across is that if you look at a graph of the incidence of low back pain after physical activity you will see that it is U-shaped. According to their study of 3364 subjects, people who exercise minimally have a higher incidence of back pain, but so do people who engage in more strenuous exercise. Those doing moderate levels of exercise have the lowest levels of back pain.

Your spouse understands this intuitively when he says: ‘In a bit love, my back is playing up’ when you ask him for the third time to put the bins out. He thinks that he is engaging in strenuous exercise, whereas in reality he does almost no exercise. So, it’s little wonder that he gets back pain.

Our spouses all believe that their thinking is correct. But is it? A recent paper [2] suggests otherwise. These researchers, from Portsmouth University, studied 5802 people over 50yrs old, and found that the only level of exercise that reduced the incidence of musculo-skeletal pain was a high level of exercise.

So, it seems that you would be justified in informing your poor spouse that if, in addition to taking the bins out, perhaps he could also cut the grass and trim the hedge? He might get a bit less back pain!

Furthermore, the same recent study found that being overweight increased the risk of suffering from musculo-skeletal pain, as did poverty, and being female. There are plenty of societal issues for us to address.

I’m just off to put the bins out……..

btw…. these studies are all looking at groups of patients and seeing what is best ‘in general’. You cannot simply apply group statistics to an individual. There are, of course, individuals for whom doing high levels of exercise will cause more problems. So, get some individual advice if you are thinking about launching into a new physical exercise regime!

  1. Heneweer, H., L. Vanhees, and H.S. Picavet, Physical activity and low back pain: a U-shaped relation? Pain, 2009. 143(1-2): p. 21-5.

2. Niederstrasser, N.G. and N. Attridge, Associations between pain and physical activity among older adults. PLoS One, 2022. 17(1): p. e0263356.

Muscle tear….or DVT?

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I’ve just done my first Parkrun. For those that don’t know anything about Parkrun, it is a free, community-led international event that happens somewhere near you on a Saturday morning. It is a 5kilometre run, which is timed. It felt like hard work, and I got too hot as I had kept my fleece on, which was obviously a mistake.  I’ll let you know what my time was at the end! Parkrun has turned exercise back into what it should be: done by all, easy to access and free. Here is a link to the Abingdon Parkrun

Anyway, after the run I saw one or two participants stretching their calf muscles with rather pained faces. Presumably they had simply pulled a muscle in the leg. A bit of stretching and a mix of exercise and rest, and they’ll be fine. One of the dilemmas that clinicians have is whether leg pain like this is just a pulled muscle or is a DVT, particularly if the patient has not been doing any exercise that might have injured a muscle. I saw one such patient a couple of weeks ago who had pain in his lower leg. He hadn’t done any vigorous exercise and the leg was a bit swollen. I wondered whether he had a deep venous thrombosis (DVT)?

A DVT is a clot of blood (or thrombus)  in one of the veins. The blood clot prevents blood flowing through the vein, hence the swelling. The worry about a DVT is that some of the thrombus can break off and travel through the heart and then get lodged in one of the pulmonary arteries that carry blood to the lungs, called a pulmonary embolism (PE). This is why you don’t want to massage the leg of someone who possibly has a DVT.   PE can cause shortness of breath and chest pain and is a cause of death. So we do need to know if these patients have a DVT or not. If they do then they need to be treated with an anticoagulant, quite typically apixaban (Eliquis).

The way that we can check to see if someone has a DVT is to use an ultrasound scanner to see whether the vein can be squashed. Arteries have tough walls and should not be squashable with compression. Veins have thin walls and should normally be squashable, a bit like a slightly flat bike tyre. If a vein has thrombus in it, it can’t be squashed, a bit like an overinflated tyre. You can see the arteries  in this video. They can’t be squashed. That’s normal. The veins are just above the arteries and in the video you can see that the vein in the right leg can be squashed. The vein in the left leg can’t be squashed because there is thrombus in it. This patient did have a DVT in his left leg.

The GP was very helpful and put him on apixaban and sent him to the Churchill hospital, where the DVT was confirmed. The anticoagulant will minimise the risk of him dying from a pulmonary embolism. Good result!

I hope that the Parkrunners who had calf muscle twinges all recover quickly. I came 222nd out of a field of 316 and did the run in 30mins 39secs. Not at all fast, but I enjoyed it, and will do it again. But if the weather is mild, I’ll leave my fleece off! There was a great sense of community. Maybe I’ll see you there one day?

#calfmuscle, #DVT, #calfstretching, #deepvenousthrombosis, #pulmonaryembolism, #sportsinjury, #chiropractorabingdon, #parkrun, #parkrunabingdon, #chiropractic, #BCA, #BCAfamily, #POCUS

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