Benefits of Owning a Dog!

There's a fantastic article in today's NY Times about the benefits of owning a dog:

http://well.blogs.nytimes.com/2014/04/07/life-with-a-dog-you-meet-people/?_php=true&_type=blogs&_r=0

"Studies of the health ramifications have strongly suggested that pets, particularly dogs, can foster cardiovascular health, resistance to stress, social connectivity and enhanced longevity."

LWSS believes in the benefits of having a canine companion!  If you have been to our office, chances are you encountered Nala, Wynnie or saw Bucky's pictures in Dr. Chimes' exam rooms.  There's something about these furry friends that simply improves life :).

The story of "low fat" diets,and how medical evidence is influenced by politics

Interesting story in NPR about low fat diets, and emerging evidence that they may ultimately be harmful

The story is interesting in of itself, and I agree with the main premise- diets low in fat and high in processed carbohydrates are unhealthy, and healthy fats SHOULD be part of most people's diets.

I am in many ways more interested in a second story here- the way medical evidence is used, and the politics that lead to medical "same think" and prevents implementation of new information.  As was noted in the article, Walter Willett (Chair of Nutrition at Harvard) was concerned that the classic food pyramid (with a focus on high carbohydrates and low fat) was misguided, but had trouble publicizing concerns because of political factors.

Why is this important?  Because one of the assumptions of the ACA (Affordable Care Act, aka Obamacare) is that we already know what we need to know, and what we need to focus on is have physicians cede their judgment and rely more and more on evidence-based guidelines.  This is a mistake.

The great baseball writer Bill James, on his wonderful website Bill James Online in the "Hey Bill" section, had a great recent commentary on the dangers of assuming we already know everything we are going to know:

"I remember my Grade School principal, who attended college just after World War I, told us that when he studied chemistry in college, his professor told the class that they were studying science at the right time, because all the important discoveries had been made now; everything important that was going to be known was known, now, so it was a good time to study science. He told us this, of course, to point out the absurdity of assuming that the search for knowledge is ever finished. . . .. . When Perry Miller was in graduate school at the University of Chicago, late 1920s, he told his advisor that he wanted to study the Puritans. The advisor told him that the Puritans had been studied to death, everything that could be known about them was already known, and he should choose some other subject to work on. He got a different advisor, and stuck with the Puritans. He spent most of his career studying the Puritans, and became one of the greatest historians of the 20th century. He had dozens of protégés over the years, and many of THEM spent THEIR careers studying the Puritans, and many of them went on to distinguished careers, studying the Puritans. . . .. .. Again, the inherent absurdity of suggesting that a field of knowledge is ever "finished". No field of knowledge is ever finished. The intellectual understands that, and accepts it. It's Black Letter Law. A college undergraduate in Physics is allowed to challenge Einstein--if he has argument to make. . . . .. .. It isn't that way, in the rest of the world, and I have spent my career battling this. . ..this turgid, anti-intellectual assumption that everything worth knowing is already known. The non-intellectual world assumes that knowledge is the property of experts, that people who are not experts are not allowed to challenge the experts, but can only learn from them. When I started writing about baseball, I was the undergraduate in Physics who was challenging Einstein; not Einstein, but Casey Stengel, Sparky Anderson, Dick Young and the Elias Charitable Foundation. In the minds of many people I HAD to be wrong, because these other people were the experts, and I hadn't even played the game, so of course I couldn't be right and the experts wrong. I still get the same argument today, in a different form; people will tell me that the advantage inherent in sabermetrics has played itself out now. Everybody knows these things, so the advantage that WAS there, in the Moneyball era, has evaporated. Same argument; everything is known now; shut up and let us go about our business. The gentleman had forgotten this Black Letter Law, and had lapsed into the assertion that I shouldn't offer a novel theory about this, because. . .well, this has been studied; everything worthwhile is known about it. I didn't want to bust his balls about it; I assumed that he would be embarrassed if I pointed out to him what he was saying, so I tried to say it in the gentlest way I could, saying that I would be surprised if any historian were to make that argument. . .. .. .... ...You, on the other hand, I will bust your balls. Pay more attention in class, kid. If you were half as smart as you think you are, I wouldn't have had to explain this to you."

Meet the Experts: Eric Wisotzky

Meet the Experts: Eric Wisotzky

Gary: For our next feature, we are highlighting Eric Wisotzky, a rising star in the world of PM&R.  Eric is a national leader in the emerging field of Cancer Rehabilitation, and has an interesting background that includes time in the military, and leadership work in education.

Eric and I met one another through the world of resident education.  For several years, I ran the Resident and Fellow Workshop at the annual meeting for the Association of Academic Physiatrists.  My co-coordinator Chris Visco was Eric's residency mentor, and Chris praised Eric so highly that Eric became the first resident to serve as a teacher at the workshop.  Several years later, when Chris and I were planning our succession, Eric was a clear choice to take over the workshop, which he now leads along with James Wyss.

Let's start there by way of introduction.  Eric, can you tell us about your love of resident and fellow education?

Eric: I personally felt that many of my educational experiences, especially as a medical student, left a lot to be desired.  As a medical student, I clearly recall times when I said to myself, “It will be my mission to ensure that future students have a better educational experience than mine.”  In that regard, I try to make the educational experiences of my medical students and residents as academic and as fun as possible.  I personally believe that the academic factor and fun factor are equally important and will lead to the most effective learning environment.

Gary: Interesting.  I think that rings true- much of my motivation to become a teacher was, like yours, rooted in less than satisfying experiences as a student.  Similarly, I find that many of my motivations as a physician are rooted in less than satisfying experiences as a patient. 

How do you feel your love of resident and fellow education carries over into your interactions with patients?

Eric:  I feel that the teaching environment that I work in greatly enhances my patient care.  My patients generally enjoy interacting with my residents.  I’m surprised at the number of times patients disappointedly ask me on follow-up visits, “Where is your resident?” if I do not have one with me that day.  I learn a ton from my residents.  They learn from other doctors that may use different approaches and my residents will often say, “Dr so-and-so likes to do this in this situation.”  I consider myself fairly open minded.  I don’t mind when the resident brings up other suggestions and I often learn new approaches this way.  I strongly believe that as supervising physicians, we need to remember that we are not necessarily smarter than our med students and residents, we are simply more experienced.  I feel that not utilizing the brainpower that a student or resident brings to the table is a lost opportunity for patient care.

Gary: Seguing into communication, one of my favorite things about you is how good it feels to talk to you.  I've noticed a few strengths in your communication style- you project warmth, but you also clearly reflect with detail that makes it apparent that you've heard the content of my message.  Two questions for you.  First, is that consistent with how you view yourself as a communicator, and second, is that something that comes natural to you, or is that something you've cultivated over time?

Eric: Yes, I do view myself as a good communicator.  It is something I pride myself upon.  I get such great pleasure out of seeing the understanding on a patient’s face when I explain their medical condition to them.  It is really gratifying when a patient says, “Oh, I never understood what was going on with my body until now.”   I never really understood why some doctors have such a difficult time not speaking medical jargon to patients.  The way I always think of it is that non-medical speak was my first language.  I learned “medical language” later in life.  Therefore, I still think it’s a lot easier for me to explain a patient’s medical condition in laymen’s terms, because the laymen’s terms are my “first language”.

I would like to think that I am very attuned to my strengths and weaknesses.  I am very self critical so I feel very aware of what I need to improve upon.  I know communication is a strength of mine.  I cannot say that I have cultivated it, for whatever reason it has come naturally to me.

Gary: Can you talk more about your military background, and how that has shaped the way you view medicine and communication?

Eric:  I was in the United States Navy for 5 years, 3 of which I served as a flight surgeon.  This essentially means that I was the primary care physician for a group of military aviators.  I took care of a C-130 squadron and had the opportunity to travel the world with them.  My military experience was the most important contributor to my professional development.  Before I worked in the military, my professionalism needed a lot of work.  I learned great leadership skills in the Navy.  My experience in the military makes it harder for me to deal with the managed care system now, because in the military you generally can do whatever you feel is the right treatment for that patient. 

  

Gary: Another thing I've admired about you is your willingness to invest yourself in a career that most people do not know much about.  Can you explain what cancer rehabilitation is?

Eric: Cancer and cancer treatments can really wipe people out.  A huge percentage of cancer patients are healthy and feel good when they are diagnosed with cancer.  It’s not until after they are treated that they become fatigued, deconditioned, and have pain and balance problems, amongst other issues.  Rehabilitation is a standard part of treatment for people who have strokes or brain injuries.  However, historically we have not rehabilitated cancer patients despite major changes in their functional status after cancer treatment.  Cancer rehabilitation aims to bring patients back to their baseline function after battling cancer.

Gary: I am sure a common question you hear is "why do I need a cancer PM&R physician, when I already have an oncologist?"  Shed some light.

Eric: In my mind, this question is like asking, “why do I need a hairdresser when I already have a plumber?”  The skill sets and training of an oncologist and a PM&R physician are very different.  Oncologists are fantastic at treating cancer.  We know this because patients with cancer are living longer and longer.  In the system I work in, the oncologists love working with me, because I help the oncologists do what they do best – treat cancer.  Rather than the oncologists having to spend tons of time trying to manage all the functional side effects of treatment, they can put those issues in my hands.  While most oncologists get some training and experience in managing functional side effects, in general they are not very good at it.  I’m not putting them down in any way, it is just not what they are trained to do.  The oncologists I work closely with agree with this point.  That’s why they love sending patients to me.  They can spend more time with the patient talking about cancer.  I can spend lots of time with the patient talking about their function.  The patients go back to the oncologist and thank them for referring them to me.  Everyone is happy.

Gary:  That's such an important message.  Can you talk a bit more about the role of exercise for patients with cancer? 

Eric: Exercise is a booming area in cancer care.  The body of evidence that demonstrates that exercise can decrease the risk of cancer recurrence is overwhelming at this point.  Studies have shown that exercise can reduce the risk of cancer recurrence just as well as hormone medications such as tamoxifen.  Many experts believe that in the future, all cancer treatment protocols will include exercise, such as: “surgery, chemotherapy, radiation, exercise”.  At this point, any oncologist who is not recommending exercise for their cancer patient, unless there is an obvious contraindication, is doing their patient a major disservice.

  

Gary: In particular, can you talk more about risk of fractures in cancer patients?  I find that many oncologists are so concerned about patients falling and breaking a bone, that they discourage their patients from exercise out of a sense of fear.

Eric: Most cancer patients are not at high risk for fracture.  If cancer has spread to bone, there is a potential risk for fracture.  Scales exist that can help predict the risk for fracture.  If the risk truly is high, often surgery will be recommended to fix the bone before it fractures.  This is because it is safer and easier to fix a bone before it fractures than after it fractures.  For patients with cancer in their bones who are not at high risk for fracture, exercise should be encouraged.  Pain is a great guide.  If a certain exercise causes pain in the area of bony cancer, that exercise should be avoided.  If it does not cause pain, the patient can keep going!  One important additional factor to consider is the patient’s balance.  Chemotherapy can affect nerves, which can impact balance.  If a patient’s balance is considerably affected, then they may be at higher risk of falls and fractures.  This is something that a PM&R specialist can assess and help manage.

Gary: Even amongst the small world of cancer PM&R specialists, you are even more specialized in your usage of ultrasound as a tool to help patients.  Can you tell us more about how ultrasound helps you with your patients? 

Eric: In general, my use of ultrasound is no different than any other musculoskeletalmedicine physician.  It is common for me to see breast cancer patients with rotator cuff tendon problems.  Ultrasound is so useful to characterize these problems in the office.  It is certainly useful to help in performing accurate injections. 

More specifically to the cancer population, I have started performing some less commonly performed nerve injections using ultrasound.  For example, it is very common for breast cancer patients to have pain in the armpit area after lymph nodes are removed.  I never really understood why until I learned my surgical anatomy.  There is a nerve in that area called the intercostobrachial nerve that causes this pain.  I studied the anesthesia literature which helped me learn how to perform an ultrasound-guided injection to block pain from this nerve.  This technique has been very helpful for my patients. 

Another example is in head and neck cancer patients (who badly need rehabilitation).  There is a nerve in the neck that can be affected by surgery and radiation called the greater auricular nerve.  If injured, it can cause severe ear pain.  When I first started seeing these patients with ear pain, I did not know how to explain it.  However, after studying my anatomy, I realized this nerve was the culprit.  I learned how ultrasound can help me inject around this nerve to decrease pain.  So, while I clearly do not need ultrasound to help all of my patients, it can be a very helpful tool for certain patients.

Gary: The more I talk to you, it makes me wish we were in the same region.  So many patients would benefit from your care!  For physicians like my partner Garrett and I, what we can we do to help our patients who have cancer?  In particular, I have some patients who I have already been seeing for other conditions, who then develop cancer.  How can I best be their advocate?

Eric: It is important to think about the pre-existing musculoskeletal, neuromuscular, and functional issues that your patient already has and how they may be affected by cancer.  If your patient has shoulder issues, they most likely will worsen after a breast cancer diagnosis without rehabilitation.  If your patient has a nerve issue, this most likely will worsen if your patient is treated with chemotherapy.  If your patient has difficulty walking, this can worsen after cancer treatments.  The good cancer rehab doctor will try to preempt functional loss that can occur during the trials and tribulations of cancer treatment.

The basic principles of what a cancer PM&R physician does are minimally different from what most PM&R physicians do.  In general, most physiatrists can take great care of these patients.  However, I do believe there are some subtleties to caring for cancer patients.  The first thing that really helps is having a decent understanding of cancer treatments.  You don’t have to be an oncologist, but having a basic understanding of the treatments helps me understand what has happened to my patient’s bodies and how their function has been affected.  Secondly, I think there are few little tricks I know that seem to work well for cancer patients.  I believe going to a cancer rehabilitation symposium like Sloan-Kettering’s annual symposium is a great way to learn some of these tricks.  Also, we should be pushing our national leaders to include cancer rehabilitation lectures at our national meetings.

Gary: Eric, thanks again for this interview.  I sincerely feel that you are one of those people who always brings something positive to the table, and never leaves anything negative.  Thanks for making the world a better place

Positive Patient Feedback

"My experience at Lake Washington Sports and Spine has been great.  It starts with the front office, they are very welcoming and most helpful.  Next is Dr. Chimes's Medical Assistant, he is very courteous and professional.  Last but not least is Dr. Chimes, who is very easy to talk with, covers everything and gives me hope that my problem will be managed.  Dr. Chimes is the first doctor I have ever had that thanks me for being his patient.  WOW!!"-Debbie P.

Thanks for the kind words, Debbie!  We feel fortunate to have such wonderful patients, like you!

Tips on reading the news: don't confuse "Quality", when they really mean cost containment

This article by Bruce Gans highlights yet another Obamacare casualty- acute inpatient rehabilitation.

Acute rehab hospitals are the facilities where people recover from severe injuries like spinal cord injuries and traumatic brain injuries.  Bruce Gans is part of the leadership for the Kessler Institute of Rehabilitation, which is where I trained for residency.  It is most famous for being where Christopher Reeves recovered from his spinal cord injury, and is generally considered one of the premier rehabilitation facilities in the world, #2 in the current US News rankings.  It's a great facility, and where I'd want my parents treated if something horrible happened to them.

..... and Obamacare is cutting access to facilities like Kessler, Rehabilitation Institute of Chicago, and other world class facilities.  As Dr. Gans notes, the ACA treats nursing homes as equivalent to world class rehab facilities, despite evidence that they are not equivalent.

It's part of a broader trend in what I call an abuse of research.  In an ideal world, research is used to help people.  However, the ACA is primarily focused on cost containment, so it looks at research studies and tries to find cheaper alternatives to the standard of care, and find studies selectively that support the use of cheaper alternatives as equivalent treatments.

That's simply not right, and does not serve the needs of patients.

Under Recovery

My colleague Brian White, a PM&R physician based out of Cooperstown, NY, has an expression that I really like- "There is no such thing as over-training.  It's under-recovery."

Probably the most common sports injuries I see are what I call chronic overuse injuries. Whether it is patellofemoral syndrome, tibial stress fractures, tennis elbow- all of these are examples of not allowing the body to sufficient time and creating an optimal environment for recovery.

The body needs a few things to recover properly:

1. Rest

2. Nutrients

3. An optimized endocrine environment

Taking these 1 at a time:

1. Rest

These refers to both sleep and muscle recovery.  It's important for athletes to get enough sleep to recover.   There are indicators that let you know you are not getting enough sleep.  One is that you should feel refreshed when you wake up.  The second is that if you wake up with an elevated heart rate, your body is telling you need more time to recover.

Another form of rest is cross-training.  For example, many age-group triathletes need more time to recover between workouts than they did when they are younger.  A good indicator that you are not allowing for optimal recovery is that you feel muscular fatigue at the beginning of your workout.

2. Nutrients

The body needs building blocks to recover.  For muscle in particular, the most important resources are amino acids, which are the building blocks for recovery.

Not all proteins are created equal.  Some are more bioavailable than others.  This will be a separate post in the future, but the general hierarchy is that essential amino acids are better than whey protein, and whey protein is better than soy protein.  The commercial products I generally recommend are Benevia Strength & Energy (www.gobenevia.com), or the Whey Protein formulations available at Sam's Club and Costco (which are high quality and affordable).

3. Endocrine Environment

A growing body of research shows that in order for your body to recover appropriately, you needs hormonal signals to let it know that it is safe to recover.

When the body is breaking down, this is called catabolism.  During times of stress or overwork, the body will break itself down to make sure that building blocks are available in the bloodstream.  When the body is building itself back up, it's called anabolism.

There are 3 common endocrine syndromes I see that inhibit recovery- one in women, another in men, and a third in both sexes.

The endocrine issue that affects women is called the female athlete triad.  Technically, the female athlete triad refers to fractures, absent periods, and an eating disorder, but the way I view it clinically is that the female athlete is not taking in sufficient nutrient content for her caloric expenditure.  Women's bodies are very well calibrated, and the body will not allow itself to have a period unless there are sufficient nutrients to support both the female athlete and a potential baby.  So if you are a female athlete and do not have a regular period, you should have this evaluated by a health professional familiar with the female athlete triad.

The endocrine issue that affects men is hypogonadism.  This under-recognized disorder is when a man's body reduces it's natural production of testosterone because it is under stress.  If you find that you have decreased energy, loss of muscle bulk, difficulty with recovery, it's possible that your testosterone level has dropped in response to the repeated stresses of exercise.  This is especially true if you have a decreased libido, which is more common in hypogonadism than in similar appearing conditions like hypothyroidism and depression.

The final endocrine issue, which can affect both women and men, is Vitamin D deficiency.  The body can get Vitamin D through both diet and sun exposure.  Vitamin D deficiency may be especially common in areas that have lots of cloud cover, including my home town of Pittsburgh.  Therefore, in patients who are not recovering as well as anticipated, Vitamin D deficiency is one of the first things I check for. 

The key to low back pain - stratification and the Katie Couric effect

What is the best way to treat low back pain?

I get asked this question all the time, whether I am seeing patients in my Sports & Spine clinic, lecturing at national meetings, or meeting with other experts.

There is one key to management of low back pain- stratification.

What I mean by this is that low back pain is not one diagnosis, and therefore trying to treat all low back pain with one approach is not effective. In a typical day, I may see patients who have many different causes of low back pain, all of which are best managed with different treatment approaches. The approach to managing an annular tear in a 23 year old Ironman triathlete is dramatically different than that of a 74 year old with zygapophysial joint arthropathy, which is dramatically different than the approach in a 34 year old woman with post-partum pelvic floor dysfunction.

Some of these patients I manage with an exercise program, others I may manage with an image-guided injection, and others I may manage by working in a team with the physical therapist or chiropractor. The key is that I recognize that every patient is different, and no one approach will work for everyone.

Unfortunately, many treatment recommendations are based on the assumption that low back pain should be treated as one entity, and therefore one basic approach should be used.

So, if you have low back pain, the biggest determinant in getting better is appropriate stratification into the appropriate treatment groups. Some of this is related to determining the appropriate diagnosis, but often times we can stratify patients into appropriate treatment groups even if we don't know the actual diagnosis.

For example, many patients are surprised to find out that if you want to get better, it is more valuable to know a patient's directional preference (i.e., which movements are most painful, such as putting on shoes and socks in the morning) than it is to look at an MRI. If I know that a patient hurts more with certain movements, I can design a physical therapy program that takes this into account. This is of great benefit to this physical therapist, and as Audrey Long demonstrated inher award winning research in 2004, if we design physical therapy programs with a directional preference in mind, the probability of improvement increases dramatically.

But I have many patients say to me "I hear you, but I've always been told that if you really want to know what is causing my low back pain, I need an MRI." MRIs are wonderful tools, but the reason they are not as helpful as you might imagine is because of what I call the "Katie Couric Effect."

We all know Katie Couric. Back in 2000, in the days before we had HD televisions, we didn't notice that she was actually a woman in her 40s. When she started working for CBS on the nightly news, two things happened- Katie Couric turned 50, and many of us started watching her in HD television.

Katie Couric is a very attractive woman, but when you look at her in HD television, many things are suddenly apparent that were not apparent on a regular television. She is the same woman that she was on a regular television, but because of the higher resolution of the TV, we are now more aware of some of the natural changes associated with aging that we would have been blissfully ignorant of otherwise.

Same thing with back MRIs. Just as the natural processes of aging can bring along gray hair and wrinkles, the normal healthy spine has some age-associated changes, including degeneration of the disks and joints. Much of this is incidental, and therefore when we look at a spine MRI, most of what we are looking at is incidental findings. And often times, the main cause of low back pain may not be seen on MRI.

Which brings me back to what is the best way to treat low back pain. The key is to find someone you trust who is able to figure out what is the best treatment approach for you. That person may be a Sports & Spine PM&R physician like myself or Dr. Hyman, it may be a surgeon, it may be a chiropractor, it may be a physical therapist, it may be an acupuncturist, etc.

Ultimately, you need someone who can see you as an individual, and has the skill set necessary to tailor a program that is appropriate for you.