Showing posts with label wellness. Show all posts
Showing posts with label wellness. Show all posts

Saturday, September 20, 2014

Lessons From Physical Therapy


I remember the first time I experienced any significant knee pain.  My wife and I had just purchased an old house and as part of the sweat equity that young homeowners do we were going to refinish all of the hardwood floors ourselves.  If you have ever tried that, the most imposing part of the task is sanding all of the floors.  Hardwood floor sanders are very heavy pieces of equipment with cast iron bodies.  My first task was to carry this machine that I guess easily weighed over a hundred pounds up to a high second floor in our old house.  That was about 25 steps and a landing.  By the time I got to the top, it felt like both knees had bottomed out and were starting to creak.  At the time I was a competitive cyclist and training by putting in 200-250 miles on the roads and hills of Duluth, Minnesota.  I had never encountered this type of pain before during cycling, speedskating or weight lifting.   I compensated the best I could by taking the sander down just one step at a time and bringing it up and down again after we ruined the first staining attempt.  Eventually the pain went away, but I had learned several valuable lessons.  Cycling for example, did not cause any knee pain even after this acute injury.  I developed a strong preference for cycling and skating and decided to forget about running.

A couple of years went by and I developed some pain in my lateral knee.  I had already been diagnosed with gout in medical school and compared to gout pain most other musculoskeletal pain is minor.   My experience with physicians diagnosing gout was very mixed and I did not want to get a recommendation for medication if something else would work better.  Instead of seeing a primary care physician, I went in to see a physiatrist who happened to be a sports medicine doc.  He jerked my knee around and was satisfied it was stable and showed me some basic iliotibial band stretching exercises.   Within a week the pain was was gone.

My most foolhardy adventure in knee injuries was trying to extend my usual 40-50 miles training rides to 100 miles with no buildup.  I was out riding the roads in Washington County and remembered a theoretical 100 mile loop that I always wanted to ride.  It was a hot summer day, I felt very fast, and I had plenty of daylight so I took off.  At the 3/4 mark I was coming up a long steep grade and felt some left knee soreness that persisted the rest of the way.  My knee was burning when I stopped and I ignored it and did not ice it that night.  By morning I had developed a significant effusion and could not bend it.   I saw an orthopedic surgeon the next day who jerked my knee around, told me it was an overuse injury, and put my leg in a knee immobilizer.  Within two weeks I was out cycling again.

At other times I have allowed my body to get seriously out of whack.  After years of cycling I started to realize that I ended each session with severe neck and shoulder pain.  After numerous adjustments to the stem length on my bike, a physical therapist figured out I was was extending my neck too far to look up from my riding position and fixed the problem by modifications to my riding position and neck exercises.  At one point, I was almost exclusively cycling and got to the point it was painful to walk around the block.   The solution was again exercise modification and exercises to improve hip flexibility.  

All of this experience has led me to be very conscious of knees and other joints and keeping them in good working order as I age.  Not just my joints but the joints of my wife, family and friends.   It is kind of amazing to hear the emphasis on physical activity at all ages and yet there is no information out there on joint preservation or how to preserve your back.  Many people are surprised to learn that the circulation to intervertebral disks in the spinal column is gone at some point in the late 20s.  That makes biomechanics and muscle conditioning some of the most important aspects of joint and back function as you age.  It also makes physical therapy and exercise some of the most important tools to maintain musculoskeletal function with aging.   When I develop some kind of musculoskeletal pain, the first thing I do is call my physical therapist and schedule an appointment to see her.   She does an examination and an analysis of the biomechanics of the problem and tells me how to solve it.  I have been through the process many times with a physician and the main difference is that there is no biomechanical assessment, no actual manipulation at the time that may be useful, and no specific exercise program to make it go away and stay away.

The results of a medical evaluation are as predictable.  You have a diagnosis of muscle or joint strain.  Use ice or heat whichever one makes you feel better.  I have been told by rheumatologists that there is really no scientific basis for the heat versus ice recommendation only the subjective response.  And of course the recommendation for NSAIDs (non-steroidal anti-inflammatory drugs like ibuprofen) or acetaminophen.  I ignore the NSAID recommendations and take as few tablets of naproxen every year as I can.  I consider NSAIDs to be highly toxic drugs and avoid them even though they are effective.  I had a rheumatologist at a famous clinic tell me that the best evidence that NSAIDs were effective was the negligible amount of joint cartilage that was left when patients came in for joint replacement therapy.   Strong evidence that NSAIDs could knock out the pain as the joint deteriorated.   The only time that I was ever offered an opioid was when I had my first gout attack.  I was seen in an emergency department for severe ankle pain and discharged with a bottle of acetaminophen with codeine - a medication that is totally useless for gout pain.

In clinical practice I see a lot of people with chronic pain.   I notice that many of them are taking NSAIDs on a chronic basis and experiencing complications of that therapy like renal insufficiency.   I notice that practically nobody sees a physical therapist.  I notice that many people are now started on oxycodone or hydrocodone for mild sprains and injuries involving much less tissue injury than many of the injuries I have sustained during sports.   There are also many people who do not receive adequate advice on modifying their activities once an injury or series of injuries has been sustained.   For example, should a person keep running if they have sore knees, are 30% overweight, and have radiographic and physical exam evidence of degenerative joint disease?  Many people seem to have the idea that they can just wear out joints and have them replaced and the replacements will be as good as new.   Some will decide that it is just time to hang it up and start to sit on the couch and watch television.  They are surprised that their pain worsens with months of inactivity.   Some of the patients with back pain decide: "This pain is so bad that physical therapy is not going to do anything.  I am going to get surgery as soon as I can."  The widespread ignorance and neglect of musculoskeletal health is mind boggling to me.

I got into an exchange with an orthopedic surgeon in our doctor's lounge one day - over lunch.  He wanted to talk about narcissistic personality disorder and I wanted to talk about the biomechanics of the knee and hip joints.  It was a lively exchange and in the end he agreed with me about the huge importance of biomechanics during physical activity and as a way to prevent injury and degenerative disease.  It turned out he just wanted to hear about the personality disorder and did not have an opinion on it one way or the other.

I teach a lot about central nervous system plasticity in a neurobiology course that I give several times a year to different audiences.  Widely defined, plasticity is experience dependent changes in the nervous system.  There are a number of mechanisms that can lead to these changes.  Kandel and others have pointed out that these are the mechanisms of animal learning.  Two examples jump out of those lectures.  The first is a physical therapy example of knee extension exercises in the treatment of knee injuries.  It has been known for some time that quadriceps strength and balance through the knee are critical factors in knee rehabilitation and the prevention of future injuries.  Research in this area shows that increased quadriceps strength can occur in the same session.  The other example I use is a guy who wants to go to the gym to increase the size of his biceps.  He starts doing curls and within 6 weeks his strength has increased by 25% but there is no muscle hypertrophy.  His biceps diameter is unchanged.  What do these two examples have in common?

The common thread here is CNS plasticity and everything it allows us to do.  Plasticity will allow your to keep your joints healthy and relatively pain free if you allow it to.  You have to be willing to accept the idea that pain can come from deconditioning and biomechanical problems that are reversible by plastic mechanisms.  The only additional information needed is if it is safe to exercise and that can be provided by a physician and a physical therapist.

And the lesson for psychiatry?  Chronic pain patients certainly need to hear this information especially if they are deconditioned.   People addicted to opioid pain medications who are not getting any relief need to hear this information.  Patients in general with exercise modifiable conditions who see psychiatrists need to hear this message.  There is also a lesson for psychotherapy no matter how it is delivered.  Kandel's original example of plasticity was a psychotherapy session.  If your brain is modified by exercise there is no reason to think it can't be modified by anything from straightforward advice to more complicated therapies.   Success in that area can lead to the limited or no use of medications and a conscious focus on what is needed to maintain health like I discuss from my own experience.  I certainly don't take any medication for pain that physical therapy or exercise adequately treats.  The same argument can be applied to anxiety and depression that can be adequately addressed by psychotherapy or other psychological interventions.  On the other hand if most people don't know that physical therapy, exercise and activity modification successfully treats musculoskeletal pain and other problems they are unlikely to try.    


George Dawson, MD, DFAPA

Supplementary 1:  There are currently only 4 Medline references on biomechanics plasticity sports.  This seems like a promising area for sports medicine, physical therapy, and rehab medicine.

Supplementary 2:   The photo at the top of the page is an exercise I do to alleviate knee pain that I learned from the book The Knee Crisis Handbook by Brian Halpern, MD with Laura Tucker.  The exercise is called the quad set (p. 238) and although the author suggests a towel under the knee, I am doing it on a styrofoam roller.  This book contains a wealth of information on knee health.  I do not recommend doing what you see in the picture without reading the book.  I have no conflict of interests related to this book and purchased it online entirely for my education.

Supplementary 3:  I could not figure out where to fit it in above but after 25 years riding with 175 mm crankarms on my bike, I dropped them back to 172.5 mm.  The bike fit expert for my new bike was convinced it was a good thing to do.  My new bike rides so much differently it is difficult to know what to attribute to crankarm length.  

Tuesday, September 16, 2014

Is SAMHSA a managed care company?

As I read through their flagship document:  Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018 that was what came to my mind especially when I read statements like this:


"Over the past year, SAMHSA leadership with staff to establish a set of internal business strategies that will ensure the effective and efficient management of the Strategic Initiatives. The resulting Internal Operating Strategies serve as the mechanism through which SAMHSA will optimize deployment of staff and other resources to support the Strategic Initiatives. These Internal Operating Strategies (IOS)—Business Operations, Data, Communications, Health Financing, Policy, Resource Investment and Staff Development—articulate SAMHSA’s effort to achieve excellence in operations and leverage internal strengths by increasing productivity, efficiency, accountability, communications, and synergy." 

Being employed at one time in a large managed care organization, I am used to seeing business speak like this.  I learned to cringe when I read it because any Strategic Initiative based on business speak rather than science or clinical expertise typically ends up being a nightmare.  That's just my experience, but any American who survived the last financial debacle has to be sensitized to words like "productivity, efficiency, accountability, communications, and synergy."   I have a previous post on the Orwellian nature of the word accountability in case  you missed it.  But you can substitute any of a number of words in this paragraph - like excellence.  We used to have a term in medicine called quality that actually meant something.  Excellence as used in the business community is a whole new ballgame.  The number of centers of excellence and top hospitals and clinics based on business measures can be astounding.  You can probably drive out in your community and see one of these banners wrapped around some facility right now. 

SAMHSA is supposed to be the federal government's lead agency for the treatment of mental illness and substance use disorders.  There has been some debate, but I think the political strategy of SAMHSA is very clear and that is to continue the rationing and managed care tactics that have been in place for the past 30 years and make them official government policy.  Lately they have been using tactics that I have seen from these companies over the past 10 years.  Here is what I am seeing so far.

Consumer slogans and concepts are identified that are easy (and free) to support.  Micky Nardo, MD posted their pamphlet on their working definition of Recovery .  This is their "primary goal" for the next year and it was supposedly built on among other things: "consultation with many stakeholders" .  The pamphlet goes on to the definition of recovery with no apparent rules for their all inclusive definition.  For example, does everyone in recovery need to have all of the elements of the definition?  Are there exceptions?  If someone is lacking an element would we say their are not in recovery?  Is this just a subjective and totally personal assessment?  Or is this a goal? If so, why is the lead agency for mental health and substance use promoting it and making it a primary goal?  Note the goal here is "behavioral health".  Behavioral health is the managed care version of mental health.    SAMHSA is therefore supporting the managed care view of the world.  That world view has rationed and otherwise decimated resources available for the treatment of mental illnesses.  Just a few observations on the 10 page pamphlet.

Social media is used for marketing purposes.  Well it is the 21st century and this is how everybody including government agencies gets noticed these days.  I got this cheery notification from SAMHSA in an e-mail this morning:



  Nothing like using a standard Internet marketing strategy to discuss a process that has no proven efficacy in treating mental illness.  This is the kind of marketing approach to medicine and mental illnesses that I have seen and expect to see from managed care companies.  It usually happens right before they decide they will financially penalize you for NOT practicing Wellness activities.  In a plan where I was enrolled each employee had to pick a Wellness activity and a counselor would call at intervals and decide if you were in fact compliant with your activity.  Noncompliance meant higher premiums.  In the business world wellness can cost you.

Since SAMHSA is really not a managed care company, why are they using their marketing and political strategies?  The most likely explanation is the unparalleled success of managed care against physicians and other traditional health care organizations.  SAMHSA seems to have surprisingly little expertise in treating significant mental illnesses.  That puts them on par with most managed care companies in the US who if they are honest will flat out tell you that their job is to extract as much money as possible from subscribers who believe that they signed up for some kind of mental health or substance use benefit and send it somewhere else.  That theme is repeated time and time again in corporate America and nobody would fault an American corporation with than attitude.  With a government agency, especially the lead agency there should be a much higher standard than a corporate one.  What is the evidence for my statement?

Let me focus on a section that I lecture on at least a dozen times a year and have more than a passing familiarity with and that is the excessive use of opioids and the current opioid epidemic.  It is a subsection of one of the strategic initiatives for 2015-2018:


The administrators here take the incredibly naive (or cynical) view that what they say will somehow be done.  It is eerily similar to the original statements without proof or scientific backing that were made at the start of the opioid epidemic.  In those administrative guidelines the most compelling feature was that physicians were not doing a good job treating pain and therefore they had to be educated about it.  These guidelines were written by nobody less than the Joint Commission.  Now SAMHSA in their infinite wisdom  is deciding that physicians need more education about this.  Administrators like to play the education card.  They don't seem to understand that this problem, specifically the problem of overprescribing has little to do with education and more about how physicians are being manipulated to provide services that somebody who does not have a clear picture of medical care wants.  Let's remember the SAMHSA track record here.  From the FDA web site, the FDA claims that in 2009 it launched an initiative with SAMHSA "to help ensure the safe use of the opioid methadone."  From that press release (my emphasis added in the underlined section):

"The methadone safety campaign materials provide simple instructions on how to use the medication correctly to either manage pain or treat drug addiction," said H. Westley Clark, M.D., J.D., M.P.H., C.A.S., F.A.S.A.M., Director of SAMHSA’s Center for Substance Abuse Treatment. "Our goal for this training is to support the safe use of methadone by all patients and prescribing healthcare professionals."

The operative term is "all patients and prescribing health care professionals."  In other words SAMHSA was seeing this as an educational deficit.  The detailed program is still available online.  If only the health care professionals could be educated enough by an administrative body that knows more than they do, the epidemic of methadone related deaths from overdose would stop.  The problem occurred when the CDC looked at the epidemiology of single and multiple drug deaths involving opioids and found that the methadone related deaths occurred at much higher rates in both categories than other opioids.  Their recommendation stands in contrast to the SAMHSA educational initiative. From that document - my emphasis added in the underlined section:

  • Between 1999 and 2009, the rate of fatal overdoses involving methadone increased more than fivefold as its prescribed use for treatment of pain increased.
  • Methadone is involved in approximately one in three opioid-related overdose deaths. Its pharmacology makes it more difficult to use safely for pain than other opioid pain relievers.
  • Methadone is being prescribed inappropriately for acute injuries and on a long-term basis for common causes of chronic pain (e.g., back pain), for which opioid pain relievers are of unproven benefit.
  • Insurance formularies should not list methadone as a preferred drug for the treatment of chronic noncancer pain. Methadone should be reserved for use in selected circumstances (e.g., for cancer pain or palliative care), by prescribers with substantial experience in its use.

The CDC does not believe that the problem with the disproportionate deaths from methadone is an educational deficit.  They believe it is a problem inherent in the drug, clinical setting, and experience of the physician.  It should definitely not be prescribed by all physicians, even if those physicians are educated.   SAMHSA apparently still believes in the educational deficit.  As I have posted the associated regulatory problems includes the FDA and their continued approval of high dose opioid products against the advice of their scientific committees, and their plan to educate physicians to safely prescribe these products.  I am using this example to illustrate that SAMHSA's approach, educate the masses and they will accept wellness and their health will improve by practicing wellness is a pipe dream of extraordinary dimensions.  It does not work on a focal issue, why would it work on a population wide basis?

Paul Summergrad's take on the politicalization of wellness/recovery versus psychiatry/medicine was a very accurate statement.  Americans in general are intolerant of probability statements.  Blog discussions are a particularly intolerant environment.  I do not agree with his support of integrated or so-called collaborative care.  It is no surprise that SAMHSA supports and has a leadership role in this managed care strategy.  He stops short of pointing out that SAMHSA has nothing to offer patients with severe mental illnesses.  

Besides being basically a pro-business strategy, the SAMHSA initiative also takes the grandiose approach that there are no psychiatrists out there (I will let other mental health clinicians speak for themselves) who want to see the people they treat recover and lead meaningful and satisfying lives.  They make it  seem like their simple business objectives will be better at this goal than personalized treatment provided by a psychiatrist.   That may provide a rallying point for the detractors of psychiatry, especially when the APA chooses not to counter the insult, but it is not a concept based in reality.  There is nothing more important in the practice of medicine than how a patient does under a physician's care. 

I think it is time for SAMHSA to put up or shut up.  Even though they have probably stacked some of the outcome statistics in their favor ahead of time and some of the outcome measures are as vague as managed care company measures of excellence (both proven business strategies), let's see what happens.  And let's see if the Big Pharma critics are as skeptical of their outcome statistics as they are of a typical pharmaceutical industry funded clinical trial. 

So far they have a solid check minus on the opioid initiative.

George Dawson, MD, DFAPA