Old Men Throwing a Football…

 

Three days ago – I drove up to my hometown on Lake Superior to visit relatives and some friends that I have had since childhood.  From about 1963 to 1973 we played football primarily but also several other sports in and around the only park we had as kids.  For a few months in the winter, it was a skating rink.  The rest of the time it was an abandoned field.  For about half of those years, the field was next to a ravine with a small swamp at the bottom of it.  Eventually the ravine was filled in and it was an even rougher field to play one.  We stuck to the rink surface, an abandoned lot across the street and in the wintertime the streets lined by snowbanks.  Of course, in the fall and winter we typically played in the dark after school.

And we played every night – in the rain, snow, and subzero weather.  There was no formal start time. Sometimes I would hear a pebble bouncing off my bedroom window and look out and the boys were all there waiting.  Other times I would step out into the alley and two blocks away see one of my friends waving his arms in a crossing motion over his head.  I would reply with the same motion, and we would head to the field. People would filter in when they saw us there warming up.  Quitting time, was highly dependent on when the neighborhood store closed (usually 8:30 PM).  The winner was often determined by that quitting time: “Whoever gets to this score or 8:15 PM”.  Our post game ritual was consuming 16 oz RC Colas at the store, and we couldn’t miss it.  

Most of these games were 2 on 2 or 2 on 3 passing games.  As a result we could all throw well and learned to catch a football very well. What was remembered three days ago was learning how to catch a ball that disappeared above the streetlights in the extreme dark cold of winter when it suddenly reappeared under the lights.  We would say “it came out of nowhere” – but we would catch it. On this day we did not do any kicking or punting, but I also remembered the guy in our group who taught himself to punt a perfect spiral.  It was amazing to see and that disappeared above the streetlights for a very long time before it came into view.

Today we were focused on short passes of 10-30 yards and throwing flat minimal arc spirals. I still recall my high school coach showing us how to throw a spiral with the nose of the ball slightly elevated for more distance and that was what I was going for.  I wondered if we were going to throw for distance like we used to do but that never happened.  The focus was on these short passes and catching the ball in the hands.  The fall detection on my watch was set off by catching a few of these passes. These passes still had a little heat on them. One of my friends talked about having "$1,000 hands" based on what he caught at work and telling the story of how he developed that ability. 

Only a couple of us played organized sports.  I wrote about that in another post. But the caliber of play was high.  Playing a sport every day for 10 years brings with it a high degree of athleticism both in terms of conditioning and coordination.  And it seems hard to believe these days but the only diversions available to us was very mediocre black and white television transmitted through the air and reading. Technical problems were common with the TV and to see a show you had to be there. It seems hard to believe now - but there was no on-demand viewing or recording.  Reading was limited by what you could buy or borrow from the library. At the same store where we drank the RC Colas – a bookmobile showed up every Saturday.  I remember borrowing and reading When Worlds Collide - a novel written in 1933 - and being fascinated by it.  Toward the end of my football period I worked for the library and mailed books out to other bookmobile locations.

That lack of diversions – technical and otherwise may have kept us focused on our game.  Several people commented to me that nobody ever plays in that field anymore.  On some days we had 10 or 20 additional players.  But these days nobody ever shows up and plays every day.  The city baseball and softball leagues have also been decimated far beyond what could be accounted for by a population decrease. It seems that in small town America not many people are playing sports anymore.

As we were throwing the ball around. One of my friends reminded me of a time when I threw him a pass and he dropped the ball.  I told him to take his gloves off so he could catch it the next time and it was 17 degrees below zero at the time. I am certainly not the same guy I was back then – you become a better person with age.  I asked him what he made of that today and he summed it up: “That’s just the way it was back then.”  There were definite periods where we were unnecessarily rough and angry. But I don’t recall any out and out fights.  The roughness of the game when you are a kid is a source of pride.  We were all from the East End and we had a shared "wrong side of the tracks" blue collar mentality. To this day – one of my friends in the photo gives West Enders a rough time.  He told me that he recently asked one of them: “Did you even play outside when you were kids?”  Trash talking is not a new invention.

The shared experience is something I never thought about at the time. I heard a recent piece on This American Life about the importance of camping to some people and how there were campers and non-campers and the non-campers would never understand the emotional importance of camping.  The same thing was true of our football games.  It gave us all meaning at a time in our lives where there wasn’t much. It gave us a chance for intense emotional expression and eventually being able to control that expression.  It helped us through some pretty bad times. I still remember hearing the pebble bounce off my window and telling the guys: “I can’t play today – my Dad died last night.”  I remember the expression on their faces when they heard that news. I remember it as clearly as if it happened yesterday.  All of the homilies that I heard at various sports banquets about the importance of teamwork - rings hollow. It is more important just to be there and share the experience.  Nobody ever tells you that when you are a kid beating yourself up for losing a game. It really doesn't matter who wins or loses.  It doesn't matter how you play either. It just matters that you show up and keep showing up.

This day - it was happier times.  We had all just finished working - as in retired.  School, work, and in some cases military service were all necessary distractions from our game. One of my friends has just completed 41 years of work without missing a day and for some of those days he was working 7 days a week. We had all dodged severe medical problems of one form or another.  We had all survived COVID so far and had the vaccinations. It was a good day to be alive on our childhood playing field.   

We may have lost a step or two but old men can still throw and throw quite well.  But there were no diving catches.

 

George Dawson, MD, DFAPA

Thinking and Shoveling the Snow

I got a late start today.  It was 1:30 in the afternoon but the sun was already low in the sky.  That violates one of the cardinal rules of snow shoveling.  If you are  shoveling light snow  and can get most of it up off the concrete - the sun will do the rest of the work and melt it off.  If it is too cold to melt on a dark surface sublimation can occur and it will transition directly from a solid to a vapor.  At this temperature and sun angle - I would be lucky to get 2 hours of melting.

One of the other cardinal rules of snow shoveling is that timing is everything.  I was up briefly at 7AM today.  It was still dark out, but there was plenty of activity in the neighborhood.  People shoveling, snowblowing, and plowing.  It was still snowing lightly at the time.  If you clear off the snow too early, there will be another inch or two of snow on top of your concrete.  If that happens consistently you might not see concrete again until the spring thaw.  I looked around and that had happened to several neighbors.  I also noticed that one of my neighbors had cleared off about 90% of the heavy snow from my driveway with his snowplow.  I am very appreciative of that.  At a psychological level it is a mixed blessing.  In my 20s, 30s, 40s, and even 50s I was a snow shoveling machine.  I would attack any depth or distance of snow with a thin steel scoop shovel and dispatch it as fast as I could.  Now I am becoming the old guy down the street who might be overdoing it.  Maybe they are right - decreasing snow shoveling vigor may be just another sign of heading toward decrepitude.

I have the inevitable associations to learning how to shovel snow from my father.  The theory of extending the shoveled surface out onto the grass for an inch or two so that any run off does not pool on the concrete and freeze.  Today for the first time, I realized why we used steel scoop shovels with short handles.  These were the shovels my old man used to shovel coal into a steam engine locomotive boiler when he started out as a fireman on the railroad.  He let me watch him once in a switchyard near our house.  I was only 5 or 6 at the time, but he was shoveling coal the size of softballs into that boiler.  You could only do that job with a light steel short handled shovel.  I have the usual associations about knowing my father for only 16 years or less than half the time I knew my father-in-law.  Today I had the thought that all of my interactions with and reactions to my father were the product of a brain that was 10-15 years away from neuroanatomical maturity.  What would it have been to know him as a mature adult?  How has that affected me?  If I had a son myself - what would I try to pass on to him about snow shoveling?  At this point - not having a son I will never know.  The snow shoveling knowledge of the Dawson clan dies with me.  Even the most liberal college will probably not have a "Snow Shoveling 101" for the curious.

I drag out the snowblower and fire it up.  There is still an uneven 3 - 8 inches of snow to clear up.  The snowblower is about 20 years old.  It was a birthday present to my wife.  Believe it or not she requested it - but she might have not disclosed her real motive for that.  She was probably concerned about me throwing snow around with that scoop shovel like a blender and thought: "OK - how long can he keep doing that before something bad happens?"  She tells me to use the electric starter so it doesn't freeze up and I oblige.  I start snowblowing in an arc over 90 degrees back and forth blowing all of the snow to the eastern side of my driveway.  I realize that my driveway alone has more area than all of the concrete that my father and I used to shovel at the family home.  I wish that I knew more about graph theory.  The pattern that I use to shovel the driveway could probably be optimized by graph theory.

After that I get out a shovel.  It is no longer a scoop shovel.  It is an  all plastic shovel with a 90 degree bend in the middle.  They sell a lot of these shovels these days.  I am very skeptical of the  mechanical advantage, but it does allow a more erect posture in the process.  I am using it because I have to shovel on a textured concrete sidewalk and can't use steel shovel or a snowblower without scratching the surface.  I shovel a scoop wide margin up the right hand side of my walkway and then come back cross cutting the width of the side walk.  Swing the shovel from left to right and throwing the snow off the end - the same way my father used to shovel coal.  It takes 30 swipes and I am clear.  I check my heart rate and it hasn't budged.  The last time I shoveled a week ago it was up about 20%.  As I was shoveling I thought of an exercise device that would mimic snow shoveling.  In many ways it is a whole body work out.  Kind of like a kettle bell at the end of a longer handle.

I also fantasize about high tech approaches.  For some reason I have become more and more fascinated with tractors.  I was watching the Discovery Channel late one night and saw a small Swedish tractor that was designed to clear airport runways.  They were using it to build an ice castle.  It was designed to eject large amounts of snow directly over the front of the drivers cab.  I think about what a great time it would be to drive this tractor all day long - moving tons and tons of snow.  I conclude it is a narcissistic snow shoveling fantasy - a probable reaction to my concerns about becoming a less competent snow shoveler.  Still it would be nice to drive that tractor even for a day or two...

I come back to the main driveway and decide that I need to go over it with a shovel it see if I can expose more of the concrete surface to the sun.  This time I create several shovel widths down the west side and cross cut from west to east about 60 times.  I look at my activity monitor and notice that it has only taken about 3000 steps to do the entire job.  I have the thought that with the exception of some time I spent in East Africa, I have been shoveling snow for 50 years.  I also recall that in the famous Halloween blizzard/storm of the century my father-in-law and brother-in-law shoveled a foot of snow away from my old Chevy Chevette, crawled under it, and dropped in a new starter motor.  It was parked on the street at the time, it was nighttime, and it was 5 below.  They had to run a hundred yards of extension cord out to the street to do the work.                    

You might say that I am emotionally connected to the snow and shoveling it.  There is a lot of meaning there and in my 50th years of shoveling it - that meaning is not diminished.  It might explain why I have no interest in moving to warmer climates. Thinking a lot about things has always worked for me.  Shoveling snow is time to think and reflect.

I occasionally think of the limitations to all of this thinking.

Driving motorcycles is just one example.  I stay off of them.


George Dawson, MD, DFAPA

Testosterone Study Is Disappointing For More Than The Obvious Reasons

Testosterone

Testosterone replacement has been a controversial issue, despite a large number of physicians who prescribe it, FDA approval of products for mass marketing, and a number of advocates that see it as an anti-aging and performance enhancing drug for aging men.  The science behind is has been surprisingly slow.  In an era where inequities in health care are often argued by race or sex, this seems to be one where the science at least lags far behind what is known for women.  Expert opinion about testosterone replacement has changed very little over the years, despite much popular literature about how this has occurred for years in Europe and there is widespread benefit for physical and emotional well being of men as they age.  From a clinical perspective, psychiatrists are seeing more and more middle-aged men on testosterone replacement.  This treatment modality has significant implications for any medical treatment provided by psychiatrists as well as associated comorbidity.  From a psychiatric perspective it is also important to determine if the testosterone use is more than indicated, is associated with increasing muscle mass and body image changes, and if it occurring in the context of unreasonable expectations like preserving youth , reversing the effects of aging, or athletic performance enhancement.

In the most recent study of men 65 years of age and older the authors examined the effects of treatment with testosterone gel for a period of one year (1).  The total number of subjects was 790 out of a total of 51,085 men who were screened.  In order to qualify for the trial testosterone level had to be sufficiently low (less than 275 ng/dl) on one of two samples and that eliminated 85% of all of the screened men.  The trial was designed to look at physical function, sexual function, and vitality.  The treatment resulted in testosterone levels that were in the mid-normal range for 19 to 40 year old men.  Despite considerable medical comorbidity in the recruited patients there were clear cutoffs for medical comorbidity.  Those cutoffs included a history of prostate cancer or risk of prostate cancer on the Prostate Cancer Risk Calculator, other conditions known to cause hypogonadism, medications known to effect the concentration of testosterone, high cardiovascular and severe depression (PHQ-9 score >20).   The overall results showed that there was moderate benefit on sexual functioning and some benefit with mood and depressive symptoms but no effect on physical functioning or vitality.  A look at these measurements is instructive.

Physical Function was assessed using the 6 minute walk.  Recent normative data has been established for various age cohorts using subjects from several countries.   That data establishes normative curves for age cohort stratified by sex.  The six-minute walk distance (6MWD) ranged from 559 +/- 80 meters in 60-69 year old men to 514 +/- 71 meters in 70-80 year old men.  On two trials subjects usually walked on average 12 meter farther on the second trial.  In the present study, the criterion for a positive effects from testosterone was a walking distance increase of 50 meters.  When compared with controls, the testosterone treated men had significantly more men increasing the distance walked by 50 meters, the percentage of men exceeding this measure, the change from baseline, and the percentage of men with higher scores on the physical function domain test (PF-10) from the Medical Outcomes Study 36-Item Short Form Instrument (SF-36).  One of the concerns I had reading this methodology is the use of testosterone for physical performance enhancement.  Is it effective without using a training program?  Were the subjects in this study advised to extend their walking distances or speed?  Without it I am skeptical that it would have much of an effect.

Vitality was determined by measures on the FACIT-Fatigue score as the primary outcome measure.  Interestingly FACIT stands for Functional Assessment of Cancer Treatment and their web page links to an extensive list of modified rating scales.  I could not tell if the rating scale had been validated in normal 65 year old men without a cancer diagnosis.  No significant differences were noted between testosterone treated men and controls.  On secondary measures testosterone treated men were more likely to report higher energy at the end of the trial, but that measure was unspecified and may have been a line item in the SF-36.

Sexual Function was measured primarily by question 4 of the Psychosexual Daily Questionnaire.  This item is a 12 item yes-no checklist of male sexual behaviors, thoughts, and fantasies.  Greater testosterone levels achieved in treatment correlated with higher testosterone levels.  A secondary measure - the Derogatis Interview for Sexual Functioning in Men-II (DISF-M-II) also documented increased sexual desire and it was also used as a screen for participants in the Sexual Function arm of the trial.  The sexual function measures do appear to be more straightforward, but they are all self report measures over considerable time frames.

One of the most interesting aspects of this trial was an analysis of the side effects.  One of the main concerns in treating men with testosterone is the risk of prostate cancer that is sensitive to testosterone levels.   I have had personal communication with physicians who were treating patients with testosterone who developed widely metastatic prostate cancer.  The significant adverse effects in this trial were all summarized in a table.  There were 394 placebo treated men compared with 394 testosterone treated men.  The events were summarized according to prostate-specific antigen (PSA) level increases, diagnoses of prostate cancer, elevations of hemoglobin, myocardial infarction, stroke, all cause cardiovascular death, death and hospitalization.  Although there were a greater number of PSA elevations in the testosterone treated men, there was only 1 case of prostate cancer (compared to 0 in the controls) during the year of study and 2 cases of prostate cancer in the testosterone group and one in the placebo group in the subsequent year of the study.

The rationale for this study was try to to add to the results of previous trials that showed inconsistent results of testosterone replacement on muscle mass, body fat, sexual function, energy level, and physical function.  It is disappointing to read through all of these details and find out that there was not much of an effect and that the methodology in the 21st century is so weak.  The only good news that I can find in the article is that it is relatively safe to replace testosterone in 65 year old men who are rigorously screened for hypogonadism and prostate cancer risk.  Although selection bias for a project like this is certainly a consideration, I asked myself whether men self-selected for replacement by low testosterone ads would be rejected at the 85% level by their physicians.  Of course the researchers here point out that the risk over the long run can only be determined by larger trials or (my opinion) post marketing surveillance.  But post marketing surveillance as suggested by the FDA is really a blunt instrument compared with any type of organized pharmacosurveillance or screening all new cases of prostate cancer on a particular electronic health record for testosterone prescriptions. At some level,  I wonder if the research questions would have been answered more completely by trials focused solely on each groups, but there were a very large number of investigators.  Many of the investigators have the appearance of conflict of interest through affiliations with pharmaceutical companies and many do not.

The results of this study are consistent with what clinical psychiatrists see in their practice.  It is not uncommon to see men taking supraphysiological doses of testosterone and not wanting to reduce those doses.  It is common to see men on testosterone who stop taking it because there is no clear efficacy and/or because they are concerned that the women and girls in their life will accidentally come into contact with testosterone.  But let's face it - this is really not about hypoandrogenism.  That is not what is fueling the debate.  I am not an advocate of aging gracefully and accepting what happens.  I think if you have been dieting and exercising through the first 65 years of life it would be useful if medical science could provide something to help you maintain an active lifestyle and prevent the kind of morbidity that slows you down, leads to deconditioning and the host of metabolic factors that hasten aging and death.  Preventing that pathway of physical deterioration depends on maintaining attitude, muscle, joints, and bone.  This is another paper documenting that there is no clear solution to that array of problems.

It is unfortunate that medicine does not have a scientific solution at this point - even after hearing all of the unscientific hype about testosterone and growth hormone for the past 30 years.    

                  

George Dawson, MD, DLFAPA



References:

1:  Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM, Stephens-Shields AJ, Cauley JA, Gill TM, Barrett-Connor E, Swerdloff RS, Wang C, Ensrud KE, Lewis CE, Farrar JT, Cella D, Rosen RC, Pahor M, Crandall JP, Molitch ME, Cifelli D, Dougar D, Fluharty L, Resnick SM, Storer TW, Anton S, Basaria S, Diem SJ, Hou X, Mohler ER 3rd, Parsons JK, Wenger NK, Zeldow B, Landis JR, Ellenberg SS; Testosterone Trials Investigators. Effects of Testosterone Treatment in Older Men. N Engl J Med. 2016 Feb 18;374(7):611-24. doi: 10.1056/NEJMoa1506119. PubMed PMID: 26886521.

2:  Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, Jardim J, LopezMV, Marin JM, Montes de Oca M, Pinto-Plata V, Aguirre-Jaime A; Six Minute Walk Distance Project (ALAT). The 6-min walk distance in healthy subjects: reference standards from seven countries. Eur Respir J. 2011 Jan;37(1):150-6. PubMed PMID: 20525717.

3:  Lee KK, Berman N, Alexander GM, Hull L, Swerdloff RS, Wang C. A simple self-report diary for assessing psychosexual function in hypogonadal men. J Androl. 2003 Sep-Oct;24(5):688-98. PubMed PMID: 12954659.


Brief Video:

The two minute NEJM video summarizing this trial can be found at this link.  Interestingly the video attributes sexual function, vitality, and physical function to testosterone decrease with age and yet full replacement to the point where it is equivalent to levels in much younger men does nothing for physical function or vitality.