Tuesday, February 26, 2019

habits that foster weight loss

If you’ve ever had significant or persistent knee pain, you know it can be a major problem. Climbing stairs or just walking around can be agony, and trying to exercise on a bad knee can be impossible.

For people with severe osteoarthritis of the knee — the type most closely linked with aging or prior injury — knee pain may be unrelenting and often worsens over time, causing disability and reduced quality of life. Osteoarthritis is also expensive: we spend billions of dollars taking care of this condition each year in the U.S. The prevalence of osteoarthritis and the costs of caring for it are rising due to our aging population and rising rates of obesity (which is a major risk factor for osteoarthritis).

While exercise, loss of excess weight, and medications can help, they tend to be only modestly effective and temporary at best. That’s why an estimated 700,000 knee replacements are performed each year in the United States. Though there are risks associated with any surgery and it’s not 100% effective, knee replacement surgery is the most reliably effective treatment for severe osteoarthritis of the knee.
A new study, a new approach

A recent study published in the Annals of Internal Medicine takes a unique approach to the treatment of people with osteoarthritis of the knee.

Researchers divided 148 people with osteoarthritis of the knee into two groups: one group was encouraged to access standard educational material from the web regarding osteoarthritis. This included information about medications, diet, physical activity, and exercises from the research website. The other group not only had access to these same materials, but also received:

    an interactive web-based program about how to cope with pain, with eight weekly sessions lasting 35-45 minutes in which participants learned relaxation techniques, how to balance rest and activity, ways to distract one’s attention from pain, and other strategies
    seven Skype-based sessions over three months with an experienced physical therapist. Each session lasted 30 to 45 minutes and covered home exercises to strengthen lower limb muscles. In addition to video presentations, each participant received free resistance bands, ankle weights, and a pedometer.
    email reminders that regularly encouraged participants to take full advantage of these interventions.

The study found that after the three-month period was completed, those receiving the additional pain management and physical therapy care through the internet-based programs reported significantly less pain and better function than those receiving only the standard information. And the improvement continued for at least six months after the program ended.

As is true for all studies, this one had limitations. For example, it included patients who self-reported their diagnosis. That means that some of the study participants’ knee pain could have been due to something other than osteoarthritis. And all the patients had access to the internet and the ability to use it; the result might not apply to less educated individuals or those without regular online experience. And it’s possible that the improvement noted by those receiving online pain management teaching and online physical therapy was due to the placebo effect; after all, this group had much more attention and interpersonal interaction than the standard education group. Of course, if an intervention is reliably effective, safe, and inexpensive, it may not matter much if it’s due to the placebo effect.
What’s the big deal?

While none of the interventions in this study was particularly novel, delivering them via the internet is. Increasingly, telehealth — providing medical care from a distance through telecommunications technology — is becoming more common. And in many settings, it’s already routine. A physician can talk to a patient thousands of miles away and examine certain parts of the body (such as the skin) and take good care of a patient who might otherwise be unable to get care at all. The ECG of a patient in an ambulance can be digitally transmitted to a cardiologist well before the patient arrives in the emergency room, allowing treatment advice from a specialist much sooner than in the past. Similarly, an x-ray, CT scan, or MRI can be read by a radiologist far from where the images were obtained.
What’s next?

While this study is encouraging, we still need better treatments for osteoarthritis. After all, online education, pain management modules, and physical therapy may help, but they are unlikely to prevent the need for knee surgery if the arthritis is severe.

But the results suggesting that telehealth may be able to improve the well-being of people with osteoarthritis of the knee is only the latest example of what is likely to be the widespread application of this approach to care. Considering the millions of people worldwide who lack access to basic as well as specialized medical care, the potential for telehealth to bridge this gap is enormous. hoosing the right physician is critically important, but what are reliable markers for what makes a doctor good?
And the award goes to…

Physician recognition awards can be a funny thing. By funny I mean they at times have no real merit. I used to have an office at Somerville Hospital, and I recall receiving a letter in the mail stating, “Congratulations Paul G. Mathew, MD!!! You are one of the top neurologists in Somerville, Massachusetts.” The very official-appearing letter was accompanied by an order form for various certificates, plaques, and even Oscar-like statues that I could have purchased to display for all to see the “amazing distinction” that was bestowed upon me. The punchline here is that there are fewer than 10 practicing neurologists in Somerville, so to be declared “one of the top” is not all that flattering. The issuing company produces these “awards” in order to make a profit.

Despite the lack of meaning behind these awards of recognition, there are some people who do buy these things to decorate their offices, which makes patients feel like they are seeing a great doctor. As a rule, any legitimate award should be issued by a physician group or medical society, rather than a publication company. In addition, the award should be merit-based rather than based on social media voting or some other subjective or random measure (like a doctor with an address in Somerville).

In general, I hate waiting for anything when I have a scheduled appointment time. Whether it is a haircut, an oil change, or my own appointments to see a doctor. For that reason, I hate to keep my patients waiting, and my clinic is usually running on time or even a little early. Some of my patients appreciated this so much that they rated me on I was sent a certificate in recognition of running such an on-time clinic. One of my patients saw this certificate and asked me, “Which Cracker Jack box did you get that thing from?” I found her comment hilarious despite this certificate’s being legitimate, and then realized that we had previously discussed the concept of fake awards. As she laughed at me, and I laughed at the situation, she was happy to give the doctor a taste of his own medicine. Fortunately, it was not a very tough pill to swallow.
A foreword on F words

If you look at the signs outside of a doctor’s office, there is sometimes an entire alphabet of letters after the name of the physician. Of course M.D. stands for Medical Doctor (allopathic medicine) and D.O. stands for Doctor of Osteopathic Medicine, but what do all those other letters stand for?

In addition to degrees, some physicians have fellowship designations after their name. A fellowship designation is when a physician specialty society recognizes one of its members for years of service to the organization, as well as excelling in patient care, research, and teaching. For example, the American Academy of Neurology (AAN) and the American Headache Society (AHS) both recognized me as a Fellow, which is why there is an FAAN and an FAHS listed after my name. If your physician has one of these F words after his or her last name, he or she has hit similar benchmarks in their careers. These F words are very different from some other F words used when, say, we (this includes me, too) receive surprise co-pay bills from insurance companies for services that should be 100% covered. For me, it was when we received a $400 invoice for my wife’s delivery of our daughter at an in-network hospital, which is a discussion for a different article.
More trouble with abbreviations

I recently attended a dental conference with my wife, who is a dentist. Attending these meetings not only gives me insight into my wife’s practice, but I often also learn a lot about how a patient’s dental pain can contribute to his or her headache disorders. My wife and her mostly female dental colleagues were standing behind me, as I was talking with some of the presenters. As the male in the group, it was sad and sexist that presenter after presenter assumed that I was the dentist, and the women accompanying me were my assistants (many dentists bring their staff for career development learning opportunities). My wife and her colleagues stood back as I asked question after question, at times pretending that I was very familiar with the nuances of performing complex dental procedures. During one of these conversations, the presenter looked at my name tag, and read out loud, “Paul G. Mathew, M.D., H.O.D. what does H.O.D. stand for?” I paused and then replied, “Husband of dentist.” As he shook his head in amusement, my wife’s colleagues could not contain their laughter. Fortunately for me, I was not demoted from H.O.D. to Ex-H.O.D. as a result. Gretchen LeFever Watson, then a clinical psychologist at Eastern Virginia Medical School, wanted to understand how many children had been diagnosed with attention deficit hyperactivity disorder (ADHD) at elementary schools in Virginia communities. Her findings among the 30,000 children she studied in the 1990s foreshadowed a national pattern: rates of ADHD varied widely among districts, and the rates in some communities were much higher than predicted. In some school districts, by the fifth grade 28% of boys had been diagnosed with ADHD. In other communities, being young for one’s grade increased the chances of being prescribed stimulants 20-fold. Her findings garnered national attention and additional research funding, including a major grant from the Centers for Disease Control and Prevention.

LeFever Watson’s success, unfortunately, was abruptly cut short after her medical school received an anonymous letter accusing her of academic fraud. She was placed on administrative leave, and her computers were confiscated. After a university investigation found no evidence of fraud, she was vindicated, but the effects were devastating. Dr. Watson describes the impact of the accusation as contributing “to the suppression of a large and unique dataset of risk and protective factors associated with ADHD diagnosis and treatment [and] to the total dismantling of a school health coalition… that showed promise for improving ADHD care.”

The relationship between ADHD, academic experts, and the pharmaceutical companies who promote stimulants for ADHD is at the core of Alan Schwarz’ new book, ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. As a journalist for the New York Times, Schwarz has spent years investigating the link between the pharmaceutical industry and the diagnosis and treatment of ADHD. His articles have vividly described some of the devastating psychological dangers of stimulants. His book summarizes these concerns and puts new focus on the ADHD experts who have shaped the current environment.

Many of the book’s themes will be well known to readers. For one, ADHD is overdiagnosed. Experts estimate that 5% is a realistic upper limit of children with the disorder, but in many areas of the country, as Watson found in Virginia, up to 33% of white boys are diagnosed with ADHD. By 2011 several states reported rates greater than 13% among both boys and girls. Schwarz explores how this came to pass. He investigates pharmaceutical companies’ collaboration with leading academic experts and celebrities (including Adam Levine) combined with aggressive direct-to-consumer advertising campaigns to boost recognition of and pharmacotherapy for the condition. Unlike Watson, many scientists that Schwartz profiles permit their research and expertise to be coopted by companies keen on maximizing profit.

Schwarz acknowledges that many children are appropriately diagnosed with ADHD and that a subset of these children will benefit from stimulants. What he helps us understand is the forces that have led clinicians to misdiagnose millions of children with the disease and, far too often, to prescribe stimulants that expose children to more harm than good.

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