Wednesday, March 2, 2022



Amidst our global pandemic, keeping the doctor away means heeding his or her lifestyle advice on prevention, early detection and taking in their research on what it means to truly stay out of trouble.  Meanwhile, upon review of many Americans' health challenges and concerns, we assembled some of the most pertinent questions and concerns that weigh in on their decision making process.   

Months into a new year awakens great opportunities to invest in HEALTHY CHANGE in your lifestyle.  For the many Americans who live a sedentary lifestyle, most of us use time markers (like a new year) as a sensible time to re-dedicate to new challenges.  Losing weight is the number one goal each year for most people - and the undisputed culprit to a non-active lifestyle drives unhealthy choice-making into a situational life trap.  Meanwhile, other members of the community are situated with the inability to perform physical activities due to chronic pain or a debilitating disease (ie. spinal cord injury, traumatic brain injury or stoke sufferers).  

In an interview with Dr. Jonathan S. Kirschner, physiatrist at HSS (Hospital for Special Surgery),  we found his expertise, his thought process and his insight on certain health solutions to deliver remarkable value to us all- especially those affected in some way by the debilitating effects of the pandemic lifestyle.  

Adapted from an interview with Dr. Jonathan Kirschner

During the COVID pandemic, I see two types of people; people who move less and those who move more.  Some people with more free time typically don't have to spend extra hours to commute.  Now, they've got that time for themselves (instead of commuting) working from their home office.  So that frees up more time for physical activity.  Upon revaluing life and lifestyle in general, some people have the time to commit to things like learning about the importance of health and actually take actionable steps.  Where people did not used to have time to join an exercise program, we now have the option (because of Covid) to watch exercise classes through Zoom and things like that.  

There's enough data pointing the sedentary lifestyle as the main culprit to a wide array of medical issues- not only musculoskeletal issues like back pain, herniated discs, neck pain, neck strain with everyone at the computer because of covid, but also the metabolic effects of sitting.  So if we’re not moving, we're at a high risk for gaining weight, developing diabetes and high blood pressure.  Those are some of the consequences of our modern lifestyle with all this technology and computers, whereas in the old days we had to forage for food.  We had to farm the food, lift bales of hay, walk to the water well and come back home.  We are not doing those things now.  

The best way to communicate all this is to not throw it out to the patient all at once; sometimes it’s better to make baby steps because it can be daunting.  If the patient has a lot of weight to lose, or for anyone who has not been exercising, you want to start engaging them in an exercise program.

Every little bit that you can do helps and the first part is assessing where the patient is in their readiness to change.  Some people are really just absorbing information, but are not ready to make that step -- others want actionable items or things that they can do.  I can encourage them to get up and take breaks from the computer to slowly increase the amount of physical activity.  A lot of doctors encourage walking- but then again, that's good and bad because patients think that’s all you’re supposed to do.  But to walk for exercise, you have to walk briskly at a certain pace—and you have to walk a lot.  When I tell patients that they need to start exercising more, there are really four pillars; One is AEROBIC EXERCISE.  One is STRENGTH TRAINING.  One is working on FLEXIBILITY and then the other is BALANCE.  This is especially important in our older population because that can help prevent falls.  But even in the younger population, the high level athletes, they have good balance, they have good muscle control of their flexibility and strength.  Walking (in and of itself) doesn't really make you stronger or more flexible.  So they have to do a little bit of all four. 

There's no one-size-fits-all solution and a lot of what we're trying to do is individualize our treatments to the patient.  One of the most important things I try to assess when I'm meeting a patient is to ask “what are your goals? What are your expectations? How can we meet those?” A lot of it is education to let them know what's realistic and what's not.  A lot of my treatment strategies involve therapeutic exercise, engaging in physical therapy and there are different modalities even within that.  There's manual therapy, there are different electrical therapies, there are ultrasound therapies to name a few.  Other tools include complementary and alternative medicine and mind-body treatment which I'm a big proponent of because when you have physical issues, they can exacerbate the psychological side and vice-versa.  Tools like acupuncture can be helpful for some people, but again, there isn't as I one-size-fits-all.  We try to follow evidence based medicine protocols and an integrative approach.

We want to provide the right treatment for the right patient at the right time and the number one rule of medicine is "do no harm".   Typically minimally or less invasive treatments potentially do less harm.  Some people would argue that maybe there's less benefit to those- and I tend to disagree.  Anything that can help the patient in the simplest, the healthiest and most natural form I think is best.  And that's why a lot of what we start with is really just education, looking at the quality of movement, doing physical therapy, strengthening and then when that doesn't help, that's when we think about more involved treatments, but overall I think the less invasive the better.

More than just treating symptoms new approaches in medicine are geared towards promoting healing and “regenerating” damaged or worn tissue including cartilage, tendons and ligaments.  This field is known as “regenerative medicine” and can involve oral medications, intravenous solutions or injections.  Regenerative substances can be derived from stem cells harvested from bone or fatty tissue, or from the blood itself.  Even though stem cells were discovered in human cord blood in 1978, research in this field is still considered to be in its infancy.  One of the more popular and well studied types of regenerative medicine involves Platelet Rich plasma or PRP.  Other modalities may have benefits, but for the purposes of this review, we are focusing on PRP. 

Platelet Rich Plasma involves taking a sample of a patient's blood, spinning it in a centrifuge, separating out the different components, and basically extracting/concentrating growth factors,  then injecting it back into the patient.  So, you're using your own body and your own blood to treat things.  The idea is that we're taking a chronic injury and making it more acute.  The body doesn't do as good of a job at handling chronic issues. But when you trick the body into thinking it's more of an acute problem then the body can heal that better.

There are certain cellular growth factors within the PRP, but you are also stimulating some of the local tissue responses as well.  PRP is used for treatment of tendon tears or tendinosis which is chronic tendonitis- a degenerative condition within the tendon.  It is used for osteoarthritis, it's used for cartilage and other soft tissue injuries like meniscal tears.  The research shows that PRP probably is most effective for tendinopathy and specifically lateral epicondylitis- which is tennis elbow.  I've done research on tendinopathy and PRP and also shoulder arthritis.  Part of the issue with PRP is there's a lot of variability in how it's made, who manufactures it, how it's being used clinically and the proportion of the different cells and growth factors within it.  There's Leukocyte rich PRP that has a lot of white blood cells in it.  Leukocyte poor PRP has white blood cells taken out.  By taking out the white blood cells, you are reducing the inflammation that's caused by the PRP so it's less painful.  Some people think that might be better for osteoarthritis because you don’t want to create more inflammation- versus the Leukocyte rich PRP which is better for treating tendon issues because you want some of that inflammation to help remodel and heal the area. 

We're sort of a victim of our own success.  Take cancer as an example, it's great that we can treat cancer better now- and so patients are living either with cancer or after cancer.  Whereas in the past, they would have succumbed to it.  That's a good problem to have, but unfortunately, patients are suffering with the consequences of either the disease or the treatment.  I treat cancer patients like my other patients, we're trying to improve their quality of life, their function, their mobility, but cancer patients, particularly tend to have things like neuropathy related to chemotherapy.  They may have issues with swelling or lymphedema due to surgery.  A lot of the cancer drugs, unfortunately cause wide spread musculoskeletal pain, a lot of breast cancer patients unfortunately take medicines that block different hormones that can cause pain.  Similarly, men with prostate cancer, the testosterone suppression can affect bones and joints.  So it's a good problem that people are living longer with and after cancer, unfortunately they can suffer with pain that impairs mobility, function and quality of life.

Another downfall to certain medications is the addiction that they can cause.  In the case of pain meds, we certainly want to help our patients with their pain and suffering and medication is one way to do that.  But if we can do this in a way that doesn't involve medication or especially dangerous potentially addictive medications like opiates- the better.  Instead, there are modalities like heat or ice and massage, meditating, breathing exercises,  non-opiate medication or injections.  We still need to learn more about the mechanisms of pain and the different chemicals involved - and not treating everybody with pain the same way.  We shouldn’t just automatically give them a pill to reduce their pain.  It’s important to do a deeper dive into the risk factors, what promotes the patient’s pain, find ways to adjust their lifestyle-- and then explore non medication options. 

Dr. Jonathan Kirschner is a physiatrist at HSS in New York, NY.  He helps patients to recuperate from injury or disease to enjoy a higher quality of life.  He is a board certified specialist in Physical Medicine and Rehabilitation (PMR), Sports Medicine and Electrodiagnostic Medicine.  He is also a registered musculoskeletal sonographer and uses ultrasound to both diagnose and treat neuromusculoskeletal conditions.  He completed a subspecialty fellowship training in Sports Medicine and Interventional Pain Management and received the Earl C. Elkins award for achieving the highest score in the nation on the PMR board examination.  Dr. Kirschner’s goal is to restore function, reduce pain, and promote an active, healthy lifestyle using conservative measures whenever possible.  He has won awards for his teaching skills while as a resident and attending physician.  He lectures extensively locally and nationally, has edited the Atlas of Ultrasound Guided Musculoskeletal Injections and has written numerous peer reviewed journal articles and textbook chapters on the non-operative treatment of musculoskeletal disease. 

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The tricky thing with myocarditis being virally mediated is that my child could have had a heart scan a week before she died (the day before she contracted the virus that wrecked her heart), and it would have been normal.  I am hesitant to insinuate that imaging could "clear" a patient and provide a clean bill of health without noting that this can and does occur spontaneously after viral infections, and so testing while ill or post-virally is actually the key message and window of opportunity for myocarditis detection.  (see full article)

Many of the biochemical reactions in our bodies produce toxic versions of oxygen, hydrogen and nitrogen, including how we make ATP.  These toxic molecules, which we call free radicals, have to be neutralized so they don’t damage the mitochondria.  Our bodies have powerful antioxidant defenses to keep these in check.  But when these protective systems become overwhelmed by too many free radicals, oxidative stress results and mitochondria are damaged.  (see full article)

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