Sunday, December 6, 2015

The Negative Placebo - Why Fitness Buffs Avoid Doctors

My personal trainer never visits a doctor. Neither do many of the weightlifters at the gym where I go. Part of it probably has to do with unease about appearing naked in front of a near-stranger, as well as a dislike of needles and other painful features of medical treatment. But fitness buffs have more fundamental reasons for their negative view of doctors.

     1.  They anticipate that the doctor won’t respect their values.

Fitness buffs are people who have spent years of their lives studying and fine-tuning their bodies. They have learned exactly how far this muscle will stretch and how much weight that one will lift. They know what foods and supplements work best with their particular body type. One of the rewards for this hard work is a precise sense of what and how the body is doing (proprioception). If something starts to go wrong, they usually sense it. Fitness buffs believe that proper diet and exercise can keep most people healthy most of the time.

Doctors aren’t taught much about diet and exercise in med school and they don’t learn more afterward. Many don’t exercise themselves; some are overweight. Ads for hospitals and medical practices frequently display photographs of these out-of-shape physicians, a good indicator that they haven’t gotten the message about diet and exercise either.

Doctors tend to give more credence to test results than to the patient’s own intuition about how she is doing. Some believe that patients are actually better off taking an FDA-approved medication or than trying to exercise. “People who can take statins are the lucky ones,” an MD told me once.   
2.  They don't want to be exposed to a doctor's negative attitudes.

The pursuit of fitness is based on hope and aspiration. The workouts I do each year are harder than the ones from the year before. The increased strength, flexibility, and versatility have enhanced my confidence and sense of well-being. In spite of scores of studies to the contrary, many doctors believe that exercise doesn’t work. I smiled when I read a post on Kevin MD by an orthopedic surgeon expressing appreciation for personal trainers and surprise that they could make a significant difference. 

Some doctors worry about injury; they recommend moderate exercise and advise people to “know their limits.” Fitness buffs believe that gently but persistently pushing against your limits is the path to better health. Each person needs to discover what amount and intensity of exercise works for him or her.

Doctors also believe that patients won’t follow a serious and consistent exercise program so they don’t even suggest it.

          3.  Doctors do crisis intervention, not health maintenance.

Although orthotics for problem feet can prevent devastating knee, hip, and lower back injuries in later life, this painless and inexpensive treatment is seldom recommended. Protein supplements and proteolytic enzymes can help older patients retain muscle but they are usually dismissed, along with supplements in general. If there were personal trainers in doctors’ offices, they might be able to implement some of these useful therapies and broaden a few minds in the process.
          4.    Doctors are relentless in their search for disease, sometimes finding it where it     doesn’t exist.

Fitness buffs like to think of themselves as healthy people. Doctors are trained to discover illness and to empathize with those who are suffering. Many fitness buffs don’t have annual physical exams because they fear that a misapplied test or misinterpreted test result will redefine them as sick, setting off a cascade of unnecessary interventions. I don’t have the option of staying away because I need renewals of the two or three medications I take and occasional blood tests to monitor my thyroid. Every year my doctor suspects me of harboring a different illness; every year I have to prove that I am healthy.

Heart disease and stroke are the major killers of people in the US. Stress can be a significant contributor to these illnesses. A recent study showed that women who had false positive mammograms had a greater risk of developing invasive breast cancer in future years. The researchers thought that the radiologist might have detected some subtle feature that anticipated the change. I would like to know whether these false positive women also had a greater risk of heart attack and stroke in future years. Perhaps the anxiety associated with the repeated tests contributed to future illness of several kinds. For fitness buffs, the stress involved in visiting a doctor may be too high a cost for any possible benefits.

The truth is that both fitness buffs and doctors have important information to contribute. If those insights could be shared in a context of openness and mutual respect, everyone would benefit.

Note: After following @RogueRad on Twitter, I realize that I should have called this The Nocebo - but some of my readers probably haven't taken Latin in school.

Maintaining an Imperfect Body: the Mini-Workout

Every body has them­­ – the trouble-making areas where pain, weakness, or disease tend to crop up. Sometimes they’re hereditary, sometimes the result of the wear and tear of decades of life. One of the perks of getting older is that these areas become familiar companions, not exactly friendly but no longer intimidating.

Over the years I’ve identified six or seven muscle groups or parts of my own body that are likely to cause problems. This year I’ve started doing a mini-workout of seven exercises every morning to monitore, stretch, and strengthen those areas. I also do an eighth move which is an experiment; if it turns out not to work, I’ll quit doing it. The whole series takes about 15 minutes.

Neck. When my father was in his sixties he developed a pinched nerve in the back of his neck that was very painful. Advised by his doctor, he started using a traction device to relieve the pressure on the nerve. To strengthen the muscles in the back of my neck and maintain flexibility I do this:

- Lie down on a flat surface and raise my head 2-3”. Stay in this position and count. Over several months I’ve worked up to 100. I take a break by bending forward toward my feet. I grab my heels (but that’s not essential for a good stretch).
- I return to the first position but this time I turn my head to the right and to the left as far as I can, like shaking my head “no” slowly and deliberately. I go up to 30 reps on this one.
- When I was a child I used to sleep on my stomach all the time, which meant that my face was turned to one side. As an older adult, I started to lose flexibility in the ligaments at the base of my skull so I work on them. I lie on my stomach, turn my face to one side and count. With all neck exercises it’s important to do them gently and work up gradually.

Calf and Hamstring Muscles, especially on the right side. My legs have pretty good strength and flexibility but my range of motion is limited in some exercises. This is not because of arthritis – I don’t have much of that – but because I have tight, bulky calf muscles, especially on the right side and little sore spots in the calf and hamstring. A massage therapist told me I have scar tissue in those areas.

- The sore spots are in different places each day so I start by doing sleeping child pose to see where they are. (Sleeping child is the yoga pose where you kneel with your forehead on the floor and sit back on your heels.) When I find a spot, I rub and push into it with a circular motion to loosen the area. Usually there are three or four spots.
- I check my work by standing up, then sitting down into a squat and counting. Then I stand up without using my hands. Sometimes I have to stop in the middle and work on more sore spots.

Lower Back. In old age my aunt and uncle on my father’s side both had lower back problems. (My uncle had a disastrous back surgery that crippled him for life.) With that in mind, I do five superman reps. Lying on my stomach with arms stretched out in front of me I lift my upper body for a count of 25. For this one, it’s important not to tilt the head up but to look down at the floor.

Upper Back. As a young adult, my upper back muscles were so weak I couldn’t do a single push-up. P90X changed that. I do 50 of these, though I don’t go very deep on the last 10.
Sit-ups. Rounding out the core group, I do 50 sit-ups.

Balance. My right leg is a bit shorter than the left so my balance is not great. I stand in a doorway on one leg and count to 10. Then I close my eyes and count to 30. If I get shaky, I grab the door frame. Same on the other side.

Back Strength and Flexibility. Using a pull-up bar, I lift myself as high as I can. I can’t do a full pull-up yet but I’m making progress.  Holding onto the bar but with my feet on the floor, I stretch through the whole length of my back and count to 75. If I’m in a hotel room I skip the pull-up and use the top of a piece of furniture for the stretch.

Jumping. My last bone density test showed that I was losing bone mineral density faster than I would like. I read about a study that showed that a 10 or 20 jumps with 30 second breaks in between significantly improved BMD in the jumpers as compared with the non-jumping control group.

We’ll see if this routine works for me. As for the cause of the lower BMD, I’m guessing that the dosage of thyroid hormone I take for hypothyroidism has been too high for too long. My doctor has lowered the dosage. I had also cut back on my intake of calcium supplement after reading scary stories in the media. That was probably a mistake and I’ve gone back to what I was taking before. 

Update 12/31/2015:

An article in the Wall Street Journal a  couple of weeks ago persuaded me that I shouldn't be doing situps anymore. I now do variations on plank for one minute, followed by 25 rollouts using an ab wheel. 

My personal trainer explained to me that the central ab muscle, the rectus abdominis, is designed to be a stabilizer and is meant to be stretched out flat, not curled up. Doing appropriate exercises will improve its appearance as well as being safer.