Most people know what orthopedic surgeons and physical therapists are, but few of us have ever heard of or are familiar with physiatrists.  This highly underutilized medical specialty focuses on muscles, nerves and joints but in a more non-surgical approach that sees problems as being part of a larger process.  Physiatrists are called by many different names:  physical medicine and rehabilitation specialists, PM&R, sports medicine, and physiatry,

Physiatrists often work in close coordination with physical therapists, orthopedic surgeons, pain management specialists, neurologists and primary care physicians.  All physiatrists have a MD or DO designation which means they are able to prescribe medications and can do procedures such as injection of joints, EMG (electromyography), trigger point injections for muscle pain, or removal of excess fluid.  What makes them different from orthopedic surgeons is that their approach is mainly non-surgical and try to prevent the problem from progressing to the point of needing surgery.

For most minor musculoskeletal issues, a 2 week trial of anti-inflammatory medications, rest, and stretching should improve symptoms.  However, if there is no improvement an evaluation with your primary care physician can determine whether you need physical therapy, orthopedics, or a physiatrist.

For more information about physiatry, please visit the American Academy of Physical Medicine and Rehabilitation website.

Recently, I’ve been on a quest for a high-protein snack for the afternoons that can stave off hunger until dinner time.  Ideally, it shouldn’t require refrigeration, should be easy to eat, and something that I can keep in my desk drawer.  I think I’ve found the perfect snack and much more in canned sardines!

Why am I so excited?  Sardines are a powerhouse when it comes to nutrition.  They are packed with Vitamin D, calcium (you eat the soft bones within the small fishes), and omega 3 fatty acids which can raise your HDL (“good”) cholesterol.  In addition, there are some canned varieties that use olive oil, which is chock full of good fats and will also increase your absorption of Vitamin D, since this is a fat soluble vitamin and must be taken with oil to be absorbed from your intestines.  Sardines can definitely fit in with the Mediterranean Diet as one of your 3 servings of fish per week.

Unlike many other fish, sardines are also very low in mercury.  They are not predatory fish and don’t live for a long time unlike high mercury containing fish such as tuna.  Yes, even canned tuna contains a significant amount of mercury.

How can you incorporate sardines in your diet?  First, I recommend finding a good quality brand.  Try multiple types, ideally packed in olive oil.  Some are less “fishy” than others.  Keep a supply of forks as you will need them to eat out of the can.  What’s great about most sardine cans is that you just pull the lid off and don’t need a can opener.  Lastly, most canned sardines are very inexpensive and easy to carry.  The most perfect snack, try them today!

In recent years, there have been a multitude of urgent care centers and “minute” clinics often found in areas with retail shopping or attached to pharmacies.  These healthcare offices are usually open much later than most medical offices with some open 24/7 and usually offer both adult and pediatric care.  They provide convenient access to medical providers especially for minor injuries and medical issues occurring after normal business hours when most primary care offices are closed.  A trip to an urgent care center generally costs less than the emergency room, and the time saved not having to wait in a hospital ER can be even more valuable.  However, a New York Times article titled “The Hidden Cost of Retail Health Clinics” says these retail medical practices can actually increase the cost of care.  A main factor is that when accessing healthcare becomes “too easy”, people have a tendency to seek help for issues that would have gotten better on their own or with simple over the counter treatment.  The common cold is a good example.  Colds account for the top diagnosis in most healthcare office/primary care settings.  However, almost all of those are caused by viruses for which we do not have a cure or treatment.  Does seeing a healthcare provider for a common cold lasting 3-4 days improve the symptoms?  Generally, no but if given the choice people may not want to wait the few days to see their primary care provider and instead opt for going to see the urgent care down the street.

How can we change these habits?  I think there needs to be more education provided to people on when to use urgent care properly and when it is safe to wait to see a medical provider.  I have noticed a trend that people go straight to the doctor’s office (often demanding an antibiotic) when they don’t feel well with a cold, rather than giving simple remedies available from their drugstore and allowing time and rest to feel better.  Something I’ve always told colleagues is that I wish more emphasis was placed on health education in school.  Isn’t knowing how to deal with a cold just as important (or more important) as learning about the order of American Presidents?  The typical American gets 2-3 colds each year, when was the last time you needed to know that Grover Cleveland was the 22nd and 24th President of the United States (unless you were on Jeopardy recently)?  I also think primary care providers have the responsibility to teach their patients about steps they can take to improve their own health and “red flag symptoms” that should prompt them to seek medical care.

I hear excuses all the time in my office.  “I’m too busy to exercise.  I don’t have a gym near me.”  Last week, I was having a particularly busy day and realized that we all have a tendency to not exercise.  Believe it or not, I was tempted to forgo my usual 30 minutes of running even though I have been consistently running almost every day for years.  It felt like I had a devil sitting on one shoulder and angel on the other like what you see in cartoons when the main character doesn’t know what to do.  On the shoulder with the “Devil”, I was hearing “You don’t have a full 30 minutes, but only a measly 20 minutes, how much of a workout would that be?  It won’t be worth it to get changed into workout clothes and shower.”  The “Angel” said, “Any amount of exercise is better than nothing.  Even if you burn just 100 calories, that’s better in the long run than no extra calories burned today.”  Suffice it to say, the Angel won out.  I ran just 20 minutes on the treadmill, which actually seemed a lot longer than I remembered 20 minutes to be!  I felt great afterwards and didn’t even need a coffee in the afternoon.  I also slept very well that night and that led to an even better day.

On a related tangent, I believe there are two vicious cycles that we fall in and out of throughout our lives.  One is a vicious cycle of unhealthy habits.  What do I mean by this?  Let’s say someone is eating something unhealthy, usually something high in fat and sugar.  Afterwards, the person will experience a rush in blood sugar followed by a rapid decline which leads to feeling tired.  The person will want to rest by sitting on a couch or lying down.  Exercise is the last thing on their mind.  That night, the person may not sleep so well and the following day he/she may feel more tired.  As a quick fix, they may grab something high in sugar to “wake up” with a sugar high and this starts the cycle all over again.  Eating unhealthy foods leads to lack of motivation to exercise and poor sleep.  Weight gain exacerbates the cycle, by causing more fatigue or even lead to a condition called sleep apnea that severely interrupts sleep leading to daytime sleepiness. Believe it or not, there have been many studies regarding sleep deprivation and insulin resistance leading to higher sugar levels in the blood and possibly leading to early diabetes.  Some nutritionists believe concentrated sugars can even be addicting.  Just as drug addicts experience withdrawal symptoms when they stop using their drugs, people who consume large amounts of sugar can feel ill if they don’t get their usual “fix” of soda or sweets, leading them to consume even more.

The other vicious cycle is one of healthy habits.  Each morning after my run, I eat lunch.  I don’t want to put anything bad into my body. I know I just wouldn’t feel right if I ate greasy food.  A healthy salad would replenish the potassium, water, and vitamins that would refuel my muscles that I just worked out.  I feel more energetic throughout the day and have little desire to reach for unhealthy snacks that could be loaded with sugars and fats.  At night, I’ll certainly be able to sleep better and go to bed allowing my body to have enough time to repair.  The next morning, I feel refreshed and that allows me to be motivated to exercise, starting the cycle once more.

Sometimes it takes just a little extra push to get healthy.  We all need to come to terms with our bodies and have this realization at some point in our lives.  Nothing comes easy, but you can encourage that “wellness angel” side and conquer the “unhealthy devil” side.  Put reminders of your wellness goals on post-its and scatter them around your home or office.  How about putting a post-it with “Workout, Feel Better!” on your door so that when you leave the house you will think about going to the gym later that day.  Maybe you want to lose weight so that you can improve your health to be a role model of your kids.  How about putting a picture of your kids doing exercise as your lock screen on your smartphone or tablet?  Maybe enlist a friend or spouse so that you can motivate each other.  There is a law of physics that says, “A body in motion tends to stay in motion, a body at rest tends to stay at rest.”  My prescription for good health, keep moving!

This week, the CDC issued a guideline urging medical providers to use extreme caution when prescribing narcotics for pain.  Many people think that just because a medication can prescribed legally that it is different from “street” drugs such as cocaine and crystal methamphetamine (“crystal meth”).  This couldn’t be further from the truth.  Prescribed narcotics can cause overdose-related deaths and be just as addictive as their illegal counterparts.  The CDC statistics show that from 1999 to 2014, over 165,000 deaths can directly be attributed to prescription medications!

Don’t get me wrong, in the right context pain medications can be helpful but everyone should always try medications such as NSAID’s (non steroidal anti-inflammatory medications), which can actually be more helpful when inflammation is involved, or acetaminophen (Tylenol).  NSAID’s should not be used in certain groups including people with kidney disease or history of stomach ulcers, and if you think you may need doses higher than what is recommended on the packaging, you should consult your healthcare provider.  A misconception I see often in my practice is that people assume that just because they hit the maximum dose on their bottle of Advil (ibuprofen) or Aleve (naprosyn) that the medications aren’t effective.  What they don’t understand is that the over the counter label instructions have lower maximum dosages with the assumption that it is not directed by a healthcare provider.  In fact, there are much higher dosages and more potent forms of NSAIDs available by prescription only which are very effective at treating pain.

Acetaminophen should be taken at doses lower than 4000 mg in 24 hours, or 2000 mg in 24 hours for people with liver disease.  I also find that topical medications such as capsaicin cream and Biofreeze gel are greatly underutilized for minor musculoskeletal injuries.  If you are seeing your healthcare provider for pain and they want to prescribe you a narcotic pain medication, ask them if there are any alternatives or if you can take a stepwise approach to pain relief.  Maybe for the first day you could try NSAIDs and tylenol and see if that suffices.  If the pain persists, you can follow up with your provider to reassess and see if a low dose narcotic may be right for you in conjunction with continuation of NSAIDs/tylenol.

We often don’t hear about the severe side effects of narcotics.  They can cause everything from hallucinations, impaired driving leading to accidents, non-stop vomiting, falls, and even severe constipation requiring a trip to the ER.  Many times, the risks of these and overdose far outweigh the benefits.

Narcotic medications also have another negative side effect.  Take a look in your medicine cabinet right now.  Almost all of us have at least one orange bottle of pills with a white safety cap prescribed for a medical illness.  Maybe it is something you are currently taking on a daily basis, but more likely than not it is for some issue in the past.  You just didn’t get around to throwing it out or figured you may need in the future.  Now imagine if your teenage child got a hold of it.  He/she could abuse it.  Think that won’t happen to your child?  Think again, this is becoming more commonplace.  In fact, many studies have shown that a significant proportion of current illegal drug users started off by stealing old prescribed medications from others.  I recommend that if you have any unused medications, particularly narcotics, you should bring them to your local pharmacy for safe disposal.  Do NOT throw them down the toilet or in the garbage as they can enter the drinking water supply.  Don’t save up prescription medications thinking you will use them later, the risk of your child becoming addicted/poisoned is not worth it!