link.medium.com/DOMS9fi9NsbWhat is the best exercise to keep bones strong?
One night, during my orthopedic surgery residency training, I was called to the ER to admit an elderly patient. The woman had fallen at home while getting up in the middle of the night to go to the bathroom. I looked at her x-rays which clearly showed an intertrochanteric fracture of her femur—a common type of hip fracture for the elderly. The x-rays also showed the telltale signs of osteoporosis—we called it “a sparse trabecular pattern” or very washed-out looking bone—the disease of weakening and fragile bone that is all too common amongst the elderly. Her bed was surrounded by several concerned relatives. I spoke with the patient and her loved ones about the diagnosis, the need for admission and subsequent surgery. Her return to an independent living status in her own home was threatened. It was already the fourth patient who had to be admitted for this very same diagnosis during my 24 hours on-call. This pattern was not entirely uncommon on many other nights of call ahead for me.
A global epidemic
Osteoporosis has become a near epidemic for our ever aging population. The estimates are somewhere in the hundreds of millions affected worldwide. Prevention has become an important component for patients including early identification of the problem through the use of bone scans and treatment with subsequent dietary, supplement, and drug interventions. We spend a lot of time discussing fall prevention and accident reduction amongst the elderly. Unfortunately, the drug interventions may not work and can have serious side affects. We have a reasonable understanding that diet does influence bone health. Is there some other modifiable component in our behavior that may benefit bone health? What if we could do something prior to receiving the diagnosis of osteoporosis, before we are already behind in the game? Is there something with proven results to reduce bone loss as we get older?
It turns out that exercise can be beneficial and can reduce bone loss. The National Osteoporosis Foundation endorses exercise as a useful preventative intervention. What kind of exercise is best? If you had to answer that question in a general fashion, the best exercise is any exercise that you will engage in consistently week in and week out for a long time. This is true as motivation is critical to participation. Even the scare of a health risk does not always change the behavior so the exercise needs to be appealing. What is appealing is in the mind of the beholder so your mileage will vary when it comes to motivation. However, to be bone-building (osteogenic) another element is needed besides participation. So what if you were truly motivated by the question of what exercise helps with bone health maintenance? Is there a “best” exercise?” By phrasing it that way, you are trying to apply a type of business analytic to the question. Which single exercise provides the greatest benefit and is the most time efficient? There will also be the components of cost and likelihood of maintaining the exercise over a long period of time since osteogenic potential is cumulative.
To get at the answer, it is helpful to know how exercise affects bone strength. Bone is a wonderful natural material with amazing strength for its weight and dimensions. It is an organ filled with cells, blood vessels, and nerves all within the dimensions of a beautifully orchestrated matrix of collagen and calcium crystals arranged in a mixture called hydroxyapatite. This lattice work of crystals provides bone with an interesting property. When bone has stress applied to it, a deflection or vibration of the bone occurs causing subtle electrical current shifts and a mechanical code to cells within the bone. These shifts cause a cascade of signaling called mechanotransduction which drives living cells within the bone to respond to the stress by building more bone strength. Not every activity can cause the signaling process and researchers have uncovered that the activity has to reach a a certain threshold to produce the affect. So essentially, the activities that create the greatest amounts of mechanotransduction signals will be the most beneficial to thwart osteoporosis. The signal has to be sufficiently strong and repeated frequently enough in order for a bone building effect to occur. If the signal is weak or absent, bone resorption and weakening occur as seen with osteoporosis. Without the signal, even if all other health parameters are optimized such as diet and supplements, bone weakening will still occur. We can see this with osteoporosis developing in astronauts due to the absence of gravity because very little bone stress is occurring. This is despite the fact that astronauts are by the requirement of their profession, healthy! To no surprise then, the most mechanotransduction occurs with weight bearing exercise. In other words subjecting the bones to sudden levels of stress. Sorry swimmers and bikers! While swimming and biking are good exercise for many other reasons, bone health is not one of them. They are not a weight bearing exercise and actually allow bone resorption to continue unabated.
There also appears to be a second important factor related to bone health besides mechanotransduction. It appears that bone health can be related to DNA markers of aging. One marker of DNA age is called a telomere. Telomeres act like protective caps at the ends of our DNA strands. The shorter your telomeres, the more age related change is noted of our DNA and subsequently the cells that make up our bodies. While some studies have been contradictory, shorter telomeres seem to correspond with worse bone strength and density compared to longer telomeres. The contradictions likely have occurred due to the fact that telomere length is only one marker of age and other factors such as inflammatory disease and hormonal differences are also significant when considering bone health. Fortunately, we have the ability to slow down the age-related shortening of our telomeres. Slowing down the shortening of our telomeres and possible lengthening them can occur with exercise even when we are older. Endurance (aerobic) exercise seems to yield the greatest benefits. As osteoporosis is an age-related disease, it seems that interventions that create longer telomeres are worthwhile. There are multiple hypotheses in how exercise accomplishes this whether due to reductions in oxidative stress, inflammation, or emotional stress.
So essentially we are looking for an exercise that has abundant mechanotransduction signals and an exercise that keeps our telomeres longer. Exercise activities are classified as static weight-bearing exercises (e.g., single-leg standing), high-impact weight-bearing exercises (e.g., jogging, running, dancing, jumping, and vibration platform), low-impact weight-bearing exercises (e.g., walking and Tai Chi), high-impact non-weight-bearing exercises (e.g., progressive resistance exercise), and low-impact non-weight-bearing exercises (e.g., swimming). Researchers have looked at weight bearing exercises to determine which signals the most to bone. Walking creates a force equivalent to your body weight due to gravity and is equal to 1g. Running produces forces of 3-4g, or 3 to 4 times body weight on impact. A gymnast dismounting from the parallel bars may generate up to 11g! As they have discovered, the biggest bang for the buck for bone building occurs with high impact exercise. This is because the load rate is important. If a load is applied gradual, it appears to be less beneficial than a high rate of load where bone is concerned. If looking at the act of running, the 3g to 4g force is applied to the runner’s leg and to a lesser extent, the spine, occurs in the fraction of second. Bone likes that high rate of loading. When looking at walking as an intervention, it does not seem to show much osteogenic benefit because of the amount of force and rate of force application is low although some minor mechanotransduction still occurs. The 3g to 4g level is sufficient as it can produce osteogenic changes and can be applied repetitively as demonstrated by the mileage of runners. Bone growth is stimulated by repeating the stress over and over.
What about resistance training that can produce high loads on the skeleton? There has been some disagreement in the scientific literature of whether resistance training or running is more effective. It turns out, that if you control for the affect of lean body mass, running becomes more effective then resistance training for bone mass protection. Even as little as running one minute a day had an impact. Some studies have favored resistance training but others have found running superior for increasing bone density in the spine and femur. The studies that have favored strength training noted that it required fairly heavy weights and intensity. Again, this may be difficult to sustain for many due to motivation and the fact that equipment costs or a gym membership can create a barrier for some.
Running, by definition, is considered high intensity/stress and is known to build bone mass. This effect can be increased in several ways. The use of a water bottle in the hand or a backpack adds additional beneficial stress to the spine and upper extremity bones. There is even another way to add more stress. Running hills does just that. Downhill running is considered beneficial for bone due to the increase in ground impact forces and eccentric muscle contractions. This can make trail running a big winner. Trail running often incorporates steep hills and downhill running will increase the mechanotransduction effect because of the higher impact and energy absorption of up to 5g with downhill running! Trail running has yet another benefit. Trails are not uniform. They require hopping off of rocks, jumping tree roots and streams, twisting around tight turns, and significant activation of muscle stabilizers due to uneven foot landings. It turns out that if the forces on our bones can be multidirectional, the signaling process will apply to more area of more bones. Trail running forces these postural control muscles to be activated over and over to a greater extent over road running.
How about the other analytics of cost and motivation? Cost can be a barrier to participation. It is clear that walking and running are the most cost efficient because they can be done cheaply. Many communities have trails and paths that can be used without the purchase of a membership. Very little in terms of equipment is required and when considering that the activities can be performed outdoors for free, there are no facility costs. Tennis and other paddle sports would seem to have similar mechanotransduction characteristics to running and are excellent impact sports but the additional barrier of having a willing partner(s) and an available facility can be challenging. Trying to line up multiple schedules and skill levels adds an additional level of logistical effort for paddle sports while running can be enjoyed solo. This reduces yet another “cost” barrier.
How about motivation and likelihood of long-term participation/adherence? Looking at the high impact exercises that have been researched for bone health, hopping or jumping has a very strong affect. But if we are to be realistic, the chances that someone would be willing to perform this type of of exercise over years is doubtful. Long exercise adherence relates to motivation and hopping and jumping do not capture the imagination of many adults to be sure. If one just looks at the top 5 sport participation rates in the U.S., walking was most popular, followed by weight lifting, using cardiovascular equipment, followed by running, and then water sports. If one considers participation as a proxy for motivation, walking and running would have the least barriers to access of those top five sports activities with some of the highest participation rates.
Developing improved balance will result in fewer falls and so interventions designed to promote balance are helpful in reducing fracture rates. Running in particular strengthens the gluteal muscle region more than walking which makes running highly beneficial for balance. Trail running exercises our postural control mechanisms creating necessary increased balance needs that we desire to prevent falls as well as providing that multi-directional stimulus to our bones that I mentioned earlier.
By the time I met the elderly patient in the ER with an osteoporosis related hip fracture, significant damage has already occurred to bone strength. Therefore, exercise as a preventative intervention needs to start early. Studies have shown that the most bone mass and strength gains occur before we are twenty. At the age that bone starts showing fragility though, we are long past that age. For women, bone mass starts to decrease in their 30’s and men by their 40’s. Women may have an additional risk if they reach menopause earlier. In fact, women who train so hard that they lose their periods due to this level of intensity have a higher risk of stress fractures. It seems that we cannot entirely halt the bone loss with exercise after a certain age. But we could at least slow the deterioration of our skeletons after that age. It’s also clear that building bone mass when we are young with impact type activities puts us ahead in the game for when the inevitable decline occurs.
So what is best? Obviously, a frail elderly individual with no previous exposure to trail running would be at a high risk for injury should they suddenly decide to take up this activity. So, ultimately customized recommendations should be made. For example, the activity of hiking may confer some benefits over just walking as it would combine elements of hills and increased postural control requirements and still be accessible to an older individual who cannot run. On the other hand, individuals who are not yet considered frail and have no other medical contraindications, may want to consider taking up a trail running as a sustainable exercise that can maintain their bone health and have the effects of telomere protection and improved balance. Even some modest exercise interventions have proven to be helpful because of the benefits of reduced balanced problems and improvement in other health issues that, if not mitigated, can spill over into causing reduced activity levels starting the downhill slide into osteoporosis. I believe that trail running provides the benefits of mechanotransduction, telomere lengthening, postural control, and of an economically and psychologically sustainable exercise.
My conclusion shows my own personal bias. After all, I am a trail runner. An absolute scientist will find methodological flaws in many of the studies in this area but the patterns are still compelling. While I found articles to back my conclusion, it should be made clear that there is abundant noise in the data. Some studies suggested that resistance exercise is key. Perhaps the best advice still remains that any exercise is better than none and if you will adhere to it, that is the best exercise as long as it is weight bearing. A second piece of advice would be to have at least two different activities that help hedge your bets in case the science goes the other way. So an avid runner might benefit in many ways by adding a couple of sessions of strength training per week.
Practical advice may not be absolute advice. While trail running seems to fit the criteria, in my opinion of the business analytics that I outlined earlier, it does no good if a person cannot run due to a physical condition or insurmountable socioeconomic barrier. Ultimately if your activity includes weight bearing, some bone stress from impact, and you are motivated to do it consistently, then that’s your gold mine. It just so happens, that for me, trail running fits all the bills. It is efficient, requires minimal cost, has impact and postural control at it’s heart, keeps my telomeres longer, and I am ultimately motivated to be in the natural elements.
Once osteoporosis hits, the uphill battle is harder. The fragility fracture that leads to the emergency room admission begins to become a growing risk. Maybe that can be your motivating thought to get started on prevention now.
Social Media. The Junk Food of the Mind.
The alarming realization of our minds being structurally altered by social media.
On a recent trip to Rome, my girlfriend and I went to visit The Colosseum. One of the most recognizable historical architectural masterpieces, this massive amphitheater was a symbol of the Roman Empire’s greatness but also a reflection of the society that built it. The entertainment within those walls was designed to fill a blood-lust, a grandiose pageant showcasing the extent of the empire, creating self-important images of the empire used to indoctrinate and distract the population. The games were filled with gore and death for the participants, and drunkenness, gambling, and gluttony for the crowds. This distraction diverted the attention, ever briefly, of the Plebians (public) from the reality of entrenched class social structure, poverty, and government corruption. For a largely illiterate population, this was an ideal diversion.
As we approached the main facade of the colosseum, we encountered the expected mass of crowds that visit this site daily. What I was a bit unprepared for (although I should have not been surprised) was the huge number of people taking selfies. The posing of people to get just the right shot was almost more fascinating than the colosseum itself. Many were taking literally dozens of selfies trying to perfect every aspect of the photo. In fact, the selfie activity became a distraction from the site itself. Much of this activity was undoubtedly for social media consumption. With the colosseum in the background, I was struck by the juxtaposition of the symbol of an extinct empire that provided the distraction of the games to our society’s distraction by social media. This modern distraction creates the distortion of our self-image by placing ourselves as the important element in a reality that we wish to craft for others. The Roman emperors created an alternative reality to feed the psyche of a population while selfies create a version of our selves to do the same. These edited selves become part of our online personalities and become a careful image crafted story of our lives. And as we all know, selfies are one of the most ubiquitous features of social media which is now firmly entrenched in our lives.
How did social media become an over-arching consumption of our free-time and a major form of entertainment? How did social media, paired with the forward facing camera feature of a smart phone create this herd mentality of the selfie? Is it some sort of attempt to satisfy a desperate element in our personalities/psyche?
The combination of social media along with the smart phone creates a form of superficial social engagement along with voyeurism. I started to wonder how this significant use of our time was affecting our neurochemistry, brain structure and behavior. As it turns out, the design of all of the platforms-Facebook, Instagram, Twitter, Snapchat, and the dozens of similar apps and sites take advantage of some well engrained neurological physiology and psychological impulses. Essentially, there is an engineered component for neural modification deliberately designed into each of these platforms which draws upon social and behavioral modification tools that are well-understood. A number of studies exist that show that these platforms prey upon our neurochemistry in an opportunistic way. The same evolutionary processes that were beneficial for developing survival awareness and strategies for our ancestors such as hyperawareness, social cohesion, and group behavior are being exploited. Our brain’s fundamental traits of curiosity and need for constant stimulation (distraction) are exactly what social media provides.
It is clear that social medial links into two aspects that are hard wired into our brains: reward processing and social acceptance. Researchers have been able to use imaging tools such as functional MRI studies of teenage brains. What they found was that a photo with more “likes” will excite the brain greater than the identical photo with fewer “likes”. Our brains will pay more attention to something that has been arbitrarily manipulated to be rated with more “likes” regardless of the content. The teens had increased activation in the reward pathways of the brain when their photos were accompanied with more likes. The researchers summarized the reward pathways using the scans and could actually see the difference caused by an image that simply had more “likes” than the same image with fewer: “The experience of providing Likes to others on social media related to activation in brain circuity implicated in reward, including the striatum and ventral tegmental area, regions also implicated in the experience of receiving Likes from others.” 1 The use of social media correlates very much with strengthening the neural pathways in our “reward centers” of the brain. 2 These changes are more demonstrable in the developing brain. 3 If you think that as an adult you are totally immune to this process, think again. Due to the concept of lifelong neuroplasticity, the adult brain undergoes alterations too. 4
It is no wonder, that the understanding of these potential negative brain alterations have the titans of the tech industry voicing the opinions that they do not let their children engage with these technologies or severely restrict them. 5 They recognize the dangers to the developing brain—even though they are getting extremely rich on this danger—all the while being purveyors of the platforms and technology that disseminate it ever wider.
In fact, Facebook designers themselves came out publicly to discuss the dangers of their product: “It was the result of countless Facebook decisions, all made in pursuit of greater profits. In order to maximize its share of human attention, Facebook employed techniques designed to create an addiction to its platform.” 6
Unfortunately, the news gets worse for our brains. The brain alterations created by social media use tend to reinforce certain behaviors such as shortening attention spans, reducing tolerance to boredom, and craving external social validation. The desire to keep strengthening this feedback loop (“likes”->activate reward center->inducement to create posts for more “likes”) leads to more frequent posting but also a behavior that all social media sites encourage: reciprocation. Reciprocation strengthens the feedback loop in a social circle using the concept: “you scratch my back, I’ll scratch yours,” but on a potentially global scale. This reciprocal behavior hack was also deliberately engineered into all social media platforms. 7 After hijacking our brains, our posts will gravitate into significant self-serving aspects.
Tim Urban writes in an article that sums up quite nicely the majority of status posts on Facebook:“… statuses typically reek of one or more of these five motivations:
1) Image Crafting. The author wants to affect the way people think of her.
2) Narcissism. The author’s thoughts, opinions, and life philosophies matter. The author and the author’s life are interesting in and of themselves.
3) Attention Craving. The author wants attention.
4) Jealousy Inducing. The author wants to make people jealous of him or his life.
5) Loneliness. The author is feeling lonely and wants Facebook to make it better. This is the least heinous of the five — but seeing a lonely person acting lonely on Facebook makes me and everyone else sad. So the person is essentially spreading their sadness, and that’s a shitty thing to do, so it’s on the list.
Facebook is infested with these five motivations — other than a few really saintly people, most people I know, myself certainly included, are guilty of at least some of this nonsense here and there. It’s an epidemic.” 8
Urban goes on to describe 7 of the most common posts that have one or more of the five elements of motivation mentioned above. The posts include: The Brag (including the humblebrag-“Apparently they now give PhDs to frauds and drunks. What a time to be alive!“ or “I just learned this yoga pose!”), The Cryptic Cliffhanger (“That’s it. I’m done!”), The Literal Status Update (“I’m going to the gym.”), The Inexplicably Public Private Message (“Dude, we have to hang out next time you’re in town!”), the Out-Of-Nowhere Oscar Acceptance Speech (“I just want to say how thankful I am for all of you who have touched my life.”), The Incredibly Obvious Opinion (“My thoughts and prayers are with the families in Newtown after this unspeakable tragedy.”), and The Step Toward Enlightenment (“‘Peace comes from within. Do not seek it without.’ ~Buddha”). 8 As you review these, you start to realize that an overwhelming number of posts fall into these categories. Sadly, I am guilty of posting all seven types at some point in my social media existence.
To keep the artificial edifice alive that we do not have motivations like those above exists a slew of excuses and rationalizations. I thought of these excuses myself as a way to explain how I was different. For each excuse, it is clear that they were just simple justifications for continuing behavior I was guarding. For each excuse, I could feel a tugging in my mind of why the excuse was lame. I would say to myself: “This post is about my accomplishment so as to provide other people to dream big”—as if people cannot conjure up their own motivations. Or “this post of my kids is for my relatives and close friends”—then why not simply email or group text them? Or “this post is of an important opinion that I have”—exactly illustrating the narcissistic importance of social media posting. Or “I’m just on social media because it’s entertaining. It’s like any other entertainment.” This last excuse is the most stealth because the justification is used in regards to things like television. But social media is different. It invades the small time gaps in our lives constantly. If you want to watch Netflix, you don’t do it 1 or 2 minutes a time. You usually set aside a block of time for it. If you are watching a movie, you don’t typically do it waiting in the grocery line.
In these excuses lies the likely kernel of addictive behavior: a denial system to preserve the behavior. After all, the social media platforms were directly engineered to tweak our reward centers and this is the same component of the brain that’s associated with other addictive behavior. In fact the latest psychiatric diagnostician manual (DSM) recognizes the components of Internet addiction. What is more alarming is the lack of awareness that we have that this is actually addictive and creating negative aspects to our lives. Because the use of social media is pervasive and nearly inescapable, the social cues that we use to help define what would be considered a normal behavior have become distorted and this blunts awareness of the problem. This awareness does not exist like we have for drugs, alcohol, and gambling. I’m not suggesting an equivalency between social media and these other addictive behaviors, but the framework to think about our social media usage directly lies along the lines of these social behaviors.
Not only does this online behavior become self-serving, there are negative aspects that affect our offline behavior too. As mentioned earlier, the creation of shortened attention spans, and with it the loss of deep thinking which is required for serious work and creativity can seriously harm our ability to create quality. The enforcement of groupthink with its monolithic creativity has spread the sameness of the selfie. Entire instagram accounts and Facebook accounts contain tremendous amounts of the monolithic boring selfie. What has happened to the person’s mind that has 500-1000 images of themselves in the same pose? We also see monolithic tourism driven by social media creating degradation of the experience at the very places we visit.
Unfortunately, all this hacking of our brains by social media goes on at a level which even makes it difficult for the brain to discover that this is occurring. In other words, it blunts our metacognition facilities to discover that we are being re-engineered and manipulated.
I started to wonder if my brain was being modified by my social media exposure after conversations with my girlfriend. As a therapist that works with people experiencing psychological issues, she saw in many discussions with her clients that social media was contributing and exacerbating many of their mental and social issues such as bullying, body image disorders, conspiracy mongering, paranoia, social rejection. She also noted the difficulty that these people could not simply turn these sites off. Social media held them captive. Without these conversations with her, I’m not sure I could have developed some awareness of my very own behavior and I would have just kept up with one of several justifications. So I decided to pull myself off of social media in June of 2018 in order to determine what parts of my behavior were being influenced, and what I had lost by the constant distraction of social media. The grand experiment began.
After deleting the apps off my phone, I still found myself compulsively grabbing my phone looking for a social media stream. It took about a week to extinguish this behavior. There was a feeling of being disconnected and perhaps a bit more lonely when not having a 24 hour connection. This feeling took about 6 weeks to fade. Then I noticed the positives. One of my all time favorite hobbies is reading books. Magically, I had more time to engage in this. I felt my social interactions when face-to-face becoming more focused and I could concentrate on being present. Best of all, I felt some of my deep thinking creativity start to return. This was a feeling that had been lost at about the time I started an account on Facebook.
The brain has a tendency to gravitate to certain experiences based on evolutionary design. Social media platforms synergized with smartphone availability have created an “unhealthy platform for a healthy impulse.” 9 “In short, the tech industry used behavioral science to corrupt a technology that can be positive for human beings into something that turns them into “anti-social, self-obsessed zombies.” 10 “Instant text messaging, email, and social media provide a platform for our hungry need to be connected, but also for our need to watch and monitor others, and better still, for our need to be seen, heard from, thought about, monitored, judged, and appraised by others. We might call this the hyper-natural monitoring hypothesis.” 9
At some point, it becomes apparent that social media is the junk food of the mind-immediately satisfying, emotionally consoling, addictive, unhealthy, and ultimately, unfulfilling. Social media becomes the sugary snack for the brain, ultimately toxic and weakening. Much of junk food is enticing but we all understand that a healthy diet would be better for us. And just like a junk food diet, the additive affects creep up slowly, unaware until you look in the mirror a few years later and realize the weight creep or the visit to the doctor discovers diabetes. As humans, our predisposition is to gain social connection. Deeper social engagement and deeper thinking, the kind that is created with face to face engagement requires attention span and effort is the true healthy diet for the mind. As we substitute more and more superficial engagement, we have less time for the deeper engagements. As we rely more on social media, these deeper engagements become more foreign and difficult for us to engage in. This becomes a difficult cycle to break. And just like a bad diet, it becomes unhealthy. Our social media diet seems to be headed to evermore junk status. Facebook encouraged some longer form engagement. This became shortened by Instagram that reduces the time for engagement even further. Snapchat and Twitter accelerate this phenomenon as our minds search for evermore immediate satisfaction. The parallels between how the food industry has exploited our evolutionary tendencies to gravitate towards certain tastes and how the social media industry has exploited a similar phenomenon is a not lost on us. “Just like the food industry manipulates our innate biases for salt, sugar and fat with perfectly engineered combinations. Instagram, Twitter, or Facebook are built under the ¨variable rewards¨ scheme. According to Tristan Harris former Google design ethicist, the tech industry coerces our innate biases for: ‘Social Reciprocity (we’re built to get back to others), Social Approval (we’re built to care what others think of us), Social Comparison (how we’re doing with respect to our peers) and Novelty-Seeking (we’re built to seek surprises over the predictable)’.” 7
If we think of how our minds have been co-opted by social media, we can look at the mesmerizing behaviors it creates. Who hasn’t decided that the time on the toilet was the perfect time to check social newsfeeds resulting in sitting there long enough to develop “Facebook legs.” There used to be a time where you went to the toilet and stared at the ground, or at most flipped through a magazine. But when the job was done, the job was done. Now, social media will tyrannically steal the time away until you develop a form of brief paralysis. This represents an insidious stealing of our moments. How about when we are waiting in a check-out line? How quickly do we turn to something like Facebook? Or worse yet, at a stoplight? Social media and the smartphone have created such an impatience to our attention span that we cannot tolerate a minute without a glance at out phone. Our minds are streamlined to consume social media rather than tolerate even a moment of boredom. Social media has also changed our spending habits. It encourages the “keeping up with the Jones” effect by delivering a panoply of envy that is global rather than just from the neighborhood. This is termed virtual covetousness. Interestingly, millennials have caught on to this psychological ploy and a recent survey captured the way they are trying to gird their minds against this behavior: “The survey results suggest an interesting strategy to help them get there—ignore their friends’ social media posts. How’s that? Well, it seems virtual covetousness has taken on a life of its own for the digital generation. According to the survey, overspending because of what they see on social media (in tandem with the ease with which it takes your cash) was the largest ‘bad’ influence on how they managed their money.” 11
How can we improve our “mind’s diet?” Like most food diets, it is difficult to completely eliminate junk food indefinitely. Long-term resistance can be developed but requires persistence. For social media, as with a diet, we cannot rely entirely on will power since that fails in the majority of people that try it. Given the likely compulsive feelings that occur with posting daily selfies, posting a frequent status update, and knowing the dopamine reward brain chemistry that science has discovered, social media use represents a difficult behavior to extinguish. My own experience required a procedure akin to a dietary cleanse. I had to delete the apps from my phone.
In order to take any action towards improvement starts with self-awareness. As with most areas of social behavior that are pervasive, we have real limits to our awareness that it may have become a problem. I think that there are signs that can signal that there is too much social media in your brain diet: being on the platform every day, maybe for hours instead of engaging in a deeper social connection, not being able to read an article more than a couple of minutes before clicking away. Additional signs I’ve discovered include if you can recognize that your ability to concentrate has been impaired or that you cannot tolerate a moment of boredom. We should be welcoming more boredom in our lives! After all, boredom is often times the source of great creativity and motivation.
How else can one be aware of a personal social media problem? Sometimes the first step might be to ask a loved one who knows or lives with you whether they see these behaviors. Have them scroll through your social medial posts and see how many times you posted one of 7 types of posts that Urban described above. Another method of awareness is to try to look back and determine if significant creative hobbies started going by the wayside when social media became a constant. For younger generations, they do not have this luxury as social media has always been on for them. Still another might be loss of deeper engagement with friends, for fitting in the extra effort to meet with them. Or perhaps not engaging in intellectual activity which requires more effort like reading, playing an instrument, doing something creative not on the smartphone. Are we striving for self validation because we don’t have a strong enough internal construct to say that what we are doing in life is good enough? Are we so self-absorbed that we are deluded into thinking that many aspects of our lives are so important that others need to be informed of them?
I firmly believe that healing the brain anatomy changes wrought by social media is possible. The same aspect that changed the brain to begin with can reverse those changes—plasticity of the brain. Every time that an urge comes up to post a status update I realize that the world does not need some sort of social media entry to satisfy that urge. I try not to fall into the trap that thinks that these moments of my life need to be broadcast or are important to others. Now if I need to share these personal things, I do it directly with a text or direct message. If I think I have something of good informational value, I am more likely to post it in this blog rather than put it in a personal social media newsfeed, so that friends and acquaintances do not feel the need to create reciprocity with a “like“ if it really doesn’t interest them.
Are there reasons to be on social media? Of course there are. Charitable work, helping nonprofits, group organization for activities and events, contributing knowledge in a way that benefits a group of people that truly have an interest. A personal example of this last one is my hobby of backcountry skiing where I still embrace learning of status of an area for avalanche risks, trail warnings, maps and advice that might only be readily available on a social media platform. Sometimes as a way of asking for help or advice may be a reason. I also recognize that some professions need a constant social media presence-politicians and celebrities, for example. Business advertising would be yet another example. A litmus test to determine if posting is not merely motivated by self-image crafting might be asking yourself: “Would I pin this to a public bulletin board?” The bulletin board analogy goes further as you are trying to divorce yourself from the dopamine induced reciprocity feedback loop.
Is there anything intrinsically wrong with social media? My goal with this article is to not pass a moral judgment. Certainly adults are free to choose what they’d like to do with their time. I do want to increase awareness of the neurochemistry and anatomy changes that are occurring in the background and that may be interfering with other brain activities so that a reader can make an informed decision for themselves rather than being unknowingly manipulated. I also think that we can ask ourselves several questions when the impulse to open a social media app occurs. Are you deciding that you will post something that truly will help others or are you doing it as an image crafting exercise? Are you gaining information or are you just trying to avoid boredom or procrastinate from a task or are you missing out on an opportunity to engage with someone right next to you? I do not prescribe nefarious intent to social media companies but there is no doubt that their design is deliberate to increase dependence. In chasing the almighty dollar, they are reshaping the very structure of our minds and I resent that.
I do have some hope that social media will morph into something more beneficial for our brains and society as a whole. Platforms like Facebook are at least making the right noise to push in that direction with emphasis on groups, the willingness to eliminate hate speech, fake news, pseudoscience lunacy, and conspiracy based ideas not born in facts.
I do understand the irony of this article appearing on social media sites. However, I am not a Luddite to think that this ubiquitous medium is not valuable for idea that information exchange. It may be one of its best features. Once you try to engender this type of behavior rather than being plugged into our reward centers for self validation behavior, we may be finally getting at the valuable components that social media could truly provide.
My father, who was born before the advent of television, used to comment to me that he thought television was one of the most amazing inventions in that it could bring the world right into your home. In the same statement however he would usually a lament that the vast majority of television was utilized for wasteful programming. Social media has become the new television.
Do I still use social media. Yes. I have groups that I still get event invites and look for advice. I still respond to direct messaging. But I no longer believe in broadcasting a status update to the entire “Friend list” on a weekly or even monthly basis. I no longer scroll newsfeeds to have my senses inundated with the minutia of other’s lives. I can easily avoid the virtual covetousness.
Will some continue to argue that it is harmless entertainment? While they may, I do not believe the term “harmless” can be applied to an activity that risks our productivity, creativity, and social engagement. Chris Hedges in his book America, The Farwell Tour expresses a hope I have for myself: “Hope means rejecting the thirst for public adulation. It means turning away from the maniacal self creation of a persona that defines social media. It means searching for something else – a life of meaning, purpose, and, ultimately, dignity.“ In order to make this a reality is to remind ourselves that it is the price of our minds and the structure of our brains that is at stake in which the purveyors of social media are only more than willing to modify it to their purposes. Ultimately, the psychologists and scientists know it. The developers and inventors of this technology know it. We know it intrinsically and we know we are sometimes in denial about it. So the question is, will you go on a social media diet?
The Plebeians of Roman Society could not say no the emperor when called to the colosseum games. In this era, hopefully we have the freedom to say no to social media.
1. What the brain ‘Likes’: neural correlates of providing feedback on social media. https://academic.oup.com/scan/article/13/7/699/5048941
2. The Emerging Neuroscience of Social Media http://smnlab.msu.edu/wp-content/uploads/2017/08/Meshi_2015_TICS.pdf
3. Teens: This is how social media affects your brain. https://www.cnn.com/2016/07/12/health/social-media-brain/index.html
4. 4. Technology is changing the Millennial brain https://www.publicsource.org/technology-is-changing-the-millennial-brain/
5. Why are Silicon Valley execs banning their kids from using social media? https://www.msn.com/en-ie/money/technology/why-are-silicon-valley-execs-banning-their-kids-from-using-social-media/ar-BBPcNZP
6. In 2017, key Facebook builders disowned their creation https://apple.news/AwdAEe4FBTNK6my-U4LLIlA
7. Social Media Giants Are Hacking Your Brain — This is How. https://medium.com/@orge/your-brain-is-being-hacked-by-social-media-584ac1d2083c
8. 7 Ways to Be Insufferable on Facebook https://m.huffpost.com/us/entry/us_4081038
9. Hypernatural Monitoring: A Social Rehearsal Account of Smartphone Addiction https://www.frontiersin.org/articles/10.3389/fpsyg.2018.00141/full
10. How Evolutionary Biology Explains Smartphone Addiction. Social media companies play on biology and psychology to enslave us. https://www.fastcompany.com/90163456/can-evolutionary-biology-explain-smartphone-addiction
11. How Much Money Do You Need to Be Wealthy in America? https://apple.news/AEK5qxS_8Rl28rEmLKaPsOg
Going beyond RICE (Rest, Ice, Compression, Elevation). Give yourself the SPA treatment instead.
Inflammation is not the enemy. Moving to a new paradigm of healing.
Your typical weekend scenario unfolds as you go trail running with your friends. You’re having a great time and with a momentary lapse of attention, you step on a rock, turn your ankle, feel a “pop” associated with severe pain and you go down. Usually a few swear words are uttered as your friends gather around you. They get you up and get you back to the trailhead. The ankle already looks like a balloon. Somebody offers the helpful advice of getting ice on it and getting home to elevate it. Getting home, you slap a bag of ice all over it — how good that feels compared to the pain!—prop it up on some pillows on the couch. You are fuming about all the planned goals in the next few weeks that are going to be missed thinking that if only you can heal faster you might avoid it all. Everyone has heard of RICE—rest, ice, compression, elevation. So you ace wrap the ankle, put more ice on it, elevate it higher while you are on the couch. You turn on the tv to distract yourself realizing that now you are passively watching other people live their lives. But you’re doing the right thing, right? Everybody is doing it. It has to be the way!
While watching TV elevating your ankle, you watch athletes compete. You and millions of viewers watching pro sports are captivated when an elite athlete gets injured and magically bags of ice surround the injured extremity. It appears that this pain reducing measure has been extrapolated: that this must be not only necessary for healing but somehow improves the healing process. You have now been subjected to your own confirmation bias that RICE is the way to go.
How did we get to this point? It seems that we may have gotten off on the wrong track. Somehow the swelling associated with an acute injury has become the enemy that has to be attacked with the RICE weapon. Add ibuprofen to the mix too. By doing this, we have not only forgotten about three million years of human evolution but are potentially thwarting our own beautifully tuned biological healing mechanisms.
Our bodies evolved with amazing capabilities to heal. The healing process follows in three classic phases: inflammation, repair, and remodel. The inflammatory phase is where the stage is set for repair by releasing signaling molecules that alert repair cells to arrive, scavenging cells to remove damage, and creating angiogenesis factors that help grow blood vessels into the area. This exquisite mechanism has been refined over millions of years of evolution and 100’s of millions of years of invertebrate evolution and yet we have come to view inflammation as an enemy that we need to suppress. Like a wayward, unintentional, antiquated process that we need to modify. It turns out that RICE, while well intentioned, likely interferes with this beautifully designed process. How did RICE become so standard and why did it become so ingrained and why did it get it wrong?
In 1978, Dr. Gabe Mirkin wrote the “Sportsmedicine Book” wherein he coined the acronym RICE (rest, ice, compression, elevate). At that time, much less was known about the biological process of healing. The swelling and inflammation following an injury was viewed as a destructive process that needed to be reduced as much as possible, and Mirkin decided that the remedy was encoded in RICE. Due to the simplicity of this regimen and the supposedly intuitive concept of suppressing inflammation, RICE become widely adopted. Every injury suddenly was getting bags of ice and ace wraps. The injured part was put into a prolonged rest mode. Also, the method of RICE was expanded to treat the non-injury of post-exercise soreness and delayed onset muscle soreness (DOMS). RICE took on the role of panacea, treating every musculoskeletal ache the same.
After four decades of RICE being the injury mantra, Mirkin in 2014 reviewed the new available information and recanted (mostly) RICE by publishing an article stating why the use of ice was deleterious to healing.1 In his article on the reversal he wrote “Coaches have used my ‘RICE’ guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping. In a recent study, athletes were told to exercise so intensely that they developed severe muscle damage that caused extensive muscle soreness. Although cooling delayed swelling, it did not hasten recovery from this muscle damage.”
So what is the evidence that Mirkin used to decide that RICE was not the answer? I will briefly review each component of the acronym and the science that is now used to change the paradigm.
Rest
When we are hurting, the ability to rest does help reduce pain. We are advised by our doctors that it is an important component to heal. Two great Greek intellects Hippocrates and Aristotle disagreed on the concept of rest. Hippocrates stated healing benefited from “lay up and rest.” Aristotle countered with “movement is essential to life.”
This debate between absolute rest for injury versus activity was carried into the 19th century.2
Dr. J. Buckwalter noted: “In the last decade of the nineteenth century two widely respected orthopaedists with extensive clinical experience strongly advocated opposing treatments of musculoskeletal injuries. Hugh Owen Thomas in Liverpool believed that enforced, uninterrupted prolonged rest produced the best results. He noted that movement of injured tissues increased inflammation, and that, “It would indeed be as reasonable to attempt to cure a fever patient by kicking him out of bed, as to benefit joint disease by a wriggling at the articulation.” Just Lucas-Championnier in Paris took the opposite position. He argued that early controlled active motion accelerated restoration of function, although he noted that mobility had to be given in limited doses. In general, Thomas’ views met with greater acceptance in the early part of this century, but experimental studies of the last several decades generally support Lucas-Championneir. They confirm and help explain the deleterious effects of prolonged rest and the beneficial effects of activity on the musculoskeletal tissues. They have shown that maintenance of normal bone, tendon and ligament, articular cartilage and muscle structure and composition require repetitive use, and that changes in the patterns of tissue loading can strengthen or weaken normal tissues.”2
The concept of enforced prolonged rest was the mainstay of treatment (as evidenced by numerous biographical and medical accounts) until the mid-twentieth century. At that time, the biological underpinnings of the deleterious affects of healing of tissues was noted with prolonged immobilization or rest. Experimenters started to look at the differences of early motion vs. rest on various tissues and noted substantially healthier outcomes with avoidance of pure rest.
The global effects of prolonged rest on the body, in addition to slower healing, can include deconditioning, digestive issues, and feelings of increased depression and anxiety. On the flip side, a number of studies showed a quicker return to a higher activity level by early activity in a group of patients treated for ankle sprains.3 Ankle sprains are the classic example where RICE has been used for decades. It turns out that this ubiquitous use of RICE for this injury has no underpinnings in science. One study even stated: “Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults.”4
But like anything, too much of a good thing (motion) can be bad for many injuries and it has to be tempered and adjusted to the type of injury as will be discussed below. After-all, you want to avoid re-injury also.
Ice
Early in my running experience, I would take an ice bath after a long run. It was extremely unpleasant but I had read and been told that it reduced soreness and sped up recovery. Little did I know that, science appeared to show that this was not the case. In addition, everyone who has put an ice bag on an injury knows of the pain relief that is gained. It seems counter-intuitive that there is any sort of negative side-effect from such a simple, cheap, and pain reducing technique.
A number of studies show that icing following exercise seems to not only delay recovery but there does not appear to be much affect on soreness levels either.5,6,7 In fact, it was a study looking into the lack of benefit of icing for post-exercise recovery that ultimately lead to Dr. Mirkin’s change of heart on RICE.8 Indeed, it appears that most of the self-perceived benefit that athletes report from this post-exercise cooling ritual is a placebo affect.9
What about for injuries? Does icing help healing? Again, the answer appears to be no. A recent study summarized findings based at looking at various biochemical markers and muscle biopsies and concluded: “Despite popular belief, inflammation can be an important process in tissue regeneration. The results suggest that ice may delay inflammation, angiogenesis and the formation of new muscle fibers during recovery from severe muscle injury. These findings challenge the practice of using ice to treat muscle injuries.”10 One recent research summary found the contrarian fact that heat may be more effective: “There is limited evidence from randomized clinical trials (RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness (DOMS). The physiological effects of heat therapy include pain relief and increases in blood flow, metabolism, and elasticity of connective tissues. There is limited overall evidence to support the use of topical heat in general; however, RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of DOMS than does cold therapy.”11
For those who would want to see a passionate argument for avoiding icing after injury, Dr. Reinl has laid out his description of the negative affects of icing on injured tissues in an online post here: ICED! The Illusionary Treatment Option: Learn the Fascinating Story, Scientific Breakdown, Alternative, & How To Lead Others Out Of The Ice Age by Gary Reinl
(http://garyreinl.com/articles/The-Cold-Hard-Facts.pdf)
Compression
Placing an ace wrap or compression sock around a swollen ankle has been a common technique employed during recovery with the thought that it reduces swelling. So does it actually help?
A large review found conflicting results amongst studies but did suggest a trend towards decreased muscle soreness following exercise.12
How about for injury? It seems almost heretical to suggest that compression is not needed. There is very little in regards to scientific study for the use of compression. It would also be very difficult to create research that “blind” patients to compression in a randomized study to determine the potential of a placebo effect.
The intuitive answer is that compression reduces swelling and with reduced swelling comes better motion. Without science to guide us for or against this modality of treatment, I have some suggestions. First, compression will reduce swelling but it can also worsen it. The compression has to applied as a “gradient” so that the compressive wrap or garment does not impede lymphatic/edema flow away from the injury. Secondly, I have seen patients that during the chronic phase of swelling, where compression seems to make the swelling more persistent or have more re-bound when using a compression garment/wrap. So if you are experiencing this, it is worthwhile to discontinue compression.
My personal recommendation is that light compression early in the injury phase may be helpful to reduce swelling but that as soon as the acute swelling phase is over (first few days) that it probably should be discontinued to avoid a “reverse gradient” situation with rebound or worsened swelling. I think that compression can help during the rehabilitation phase by providing a bit of proprioceptive sense which allows a patient to more accurately determine the position of a joint. Some science seems to support this.13
Elevation
Elevation as a recommendation is in a similar category as compression. Again, it can reduce swelling but no randomized studies can indicate whether this actually speeds up or improves the healing process.
My feeling based on clinical experience with my patients is that for a short period after injury, it is appropriate for the anti-swelling effect and for the reduced pain that comes with that. It also may make it easier to obtain the lymphatic drainage gradient that would be desirable, especially if the injury allows muscle activation which would enhance this effect further.
I do think that there is such a thing as “too much elevation.” What I mean by this is that the passive process of elevation can often be used by patients in lieu of re-gaining more natural movement patterns that may be uncomfortable or they may have injury apprehension (kinesiophobia). I’ve seen many patients with a wrist or hand injury holding their hand in “the injured wing” posture weeks after injury causing themselves shoulder and elbow stiffness along with pain, disuse atrophy, abnormal muscle use patterns, and slower functional return.
A New Paradigm
It’s time to view that inflammation after injury is not the enemy but the sentinel process to achieve healing. When there is damage to the soft tissues—whether due to injury or due to a hard exercise—the immune system, responding to signals caused by damaged tissue, sends in inflammatory cells called macrophages to help clean out the damage. These cells will release IGF-1 (Insulin-like Growth Factor), one of the important hormone signals that will start the cascade of healing to eventually include in-migration of fibroblasts—cells that start to lay down collagen, one of the first building blocks to heal tissue damage. Cooling tissue can blunt the production of IGF-1 and research “suggests that the application of cold pack immediately after exercise may not only result in performance decrement but also in attenuation of the anabolic effects of the preceding training.” Dr. Mirkin, now in the anti-RICE mode states: “Anything that reduces inflammation also delays healing” including
• cortisone-type drugs,
• non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
• immune suppressants that are often used to treat arthritis, cancer or psoriasis,
• applying cold packs or ice, and
• anything else that blocks the immune response to injury.1
The curious reader might wonder about NSAIDs also since this is commonly recommended with injury. As an orthopaedic surgeon dealing with a high risk fracture, the literature has been relatively damning in regards to NSAIDs and I recommend my patients to avoid them in that scenario. For soft tissue healing, the studies are more mixed. Most of the data has come from animal studies with some showing weakened tendon healing with NSAIDs and others that did not find a negative affect.15
So if you’re not going to RICE it, what can you do? Let me suggest a new paradigm that has a scientific basis for faster healing. I have coined it: SPA
SPA—Sleep, Protected motion, Activity
Sleep
Sleep initiates vast important aspects of the healing and adaptation process. This has been studied extensively. Improving your sleep quality and quantity may be the single most important thing when dealing with an injury. Rather than discussing it in detail here, I refer the interested reader to my earlier blog post on the topic (https://juliankuz.home.blog/2019/02/16/want-to-heal-yourself-faster-do-this/). The science supporting it for improved aspects of healing is large and comprehensive. Sleep has not often been at the forefront of injury discussions but it should become a mainstay. If there is only one thing that you can do, improving your sleep during the healing process will reap the biggest rewards of any single action.
In addition to the wealth of healing brought to bear anatomically on your injury, sleep will provide you with resiliency. A large part of the battle when healing is the mental process. Life goals may have been disrupted. Family life, work, household upkeep, etc. are likely to fall behind. This is when resiliency is really needed. A mental collapse will always make the limits of the physical injury expand. Sleep provides the additional mental resiliency needed to get through this life trial.
Protected motion
The injured part, depending on the type of injury, may benefit from what I term “protected motion.” Protected motion is defined as a prescribed amount of motion that will optimize desirable affects on the injury and not impart new damage or delay healing. This is an area that has significant research devoted towards it and has very specific recommendations based on the exact type and degree of injury. In my field of upper extremity surgery, finger flexor tendon lacerations with repair, wrist fractures, and elbow ligament reconstruction (“Tommy John” surgery) provide good examples where protected motion is widely employed to provide the best result.
For flexor tendons, we use the concept of “half-active motion.” The idea is to be able to starting moving the finger in a way that does not cause the repair to rupture but still allows the joints to move and the repaired tendon to glide so as to avoid motion inhibiting scarring. With wrist fractures that are stable enough to allow protected motion, we start what is known as “dart-throwers motion.” Just as the name implies, the patient will gently move the wrist from an extended posture that is deviated towards the thumb, to a flexed posture that is deviated towards the small finger. With elbow ligament reconstruction, we allow guided motion of the elbow that reduces stiffness but avoids stress on the new ligament reconstruction.
The idea is to provide a bit of micro-stress and nutritional motion to the tissues without over-challenging the tissues
With the right degree of protected motion, tissue healing will be faster and more robust.
The concept where motion and loading of tissues cues the biochemical process of healing is known as mechanotransduction. “Intracellular pathways convert mechanical cues into biochemical responses (mechanotransduction) via complex mechanoresponsive elements that often blur the distinction between physical and chemical signaling.”16
The key to the right degree of protected motion and loading of the tissues can vary greatly based on the type of injury, type of surgical repair, and patient characteristics. In my field, the difference in protected motion for a scaphoid fracture (a type of wrist fracture) with a high risk of non-healing will be far less (or none) compared to a minor wrist sprain. Because the variables are high, no detailed recommendation can be provided in this article. The best advice would be to get a professional opinion on the degree of injury, the type of tissue damaged, and to ask questions of what protected motion is allowed. The opinion will likely vary based on the physician/trainers experience and knowledge of the injury as well as whether the diagnostic assessment has accurately determined the degree of injury. In addition, the physician/trainer may be more “old-school” or more progressive and that will also influence the recommendation.
In these variables, is the lurking question of whether a patient can be compliant. I have observed patients all across the spectrum. There will be careless or cavalier patients who would interpret “protected motion” as carte blanche for their injury and are at high risk for greater injury or delayed healing. This “give-an-inch, take-a-mile” patient often has physicians providing overly cautious parameters since it is difficult to know from the outset what type of patient response we might have. At the other end of the spectrum are patients that are too afraid to move and they will also experience delayed healing and recovery. These patients need to be encouraged to move more than they would naturally.
Activity
Ostensibly, resting the injured part is desirable but this is often interpreted the wrong way. A patient may decide that an injury gives them license to become a couch potato. Relative rest for an injury is specific. It does not mean whole body rest. That leads to deconditioning and a whole host of undesirable metabolic and emotional negative affects. However, some downtime is not entirely deleterious-while peak physical condition can be reduced by a week, some conditioning can exist out to 6 months and for a previously conditioned patient, be regained readily.17 Therefore some level of conditioning is possible with alternative methods to allow a rebound when the injury has healed without being at baseline (“starting all over”). For example, a runner may be able to use a stationary bike or swim. Gravity reduced running is possible with special treadmills. In addition, a fascinating neuromuscular feature can be used for an injured limb that cannot yet be mobilized safely. That is, exercising the opposite limb! No that is not crazy talk. Several studies support it. Studies have had participants exercise only one limb and measured growth and conditioning improvements in the other resting limb. This phenomenon is known as “cross education.”18,19
The final step is “protected practice.” This means that the player can engage in the sport in a limited way that allows them to continue to “keep their head in the game” but not resulting in impact or fall on the extremity. So if a soccer player broke their wrist, it would not be safe to engage in a full game where a collision can occur, but practice where footwork is reinforced, passing drills, etc are safe and allow the athlete to re-enter the sport quicker when the “green light” for the injury is received. Runners can use a gravity reduced treadmill that utilizes some suspension so full body weight does not occur. A trail runner could start initially on a smooth path before progressing to more challenging terrain.Throwing athletes can throw with an uninjured dominant arm if someone catches for them. Both trainers and coaches are integral to supervising and organizing this final phase of the healing process. This protected play is important not only for developing timing, coordination, and reflexes, it is also crucial for the psychological aspects of a return to sport.
Is there still a role for RICE?
I would say that in the first few hours after injury, when pain is very severe, RICE can serve as a way to reduce this extremely unpleasant aspect. I certainly think that pain relief is worthwhile for a short period and judicial use of NSAIDs in a limited brief fashion may be needed.
At some point early on, once the most extreme component of pain starts to recede (around 48-72 hrs.) it is worthwhile to transition to SPA treatment. If the injury allows an earlier transition, this is also desirable. Providing the best environment to enhance sleep, determining with expert help what protected motion can begin, and starting activity while avoiding new injury to maintain some level of conditioning will be the quickest way to heal and return to activities.
1. Why Ice Delays Recovery. http://www.drmirkin.com/fitness/why-ice-delays-recovery.html
2. Activity vs. rest in the treatment of bone, soft tissue and joint injuries. Iowa Orthop J.
1995;15:29-42.
3. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. https://www.ncbi.nlm.nih.gov/pubmed/20457737
4. What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/
5. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. https://www.painscience.com/biblio/icing-delays-recovery-from-muscle-soreness.html
6. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762537/#!po=50.0000
7. Does Cryotherapy Improve Outcomes With Soft Tissue Injury https://www.ncbi.nlm.nih.gov/pmc/articles/PMC522152/
8. Effects of air-pulsed cryotherapy on neuromuscular recovery subsequent to exercise-induced muscle damage. https://www.ncbi.nlm.nih.gov/pubmed/23739686
9. Postexercise cold water immersion benefits are not greater than the placebo effect https://www.ncbi.nlm.nih.gov/pubmed/24674975
10. Why icing doesn’t work https://medicalxpress.com/news/2015-03-icing-doesnt-injuries.html
11. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury https://www.ncbi.nlm.nih.gov/pubmed/25526231
12. Compression Garments and Exercise: No Influence of Pressure Applied. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306786/
13. Compression Garments and Performance Enhancement in Balance and Precision Tasks. https://www.researchgate.net/publication/305277266_Compression_Garments_and_Performance_Enhancement_in_Balance_and_Precision_Tasks
14. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762537/
15. Positives and negatives of nonsteroidal anti-inflammatory drugs in bone healing: the effects of these drugs on bone repair. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016595/#!po=54.1667
16. Pushing Back: Wound Mechanotransduction in Repair and Regeneration. https://www.jidonline.org/article/S0022-202X(15)35087-9/fulltext#/article/S0022-202X(15)35087-9/fulltext
17. How Fast Do You Lose Fitness When Not Exercising? https://www.verywellfit.com/fitness-use-it-or-lose-it-3120089
18. Cross-Education Strength and Activation After Eccentric Exercise. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208861/
19. Cross education and immobilisation: mechanisms and implications for injury rehabilitation. https://www.ncbi.nlm.nih.gov/pubmed/21924681
Managing Risk Pt. 2: The Parallels Between Traveling in Avalanche Terrain and Surgery.
I discussed in part 1 of this series (https://juliankuz.home.blog/2019/01/05/managing-risk-part-1-heuristic-traps/) the concept of the unconscious process of heuristics potentially blinding us to risk. This auto-pilot system evolved so that we could make rapid decisions in a changing environment where conscious processing would be too slow or fatiguing. While we might think that heuristics are a poor tool, one has to balance this against the danger of cognitive fatigue that can, at times, also lead to a higher risk decision making process. Heuristics operate in an automatic fashion. We are unaware that our decision is made by this process. Fast decision making and preserving cognitive energy is sometimes needed and is valuable. The problems occur when this decision making process is utilized for the wrong scenario where a deliberate, more time-consuming process would be more accurate and safer. Cognitive fatigue is a true danger to analysis of risk but conscious processing consumes more of the precious resource of cognitive energy. Some level of metacognition is needed to help identify which cognitive process may be more valuable for the decision at hand.
Development of this metacognition is facilitated by awareness of how our decisions are being made. As noted in part one of this article series, it is important to be aware when we are using a heuristic. It is worthwhile to be mindful of other areas of cognitive blindness including confirmation bias, anchoring bias, and cognitive fatigue leading to loss of presence. These are present whether we are in avalanche terrain or the operating room.
One of the routines that I go through before heading into the mountains for a day of backcountry skiing is to check the avalanche forecast. In a number of mountainous areas, professional avalanche forecasts are available. The forecast discusses weather, specific snowpack structural risks, the locations where particular hazards exist (altitude and aspect), as well as providing a overall rating. From these factors and other observations, a risk rating is produced on a scale of one to five— 1=low, 2=moderate, 3=considerable, 4=high, 5=extreme. Drew Hardesty of the Utah Avalanche Center and other researchers have noted that data indicated that no avalanche-related fatalities were recorded for a given period over a number of years when the day’s rating was either low or extreme. It seems that the risks are so clear to everyone on those days that humans assess risk correctly when given these polar opposite ratings. However, almost half of the deaths occur when the rating was in the middle or “considerable.” Hazardous conditions on these days are harder to detect because of their sporadic triggering characteristics due to spatial variability of weak snowpack structure. Even with this elevated danger, a significant number of people are dying when this rating is given.
What might be happening? Is it all due to heuristic traps? Heuristics may play a role in some cases but there are other factors likely at play. Many backcountry skiers and ski mountaineers have developed some degree of stress immunity in the mountain environment. This can be beneficial in order to act calmly in areas of risk but this false sense of security can also at times be from bias. Both confirmation and anchoring bias may play a role in feeding these heuristic traps and triggering them to create the wrong decision.
There is an old joke about confirmation bias- “Now that I’ve learned of confirmation bias, I see it all around me.” Confirmation bias leads to the feeling that when skiing on a risky slope, the fact that it didn’t avalanche on me suggests that my decision was correct leading to making the same decision again when circumstances might be different enough to result in an avalanche. This feeds into the concept of risk homeostasis. Risk homeostasis creates a cognitive state where increasing risks are felt to be justifiable as past risks have not lead to negative consequences and the higher sense of risk is needed to achieve the same feeling of achievement. Risk homeostasis feeds the cognitive blind spot of confirmation bias. This creates the assessment that you are in a safe area when really what occurred was that just the right specific avalanche trigger has not yet been encountered.
Another possibility is the presence of anchoring bias. Anchoring bias is defined as the propensity for humans to favor the first piece of data presented to them and to ignore later contradictory information, even if it is correct. This can be exacerbated when time pressure occurs. Like a heuristic trap, this is a cognitive short cut where we implicitly trust the initial source of information and do not update our calculations as new data becomes available because it requires less energy and may conflict with our mind-set for the day. Whether it was a friend’s report on snow conditions from yesterday or a cursory reading of the avalanche report, the decision factor becomes anchored in our minds. It is with this unwavering fact in hand that skiers may inadvertently cling to their terrain choice that can result in a poor decision. This again is a cognitive shortcut rather than reassessing the data with our own senses dynamically which may be laborious, uncertain, and slow.
These biases play a role in faulty decision making in an operating rooms. A classic example from my particular specialty would be in situation of the surgical removal of a mass (“lumps and bumps”) in the hand. Since a cancerous mass is an extremely rare occurrence in the hand, the surgeon can have the anchoring bias of going into the operating room with the decision for removal of this mass in a way that might be better suited for the extremely common scenario of a benign mass. This bias is also synergistically fed by the confirmation bias system due to the fact that a surgeon may have removed hundreds or even thousands of masses successfully this way from hand surgery patients without ever encountering a cancerous mass simply because of probability. How can we manage the risk in these scenarios?
We have a second system available for decision making: the conscious or reflective one. This is what can be thought of as deliberate processing but it is slower and more energy consuming and there are many times where these aspects prevent it from being used to manage risk. Our metacognition may be aware of when we need to switch cognitive processes from the automatic (unconscious) process to the deliberate (conscious) process. This is facilitated by recognition of a strategic mind-set. Roger Atkins in the Proceedings, International Snow Science Workshop, Banff 2014 notes the definition of a mind-set as “A fixed mental attitude or disposition that predetermines a person’s response to and interpretations of situations.”
A strategic mind-set is the other half of risk processing. Risk is a two sided coin that has the flip side of reward. We can talk about managing risk as a conscious deliberate process but reward is often managed less consciously and yet can be the factor that nudges one into taking greater risk. Adjusting the reward will automatically adjust the risk. This is where recognition of your strategic mind-set can assist with the opposite side of the coin side of risk. Having the metacognition to be able to adjust the mind-set can help make correct decisions. A rigid mind-set is directly linked to the previous mentioned cognitive biases.
As skiers we have potential desires for a day’s trip in the mountains. It may be to scale a summit, ski a challenging/dangerous line, or simply find glorious powder snow to descend. Surgeons also have desires which can include good patient outcomes, accomplishing difficult surgery, proving mastery to ourselves and others, patient satisfaction with the encounter, and the simple desire to make a patient better. If we go into the decision with a fixed desire (fixed mind-set) we may actually miss another potentially acceptable but different goal if we had adopted an adjustable strategic mind-set based on updating our actual goal rather than pursuing it despite evidence to suggest that it has become a poor goal. Some might view this strategy as “copping out” but that would miss the potential virtues of a strategic mind-set.
On this day, avalanche risk levels allowed me to go for a significant objective of skiing a couloir in the Teton Range. Photo credit: Ben Gilmore, Exum Guides
Canadian Mountain Holidays (a guided helicopter ski operation) uses a structured process to help adjust the strategic mind-set. These various structures can vary from entrenchment (conditions require discipline to hold back from seeking what would be rewarding terrain in highly risky avalanche situations), stepping-out (increasing the reward factor as confidence is being gained that avalanche risk is dropping), to open season (the highest rewards can be pursued as there is high confidence in stable snow structure).
In order to employ this structure, and reduce automatic processing, one must look at the goal in a deliberate manner. For a skier this means a broadening definition of what is rewarding. Instead of a fixed goal of a summit on a particular bad risk-profile day, the act of simply touring on a safe ridge, enjoying views, powder skiing on a less steep slope, enjoying the social aspects or solitude of the day, or gaining the benefit of exercise can feel satisfying. Flexible reward allows avoidance of risk at times with beneficial outcome. This tool can be useful to avoid the inability to define a suitable reward due to risk homeostasis.
On this particular day, avalanche risk allowed for consideration of a different rewarding goal. Here I got to ski powder in lower angle terrain and still feel immensely satisfied with the day. Photo credit: Brenton Reagan
For a surgeon who senses unreasonable risk for a patient with a surgery, a better outcome for the patient may be obtained by getting a patient to understand the issue better or providing coping strategies for the problem. We have patients that likely represent a “considerable risk” much like the avalanche rating. We may end up applying the same reason for doing a surgery that we have done countless times before only to “trigger” a sporadic complication. Maybe the patient is a smoker or diabetic or likely to be non-compliant and yet the surgery is a relatively common procedure like a bone correction surgery known as an osteotomy. An osteotomy is common enough in my field that we have very high success rates for the appropriate indications. As surgeons, we have a strong desire to correct malaligned bone anatomy and we are good at it. Our very own stress immunity and dispassionate clinical distancing from the patient (reduced cognitive empathy) can compel us to fix things. Yet at times, we might be walking into a complication from this bias. By changing our desire—to fix something surgically or correct an anatomical difference—we might change our strategic mind set by counseling the patient on non-operative methods including coping and living with the problem, so as to avoid a triggered risk which might not be prevented even with careful surgery. We switch our risk assessment by not satisfying our desire to correct the problem anatomically but yet may still create patient satisfaction with the desire of helping a patient to live better with their problem.
An example of correcting significant wrist malalignement with a osteotomy and fusion. The patient had no other significant risk factors thus allowing pursuit of pain relief in this manner. This allowed me, as a surgeon, to obtain a goal of providing pain relief, no activity restrictions for the patient, and avoidance of future tendon damage caused by the original condition. If the risk was too high, the use of a brace may create some pain relief with activity modification. This goal should not be felt as “copping out.”
Surgeons have often had mantras that help to guide this: “There is nothing that can’t be made worse with surgery” and “The enemy of good is perfect.” I am not arguing for complacency or mediocrity here. I am simply arguing that in order to allow conscious processing to take place to optimize risks, reviewing potential alternative rewards will force us to use deliberate cognitive processing. By the way, the concept of reduced cognitive empathy, while sounding very negative, is an essential aspect of being a surgeon. We understand that surgery intentionally inflicts pain in order to achieve the ultimate goal of improving or saving a patient’s life. Without reduced cognitive empathy, we would be paralyzed to take these beneficial actions.
With the cognitive tools of an adjustable strategic mind-set, recognition of bias, and understanding of underlying heuristics that we may be using, we can manage risk more accurately. As Atkins notes: “Optimal decisions require more than a conscious decision to adjust our behavior; we need to make more fundamental adjustments of our desires according to circumstance.” Again this is not an acceptance of the status quo. We are choosing when to fight the battle. We can still aspire to heroics and greatness at the right time and place.
Want To Heal Yourself Faster? Do This!
Sleep: the elixir of healing (and life!)
Julian Kuz, M.D.
Many patients ask me if there is something they can do to promote healing after injury or surgery. They are thinking that there is a dietary change (can I take more calcium?) or a therapy program that will speed things along. Being an orthopaedic surgeon, I treat a variety of injuries and perform surgeries that would benefit from optimal healing. We often discuss measures such as appropriate therapy, smoking cessation, and nutritional aspects. However, there is a step that patients can take that may be one of the most important actions they can take to improve healing.
They are surprised when I answer “improve your sleep pattern and/or quantity.” Yes, your mother was right! Yet, this answer goes beyond motherly advice and has excellent science to support it. In fact, it likely trumps all other factors as being the cornerstone to the healing process.
So what does the science of sleep say about healing? The effects of sleep improve aspects of the immune system, tissue adaptation, and pain reduction. Significant healing processes begin with the onset of sleep. In essence, this is when the repair crews of the body get out to do the most work. As it turns out, sleep affects your ability to heal through multiple mechanisms: immune system function, wound healing capabilities, adaptation response during the strengthening phase of rehabilitation, pain reduction, and accident avoidance (a not uncommon problem for patients-falling on their surgical site or injury!). In addition, the quality of resiliency which is fundamental while trying to heal from an injury or surgery is also affected by sleep. I will go through each of these below and provide references for those who are interested in learning more. This is but a small number of studies of the hundreds that support these points.
As we all know, wound healing is substantially worsened by infection and our immune system is our defense against this problem. Sleep affects the immune system immensely. Numerous sleep studies show that the lack of sleep renders your immune system much less effective making you more vulnerable to infection and delayed wound healing. “The integrity of the immune system is indispensable during the healing process, particularly during the recovery of tissue after burns, when defense cells and inflammatory mediators act in unison to promote tissue regeneration, cytokine production, and bacterial clearance…..These results suggest that a few hours of sleep deprivation is sufficient to cause adverse effects on the integrity of the immune system.”1 Recently, researchers have been able to identify the body’s sleep-enhanced pathway for doing this. “T-cells” are one of our primary infection-fighting cells that help identify the infection and begin the response of our immune system. The recent research shows that volunteers that sleep had significantly higher activation response of T-cells through a complex interaction of hormones and other molecules compared to volunteers that were kept awake.2
It is easy to understand that with the sleep enhanced effect of infection reduction mediated by the immune system, that the speed of healing tissues would also be affected given that this action is also influenced by the immune system. Healing tissues need improved blood supply and cells that produce collagen (a building block for tissue repair) called fibroblasts. Animal studies have shown that sleep deprivation reduces capillary in-growth and fibroblast production.3 Fibroblasts are integral for wound healing. This effect has also been studied in humans.4 This study used volunteers that were given blisters and then split up into a group that was allowed to sleep 7-9 hours/night and a group that was placed into sleep deprivation. This showed that sleep compared to sleep deprivation improved healing rate by up to 15%. An additional finding was that nutritional supplementation did not speed up the healing in the sleep-deprived group. This shows that you cannot overcome wound healing delay from sleep deprivation simply by better nutrition or supplementation.
Another critical factor for healing and recovery from injury or surgery is the ability to perform effective rehabilitation. I have observed that patients learning therapy exercises often forget instructions given by therapists. This can cause anything from ineffective therapy to outright damage to the healing area. Appropriate sleep will enhance not only the skill of performing a muscle related task, it will improve retention of the critical components of the task.5 This makes home exercise that most patients are given more effective and safer. The ineffectiveness of rehabilitation in a patient that is sleep deprived is multifactorial as many more aspects are affected such as pain levels.6
The association between sleep and pain are strong. Researchers have discovered that it is a two-way street. Pain will affect sleep, but sleep will also affect pain. A number of studies have used sleep deprivation as a tool to determine that it worsens pain.7 The ability to tolerate pain will affect wound healing, compliance to therapy, and the ability to remain resilient-a psychological advantage for getting through the healing process. Prolonged pain creates psychological stress which will reduce healing times by up to 25%! Multiple studies have shown prolonged healing times due to this factor.8 The ability to use sleep as a tool to reduce pain would not be lost on any of us that have seen issues with the use of opioids for pain reduction and the subsequent epidemic upon our nation. Opioids, commonly used after major injury or surgery, interfere with sleep with the resultant loss of benefits that sleep confers upon healing.9
As a surgeon, I have counseled patients on accident reduction, especially for the elderly who are at particular risk for falling. There can be many aspects in accident reduction. Sleep deprivation is a well known factor in accident causation. I have had the unfortunate experience of having a number of patients over the years who have fallen upon their injury or surgical site and have made the problem decidedly worse or substantially delay their recovery. These falls have been associated with further fractures, disruption of surgical repairs, premature opening up of wounds, and wound infections. Better sleep is an important factor to help reduce the incidence of this problem.10
Finally, there has been increased awareness on how the concept of resiliency affects our ability to bounce back from adverse life events such as an injury or surgery. Improved resiliency will help maintain or reduce the negative consequences that can occur while trying to heal including our relationships, finances, development of chemical dependency, and general feelings of wellness and happiness. The military has taken special interest in the phenomenon of resiliency and there is research that supports that improved sleep will improve resiliency.11
So, ultimately if your repair crew needs 8 hours to get ahead on the job (healing) and you are only giving them 5 or 6 hours sleep to let them do their work, guess what? Expect your pain to be worse, healing to go slower, and progress in therapy to be reduced. All of these factors can potentially reduce your resiliency and increase your chances of an accident.
Unfortunately, mentioning that sleep is the holy grail of improved healing to patients is sometimes met with resistance. Too often, patients and doctors are operating with long held social beliefs and customs suggesting that sleep is somehow optional or for the lazy. This belief is especially held true by much of the business community and even extends to parents and their attitudes towards their children’s sleeping habits (“The early bird gets the worm!”). Our modern day work and life styles betray the obvious health benefits of sleep. Another aspect is the fact that sleep is viewed as a passive rather than active intervention. People looking to improve healing are feeling they need to actively pursue something and sleep tends to be viewed as a passive activity and many have been taught erroneously that it can be easily sacrificed for other goals. They would prefer that I say that there is something like a nutritional change or supplement that could have a profound affect on healing. While those elements would have a small incremental affect, they do not trump the benefit of sleep for healing. Unfortunately, the more type A behaviorally you get about trying to sleep, the more it becomes counterproductive.
The bottom line? In addition to being compliant with your doctor’s recommendations of follow- up and therapy, improving your sleep is the single most powerful thing you can do to heal faster. Your mom was right. Go to bed!!
The ability for how to improve your sleep goes beyond the scope of this article but for those that are interested, this article can act as an initial reference.. https:// advancedtissue.com/2015/04/tips-for-improved-wound-healing-through-better-sleep/
If you want to learn more about how sleep profoundly affects almost all major aspects of our overall health, an excellent book on the topic is Why We Sleep: The New Science of Sleep and Dreams by Matthew Walker
1 Wound-healing and benzodiazepines: does sleep play a role in this relationship? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400176/
2 Gαs-coupled receptor signaling and sleep regulate integrin activation of human antigen- specific T cells. http://jem.rupress.org/content/early/2019/02/11/jem.20181169
3 Effects of Sleep Deprivation, Nicotine, and Selenium on Wound Healing in Rat. https://doi.org/10.1080/00207450490509168
4 Impact of sleep restriction on local immune response and skin barrier restoration with and without “multinutrient” nutrition intervention. https://doi.org/10.1152/japplphysiol.00547.2017
5 It’s Practice, with Sleep, that Makes Perfect: Implications of Sleep-Dependent Learning and Plasticity for Skill Performance. https://doi.org/10.1016/j.csm.2004.11.002
6 Consideration of sleep dysfunction in rehabilitation. https://www.ncbi.nlm.nih.gov/m/pubmed/21665101/
7 Pain reduction. The association of sleep and pain: An update and a path forward https:// http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588/
8 The Impact of Psychological Stress on Wound Healing: Methods and Mechanisms. https:// http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052954/
9 Opiates, Sleep, and Pain: The Adenosinergic. http://anesthesiology.pubs.asahq.org/ article.aspx?articleid=1932593
10 Falling-Asleep–Related Injured Falls In The Elderly. https://doi.org/10.1016/j.jamda.
2008.10.008
11 Sleep and Resilience—A Call for Prevention and Intervention. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835317/#!po=1.72414
Managing Risk Part 1: Heuristic Traps.
Mental short cuts that blind us.
One of my favorite hobbies is backcountry skiing and mountaineering of which one of the many important knowledge aspects is avalanche avoidance. The parallels between avoidance of medical errors and mistakes in avalanche terrain are impressive.
When analyzing avalanche accidents, a common theme emerges. A number of people involved with the accidents, despite having had avalanche education, ignored or were oblivious to warning signs during their backcountry trip that would have signaled that they were taking on a higher risk of being caught in an avalanche. Undeterred by these warning signs, they proceeded to be caught in an avalanche. As it turns out, most people who die in an avalanche are caught by an avalanche that either they or someone in their party triggered. By and large then, these are not random events—“Hand of God” incidents— but are potentially avoidable in many circumstances. What is happening that we humans are blinded to these warning signs?
A critical aspect of this knowledge is the realization of heuristic traps (McCammon I: Heuristic Traps in Recreational Avalanche Accidents: Evidence and Implications. Avalanche News 68:1-10, 2004). A heuristic is essentially a mental short-cut that we take to reduce mental processing. McCammon identifies 6 types of these traps made in avalanche terrain that any surgeon might readily identify similar heuristic errors that can be made in everyday surgical practice. The avalanche heuristic traps are known as familiarity, consistency, acceptance, expert halo, scarcity (“Tracks”), and social facilitation. These traps were identified as mistakes that were made by backcountry skiers/boarders that were, in some cases, frighteningly obvious, even to the parties involved, and is known by the acronym FACETS. The use of a heuristic trap led the involved parties to make mistakes leading to avalanche injuries and deaths despite having some or even advanced avalanche knowledge and experience.
McCammon provides the following descriptions of the named heuristic traps:
Familiarity: “The familiarity heuristic relies on our past actions to guide our behavior in familiar settings. Rather than go through the trouble of figuring out what is appropriate every time, we simply behave as we have before in that setting. Most of the time, the familiarity heuristic is reliable. But when the hazard changes but the setting remains familiar, this rule of thumb can become a trap.”
Acceptance: “The acceptance heuristic is the tendency to engage in activities that we think will get us noticed or accepted by people we like or respect, or by people who we want to like or respect us.”
Consistency: “Once we have made an initial decision about something, subsequent decisions are much easier if we simply maintain consistency with that first decision. This strategy, known as the consistency heuristic, saves us time because we don’t need to sift through all the relevant information with each new development. Instead, we just stick to our original assumptions about the situation. Most of the time, the consistency heuristic is reliable, but it becomes a trap when our desire to be consistent overrules critical new information about an impending hazard.”
Expert Halo: “In many recreational accident parties, there is an informal leader who, for various reasons, ends up making critical decisions for the party. Sometimes their leadership is based on knowledge and experience in avalanche terrain; sometimes it is based on simply being older, a better rider, or more assertive than other group members. Such situations are fertile ground for the expert halo heuristic, where an overall positive impression of the leader within the party leads them to ascribe avalanche skills to that person that they may not have.”
“The scarcity heuristic (Tracks) is the tendency to value resources or opportunities in proportion to the chance that you may lose them, especially to a competitor.”
“Social facilitation is a decisional heuristic where the presence of other people enhances or attenuates risk- taking by a subject, depending on the subject’s confidence in their risk taking skills. In other words, when a person or group is confident in their skills, they will tend to take more risks using those skills when other people are present than they would when others are absent.”
If you look at a surgical environment, you can see that these heuristic traps can also occur. The parallel errors are similar.
For example, one common procedure in my field is harvesting a tendon at the wrist called the “palmaris longus.” This tendon is ideal for use in ligament reconstruction for the upper extremity. Unfortunately, about 14% or more of the population do not have this “spare tendon.” Also, the tendon (and one of the common substitutes nearby anatomically, the flexor carpi radialis) lie in close proximity to a nerve that supplies critical sensation to a large portion of the hand. Due to the potential absence of this tendon and the proximity of the nerve, there have been very unfortunate cases of harvesting the nerve rather than a tendon! (Leslie BM et. al.: Inadvertent Harvest of the Median Nerve Instead of the Palmaris Longus Tendon. J Bone Joint Surg Am. 2017 Jul 19;99(14):1173-1182.) The authors opine: “In some of the cases described above, the operating surgeon was thought to have been in a rush or had been directed to harvest the tendon before the more experienced surgeon arrived. In other cases, the surgeon had the training and experience to distinguish between a nerve and tendon but may have been more focused on the primary operation and less focused on the steps necessary to obtain the tendon.”
The authors also state : “If perceptional blindness was a contributory cause of the inadvertent median-nerve harvest, then perhaps something happened during the surgery that caused the operating surgeon to miss the fact that he/she was suturing a nerve rather than a tendon. This may be where the situation of a surgeon being rushed, cavalier, or overconfident comes into play.”
While I do not have the direct evidence, it does not take much of a cognitive leap to see that this “perceptional blindness” can be a result of a heuristic trap. The heuristic trap of familiarity could possibly explain this, i.e. the surgeon knows about the palmaris longus tendon but does not know of its variations or absence. The consistency trap could be at play when the surgeon planned for the harvest of the tendon regardless of whether it is there or not.
There is the possibility that this perceptional blindness is caused by lack of education as the reported errors were committed by surgeons who had not completed an upper extremity fellowship (subspecialty training). In which case the “expert halo” heuristic could be in play. The surgeon knows that they are a musculoskeletal expert in general and goes ahead with the errant harvest of the nerve because they are unaware of not truly being an expert in this minute area of anatomy. The authors point out that the Dunning-Kruger effect may be at work. This is a form of psychological anosognosia: the inability to recognize what you do not know. The expert halo heuristic suggests that the surgeon (and the operating team) can lack the metacognition to realize that a different level of expertise is required.
How can we avoid this?
I believe that heuristic traps can be avoided by three elements: education, experience, and awareness. All three of these elements need to be present to reduce risk.
Formal education for backcountry skiers is available in the form of avalanche certification classes. These classes increase the chance that risk recognition can occur by discussing snow science, terrain travel choices, and providing algorithms, that if utilized, can avoid some of the heuristic traps. In medicine, the formal training to become an expert is established through the process of medical school followed by residency followed by fellowship training. This education should remain ongoing for both groups.
Experience can be gained in a gradual stepwise fashion in the backcountry by learning from direct participation preferably with a guide service. Mountain and backcountry guides bring a wealth of experience with them and can transfer this knowledge to those that are open minded. In the medical field, working with a senior partner with prior specific experience can be immensely helpful when performing more complex surgeries. In both groups, experience can expand by frequent participation. More importantly is the self-awareness that experience is a fluid process that should be built upon by constant evaluation and desire for improvement.
Third, awareness plays a large role. The awareness of heuristic traps should put us on guard to the mental short-cuts we may be taking. Perceptional blindness and the Dunning-Kruger effect can be avoided by a sense of humbleness that comes from improved metacognition of our potential shortcomings. Atul Gawande, in his book The Checklist Manifesto, refers to these errors as “errors of ineptitude.” One tool, checklists will help avoid some of these errors when applied using deliberate conscious awareness. One needs to be alert to the fact that following the checklist without deliberateness (being on auto-pilot) will lead to heuristic traps as has been seen in wrong site/surgical cases even when the checklist was used (the familiarity heuristic and/or consistency heuristic traps–i.e. ”We used the checklist-it must be right”)!
The three elements of education, experience, and awareness will hopefully lead to a flexible mental state that is constantly re-assessing dynamic risks as new information becomes available. In addition to heuristic traps, automation and confirmation bias, cognitive fatigue, cognitive overload, and simply the loss of “presence of mind” or “not being in the moment” can work against us in determining risk. I will write about that in subsequent articles.
Beethoven’s Brush with Amputation
A Medical-History Vignette.
Julian Kuz, M.D.
Originally published in Blodgett Medical Journal 3(1):7-9, 1996.
Ludwig van Beethoven (1770-1827) is widely recognized as one of the most famous composer-musicians of all time. It is precisely because of this lofty status that his medical history has been closely studied. Many aspects of his pathobiography are well known. The best known aspect concerns his deafness that he became aware of at age 27, although the etiology is uncertain.1,2,3,4,5 Numerous authors have conjectured on causes of his liver cirrhosis 1,2 pancreatitis and diarrhea6,7,8 that plagued him in his latter years. However, one little known facet of his medical history is his brush with amputation of one of his fingers.
In early 1808, while Beethoven was composing his renowned Fifth Symphony, Beethoven developed an infection of one of his fingers referred to as an “abscess” by several authors.1,3,9,10 The infection was a serious enough incident that it came up in Beethoven’s correspondence. It is mentioned in a letter from Stephan von Breuning (a friend of Beethoven’s) to Dr. Franz G. Wegeler (one of the first acquaintances that Beethoven confided his realization that he was going deaf) written in March, 1808:
“Beethoven came near losing a finger by a Panaritium [felon],
but he is again in good health. He escaped a great misfortune,
which, added to his deafness, would have completely ruined his
good humor, which, as it is, is of rare occurrence.”11
Unfortunately, no record has survived which mentions which hand or finger was afflicted.
The term ‘panaritium’ is a derivative of the Latin term ‘panaricium.’ The definition of this term is an “Inflammation of the skin fold surrounding the nail.” The preferred term used today in the medical literature that describes this condition is paronychia.12 The term felon, which had been added in brackets to the letter by a later editor, has been used synonymously with the word paronychia in the past. Today the two terms refer to different anatomical sites of infections of the finger.
Paronychia is the most common hand infection. The infection involves the nail fold. The usual cause is any mechanism that disrupts the integrity of the nail fold skin, such as by a hangnail or a small cut by a manicure instrument, followed by an infection of the nail fold. Staphylococcous aureus is the most common infecting organism. The usual treatment for a paronychia involves drainage of the pus collection, open packing of the incision, and appropriate antibiotics. Occasionally, a partial nail excision is necessary to allow free drainage of the pus. After the packing is removed, the area can be soaked in warm saline intermittently until the inflammation recedes. 13
Beethoven described his treatment in a letter to an associate when he wrote “…yesterday my poor finger had to have a drastic nail operation.” 11 This operation was most likely the removal of the nail plate, or a portion thereof, a painful procedure in this pre-anesthetic era. It also was done without any of the usual aseptic conditions and instruments that would be employed today. In another letter to Count Franz von Oppersdorff (the patron who commissioned the Fourth and Fifth Symphony from Beethoven), Beethoven states “I am still under treatment for my poor innocent finger, and have not been able to go out for the last two weeks.”
Beethoven’s nail removal was one of the few effective treatments that physicians in the pre-antibiotic era could offer. By the end of March of that year, he was already attending public events again and was at least healthy enough to go about his usual business.11 This indicates a fairly rapid resolution to the infection following his operation. Had the treatment not been successful, the infection could have raged for a longer period and posed a serious risk to his finger requiring amputation or, in the worst case scenario, sepsis and death. Also, the fact that his nail was the site of surgery militates against the possibility that this was a “felon,” an infection of the pulp of the finger. A felon would not have resolved by nail removal. No records exist that give a possible reason to why Beethoven sustained this infection. Certainly, the generally squalid conditions that many of the average citizenry (including Beethoven) of Vienna in the early 19th century played a participatory role. Several authors have postulated that Beethoven suffered from an autoimmune disease that may have predisposed him to bacterial infections. His medical history recorded abscesses involving not only the finger, but also the jaw in 1808 and foot in 1813.9,10,14,15
It is pure speculation on how a finger amputation might have affected Beethoven. Beethoven was not only a brilliant composer but also a virtuoso pianist. After his paronychia resolved, he performed both his Choral Fantasy and Fourth Piano Concerto later that same year. It is unlikely that he could have done this following a finger amputation without modifying the pieces from what we know of them today or, at the very least, having someone else perform them. This performance in December of 1808 was to be his last as a virtuoso pianist. After this, his performances became more and more marred by his encroaching deafness until he retired completely from public performance in 1815.13 Thus it is doubtful that a loss of a finger would have changed his career as a musician since deafness was already the predominant limiting factor at this time. Furthermore, it is improbable that the loss of a finger would have affected his compositional prowess at this stage of his life. Beethoven lived with many recorded painful, disruptive medical issues and yet remained a musical genius, creating a large output of works that we now enjoy. As one author wrote “…neither his deafness nor his intestinal problems and progressively decompensating liver cirrhosis stopped Beethoven from composing masterpieces of music up until four months before his death.”16
1. Ober WB: Beethoven: A Medical View. The Practitioner 1970; 205:819-24.
2. Landsberger M: Beethoven’s Medical History, from a Physician’s Viewpoint. NY St J Med 1978; 78:676-9.
3. Larkin E: Beethoven’s Illness-A Likely Diagnosis. Proc Roy Soc Med 1971; 64:493-6.
4. Naiken VS: Paget’s Disease and Beethoven’s Deafness. Clin Orthop 1972; 89:103-5.
5. Naiken VS: Did Beethoven have Paget’s Disease of Bone? Ann In Med 1971; 74: 995-9.
6. Davies PJ: Beethoven’s Nephropathy and Death: Discussion Paper. J Royal Soc Med 1993; 86:159-161.
7. London SJ: Beethoven: Case Report of the Titan’s last Crisis. Arch Intern Med 1964; 113:442-8.
8. O’Shea J: Ludwig van Beethoven. In Was Mozart Poisoned? New York, St. Martin’s Press, 1991, p. 39-65.
9. Palferman TG: Beethoven: Medicine, Music, and Myths. Int J Derm 1994; 33:664-71
10. Palferman TG: Classical Notes: Beethoven’s Medical History. Variations on a Rheumatological Theme. J Royal Soc Med 1990; 83:640-5.
11. Forbes E (ed.): Thayer’s Life of Beethoven. Princeton, NJ, Princeton University Press, 1967, p.430.
12. Thomas CL (ed.): Taber’s Cyclopedic Medical Dictionary Philadelphia, FA Davis Co., 1985, p.1212, 1236.
13. Neviaser RJ: Infections. In: Green Dp, (ed.) Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone, 1993: 973-1020.
14. Drake ME: Deafness, Dysesthesia, Depression, Diarrhea, Dropsy, and Death: The Case for Sarcoidosis in Ludwig van Beethoven. Neurology 1994; 44:562-5.
15. Cooper M: Beethoven, The Last Decade 1817-1827, medical appendix by E. Larkin, London, Oxford University Press, 1970, p. 448.
16. Schwarz A: Beethoven’s Renal Disease Based on His Autopsy: A Case of Papillary Necrosis. Am J Kid Dis 1993; 21:643-52. Figure Legend
The Journey Begins
Thanks for joining me!
Good company in a journey makes the way seem shorter. — Izaak Walton
Julian E. Kuz, M.D. 