Your big toe

I’ve recently seen a few articles about feet, especially the big toe. Is that a new thing?  Dr. Courtney Conley, who specializes in foot and gait mechanics, says that “Toe weakness is the single biggest predictor of falls when we get older.” Really?! Apparently, gripping the floor with your toe flexors is crucial in maintaining balance. (The flexor muscles are those you use to curl your toes down.) One study assessed the feet of 312 men and women aged 60 to 90, looking for bunions and other toe deformities. In 12 months, 107 people had fallen. The fallers showed significantly less strength in their toes and were more likely to have bunions and other deformities.

In addition to balance, we use toe muscles for propulsion when walking. If toe strength is compromised, everything up the chain is more vulnerable—ankle, knee, hip, and spine. Lack of toe flexor strength is implicated in bunions (hallux valgus) and lesser toe deformities, such as hammer toe (raised toe knuckle).

The big toe gets special attention. Your big toe initiates propulsion when we walk. Lack of big-toe extension (pointing the toe up) can cause gait dysfunction and can even be a limiting factor in getting up off the floor unassisted as we age. One expert says that, when pointing your big toe up, the angle should be about 50 degrees (photo). 

You can determine your toe dexterity by trying to lift your big toe while keeping your other toes flat on the ground and vice versa. Being able to move your toes independently, even a small amount, is a sign of healthy feet. One physical therapist says your toes can be agile enough to play the piano. Right.

You can do exercises to strengthen your toes, such as, while sitting, placing all five toes of one foot on a folded towel, then pressing your toes down (don’t grip) and raising your heel.

I have bunions and one hammer toe, but I’m not a faller! I tried a series of toe exercises. They’re probably worth doing, but they’re a drag to do. As to the photo: impressive! I can’t even come close.

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Administrative waste in health care

This from The Journal of the American Medical Association: The cost of health care is “the largest sector of the US economy and 29% of net federal outlays.” Here are some more of their points:

• For people with employer-based insurance, health insurance premiums represent 25% of the median family household income before having to pay thousands of dollars more to use their health insurance.
• The US spends almost twice the average on health care and administration than the 37 other countries who belong to the Organization for Economic Co-operation and Development (OECD).
• The US spends approximately 10 times more on administrative expenses than any other OECD country. Two-thirds of these costs are related to transactions or billing costs and insurance-related costs.
•  In the US, a primary care physician spends $20.49 to receive payment for a service that generates approximately $100 in revenue.
•  In medical practices, the time spent trying to get prior authorization from insurance companies is equivalent to the annual working time of 100,000 registered nurses.

The authors want the Trump administration to fix the problem.

Bonus factoid: 29% of doctors in the US weren’t born here.

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Earworms

In case you didn’t know, earworms are fragments of songs that stick in your head. I have earworms most of the time and have no idea how my mind chooses certain tunes. Once it was a fragment of a hymn! “Killing Me Softly” is a recent earworm of mine. Why that? It turns out that scientists have actually studied earworms! Psychologists call them “involuntary musical imagery” that can produce some insights into how memory works—how associations with music trigger memories or how mood is associated with memory.

One group of scientists conducted a huge survey by asking radio listeners to call the station and report on their current earworm and why they had it. From this data, the scientists determined the most common triggers for earworms. Unsurprisingly, the most common trigger is having heard the song recently, but other experiences can trigger an earworm, such as seeing a license plate with letters that bring a song to mind. Mood is also a trigger. Sadness, for example, might be associated with a certain song. Earworms are more likely to occur when your mind is wandering—when you’re not focusing on something.

Scientists also discovered that earworm songs tend to be in a certain tempo range—around 124 beats per minute (two beats per second), which is generally faster than non-earworm songs. That tempo, they say, aligns with our body rhythms—the speed at which we like to move or dance. Also, earworm melodies tend to go up and down in a regular pattern, which may help us recall the song more easily.

What if you’re tired of your earworm and want it gone? You can switch to a different song, or you can chew gum vigorously. Because chewing involves the same nerve signals you use to mentally sing the song, gum chewing interferes with your mental singing—provided you’re not chewing to the beat of the music.

I don’t mind my earworms, but now I’m back to my Killing Me Softly earworm, which has become tiresome. Alas, there’s no gum in the house.  

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RFK Jr. and the F.D.A.

But first, a word about measles: You undoubtedly know about the recent measles outbreak in Texas in which one child died, and that Kennedy, an anti-vaccine activist and newly appointed head of Health and Human Services, noted that the outbreak is “not unusual.” In fact, the outbreak is unusual. Until a few weeks ago, someone hadn’t died of measles in this country since 2015.

According to the CDC, before a vaccine became available in 1963, an estimated 3 to 4 million people in the United States were infected each year. Each year, an estimated 400 to 500 people died; 48,000 were hospitalized; and 1,000 suffered encephalitis (swelling of the brain). Since the arrival of the vaccine, endemic spread of the virus was declared eliminated. Of course, we old people were not vaccinated. As a result of my measles infection, I lost half the hearing in my left ear. (Measles can damage the nerve fibers in the inner ear.)

While scientific experts agree that Kennedy’s wacky ideas could pose a danger to human health, they also contend that the F.D.A. needs to change. (At the same time, they also say that the agency should have more resources and authority—not less—and that the FDA is the most important public health agency we have.) Here are the changes they recommend:  

• Stop relying so much on industry funding. Almost half of the F.D.A.’s budget comes from “user fees” in which pharmaceutical and medical advice companies pay the F.D.A. to review their products—an obvious conflict of interest. (The government should pay.)
• Crack down on employee-industry connections. The F.D.A. commonly hires people employed by drug or device companies and, in reverse, F.D.A. employees leave the agency to go work for these companies. Advisory committee members may also have close ties with the industry. More conflict of interest.
• Close loopholes in the approval process. While experts generally agree that the F.D.A.’s approval process for new drugs and vaccines is rigorous, some worry that such rigorous standards aren’t enforced across other divisions, most notably medical devices, food additives, and supplements.
• Break the F.D.A into two agencies, one focused on food and the other on drugs.

Happily, Dr. Martin Makary, who will head the F.D.A., seems well qualified. As one F.D.A. watcher noted, “It could have been way worse.” Fingers crossed.

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Walking

 You’re supposed to engage your glutes (butt muscles) when you walk. As Esther Gokhale, the posture lady, writes, “The buttock and leg muscles contract strongly to propel the body forward, thus getting the exercise they need while the back is spared unnecessary wear and tear.” She says that for us in industrial cultures “walking consists of a series of forward falls blocked abruptly by the forward leg. The gluteal and leg muscles are underused.” This “forward fall” type of walking jams the hip joint and every other weight-bearing joint. Now she tells me.

I’ve found it’s hard to think about contracting my butt muscles to propel me forward. But what’s easier to remember is keeping my back leg straight and the heel on the ground. When you do that, your glute muscles engage.

Here's an illustration showing you (too) many things to think about when you walk. 

Now I'm going to think about "leg externally rotated." Maybe it will keep my hips from caving inward, which is what I think caused my knee problems. 

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Hip mobility and balance

I’ve long been big on maintaining strength in my butt. Your butt muscles (glutes) help keep you upright and propel you up from a seated position. If we don’t use these and other postural muscles enough, they “forget” how to maintain balance. Picture a skeleton standing on its two little feet and how easy it would be to tip it over. Your butt and thigh muscles keep you from tipping over.

I hadn’t given much thought, however, to range of motion in my hip joints. One expert notes that “every sort of function or movement you perform is somehow related to your hips.” Your hip joint can’t function properly if it can’t move through its full range of motion or if your glute and hamstring muscles are weak. If those muscles are weak, other joints and muscles will take over, even if they’re not strong enough to manage the load. Pain and injuries from overuse may result.

Sitting for long periods can be a problem: your glutes are turned off, forcing the smaller hip flexor and lower back to provide support. Those smaller muscles become overworked, which is why they may ache when you stand up.

If the muscles around your hips aren’t working properly, it limits how easily you can move your hips. Full range of motion in your hip means that you can move your leg forward and backward, side to side, and in rotation.  If you struggle to touch your mid-calf without bending your knees, or if you have trouble bringing one ankle over your opposite knee while sitting, it means that your hip joint is limited. If you can't get up from the toilet without using your hands, it means your glutes are weak (my analysis).  

You can find plenty of exercises by Googling “hip mobility exercises.” AI will provide you with a nice list with links to additional information.

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The latest on multivitamin food supplements

According to the Journal of the American Medical Association, one in three U.S. adults take multivitamin supplements. (The Atlantic says three-quarters of Americans take at least one dietary supplement.)  Here’s what the Journal has to say about their value:

• Twenty years of studies that included almost 400,000 participants showed that taking multivitamin supplements was “…not associated with a mortality benefit.” In fact, they write, “…mortality risk was 4% higher among multivitamin users, compared with nonusers.”

• Beta carotene supplements, as well as vitamin C and E and zinc, are associated with slowing the progression of age-related macular degeneration. (Beta carotene is a natural pigment found in many fruits and vegetables, such as carrots, sweet potatoes, spinach, and apricots.)  

• Getting beta carotene from food is associated with reduced cancer risk. For at-risk people, such as smokers, taking beta carotene as a supplement increases the risk of lung cancer.

• In older people, multivitamin supplementation is associated with improved memory and slower cognitive decline.

• Taking iron as a supplement, which adds to the iron consumed in food, increases the risk of iron overload. Iron overload is associated with an increased risk of cardiovascular disease, diabetes, and dementia.

• Calcium and zinc may reduce the absorption of certain antibiotics.

Overall, the article says, “…there is little health rationale for the use of multivitamin supplements. Micronutrients come most healthfully from food sources.”

The dietary-supplement industry was valued at $40 billion in 2020. It is minimally regulated: the FDA doesn't review dietary supplements and manufacturers don't have to reveal their ingredients. 

I don't take supplements. Robert Kennedy Jr. says he takes a "fistful" of vitamins each day. You be the judge.

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Re-defining Alzheimer’s disease—maybe

Alzheimer’s disease is characterized by abnormal protein deposits in the brain. It begins with an asymptomatic phase and progresses—if the person lives long enough—to mild cognitive impairment and, eventually, a level of impairment that interferes with the daily process of living.

Researchers have developed two types of tests to diagnose Alzheimer’s before symptoms appear: blood tests that identify biomarkers, and genetic tests that identify the problematic genes. The tests show the full spectrum of the disease, beginning with the seeds of pathology deep inside the brain and ending with dementia.

Biomarker tests. A blood test can detect changes in the brain that predict Alzheimer’s disease up to 15 years before the first symptoms emerge.

Genetic tests: Genetic tests can identify a group of susceptibility genes—APOE—indicating an increased likelihood of developing Alzheimer’s disease by age 85. If you have a single copy of the APOE e4 gene, you are two to three times more likely than the general population to get Alzheimer’s by age 85. If you have two copies, you are 12 times more likely to develop the disease.  

Several groups are working to develop guidelines for diagnosing Alzheimer’s. It’s controversial. The working groups disagree on the word “diagnosis” when referring to the results of the blood test. Some prefer the word “risk,” believing that people should not be diagnosed with the disease based on biomarkers alone.

About drugs and treatment:

• Two drugs have been shown to reduce the disease progression by 27 percent, although their effectiveness in the later stages of the disease or in asymptomatic people, is unproven. The drugs cost $26,000 to $32,000 a year, with side effects that include a risk of swelling and bleeding in the brain.
• There are currently no treatments for those who have the biomarkers but not the symptoms.
• New guidelines discourage routine testing of asymptomatic people except in the context of research. But clinical trials of Alzheimer’s drugs are under way for treating people whose blood tests for the disease are positive. If such drugs prove successful, pre-symptomatic testing may become routine.  

About conflicting evidence:

• A substantial number of the people diagnosed with Alzheimer’s—based on blood and genetic tests—will die without ever having exhibited signs of dementia.
• Postmortem studies have found that up to 30 percent of people who received a clinical diagnosis of Alzheimer’s disease did not have the characteristic plaques and tangles in their brains.
• Many people have the plaques and tangles—as shown in postmortem dissections—but not dementia. In a famous study of 678 nuns, ages 75 to 107, postmortem dissections showed that the brains of many of the nuns had all the plaques and tangles of Alzheimer’s disease, but that their owners had shown no signs of dementia when they were alive. In fact, in 80% of the cases the pathology, as revealed in their brains, did not concur with the symptoms seen during life.

Something else is going on here. 

By the way, 23andMe gives you the choice of not looking at the results of the APOE gene test. I gathered up the courage, looked and got the following message: "Constance, you do not have the ε4 variant we tested." Whew!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Walking

You’re supposed to engage your glutes (butt muscles) when you walk. As Esther Gokhale, the posture lady, writes, “The buttock and leg muscles contract strongly to propel the body forward, thus getting the exercise they need while the back is spared unnecessary wear and tear.” She says that for us in industrial cultures “walking consists of a series of forward falls blocked abruptly by the forward leg. The gluteal and leg muscles are underused.” This “forward fall” type of walking jams the hip joint and every other weight-bearing joint. Now she tells me.

I’ve found it’s hard to think about contracting my butt muscles to propel me forward. But what’s easier to remember is keeping my back leg straight and the heel on the ground. When you do that, your glute muscles engage.

Here's an illustration showing you (too) many things to think about when you walk. 

Now I'm going to think about "leg externally rotated." Maybe it will keep my hips from caving inward, which is what I think caused my knee problems. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The healing power of nature

A famous study, published in the journal Science, demonstrated that nature can promote healing. Researchers found that people in hospital beds who looked onto trees had shorter stays and took fewer painkillers than those who didn’t. Just looking at nature influenced their health, triggering physiological changes in their bodies.

It turns out that not only the sight of the natural world, but also its smell, sound, and feel slows our breathing and heart rates and lowers our blood pressure and adrenaline. In other words, its effects are calming. Apparently, when out in nature, we breathe in volatile molecules released from plants. The molecules enter our bloodstream and interact with biochemical pathways, triggering beneficial metabolic processes.

Sounds, like birdsong, the wind rustling leaves, and the trickling of a stream have similar benefits. Researchers found that people who were awake during surgery experienced much lower stress levels when listening to such natural sounds than when listening to other types of sounds.  

Japanese researchers have studied the effects of “forest bathing” (walking in the woods) and have found that this activity elevates the walkers' Natural Killer (NK) cells. (Natural Killer cells are white blood cells that fight tumors and infections in your body.) The researchers theorize that inhaling the aerosols emitted from the forest are responsible for the effect. A subsequent study, in which essential oils from cedars were emitted in a hotel room where people slept, also caused a significant spike in NK cells. 

I have a few diffusers in my house that emit the fragrance of fir trees. I like the way they smell. Until now, it never occurred to me that they were beneficial to my health. They’re expensive, but maybe worth it!

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The vagus nerve and inflammation

More than half of all deaths from disease are tied to inflammation, including heart disease, stroke, asthma, diabetes, and autoimmune and neurodegenerative conditions. About a third of people with major depression also have inflammation. Some inflammation is protective, such as the swelling and redness you get when stung by a wasp. This is your immune system dealing with the venom. In such cases, your spleen releases proinflammatory molecules (cytokines) into your bloodstream to activate your immune response, a complex system that includes regulation by the vagus nerve.

But sometimes the immune system can become overactive and damage tissues. In such cases—often the result of stress, chronic infection, or autoimmune disease—inflammation can cause the proinflammatory molecules to circulate continuously for months or years. Examples of an overactive immune system include Crohn’s disease, Parkinson’s disease and chronic pain.

The vagus nerve controls the inflammatory reflex, which includes the delivery of information about inflammation from your body to your brain. In response, your brain—via the vagus nerve—sends signals to your body to regulate its immune response. In the case of chronic, harmful inflammation, the nerve pathway that carries anti-inflammatory signals from the brain to the body may be impaired.  

As with treatment for treatment-resistant depression, scientists are exploring the use of vagal nerve stimulation (VNS) to treat chronic inflammation. The treatment looks promising, as the Pub Med medical journal stated: “Clinical applications have confirmed the efficacy of VNS in managing specific autoimmune diseases, such as rheumatoid arthritis, and chronic inflammatory conditions like inflammatory bowel disease.” This treatment is in its infancy, but worth exploring if you’ve got chronic inflammation.

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The vagus nerve and depression

The vagus nerve is the longest in your body with fibers in nearly every organ, including your brain. There is one on each side of your body, each with up to 100,000 fibers. Most fibers send messages from your body to your brain, helping to maintain internal equilibrium. The information about the state of the body—such as heart rate—is carried to many of the brain regions implicated in psychiatric illness.

Investigators have long known that activating the vagus nerve with mild electrical pulses can treat epilepsy. A surgically implanted device, called a vagus nerve stimulator (VNS), cuts the frequency of seizures by 45 percent. In pursuing their research, scientists discovered an interesting side effect of the treatment: it made people happier.

A similar surgically implanted device is now being used to treat people with treatment-resistant depression. A 2017 study of 800 people with this condition found that five years of VNS fully cured 43.3 percent of them and halved the symptoms for 67.6 percent. (Depression is complex and variable. Different types of vagus nerve signals might be effective for different people.) VNS treatment strengthens connections between certain parts of the brain, including the parts associated with emotion processing. It also increases the activation of “feel good” hormones.

Now you can get devices that access the vagus nerve from outside the body. They’re called tVNS devices (the t stands for transcutaneous). You can buy these online! They come in two types, as you can see below. But studies show that surgically implanted devices are more effective.

In the interests of brevity, I’ve oversimplified this complex subject. For example, one of the research findings has shown a relationship between the vagus nerve and inflammation. I’ll discuss that topic next.

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What if you hit your head in a fall?

Friends who live in a retirement community tell us that, when residents fall, they are asked if they’ve hit their heads. If the answer is yes, they are taken to the hospital to be checked for possible brain injury. If the injury is severe, the person may have a life-threatening brain hemorrhage. But this is unlikely. If anything, the person might have a concussion. “Concussion” is another word for mild traumatic blunt injury.

My 97-year-old super-ager friend, Donna, who also lives in a retirement community, fell during a middle-of-the-night trip to the bathroom. As she was going down, she tried to fall like a 49er ("drop, roll, get up").  Nevertheless, she hit her head, but she did get up and went back to bed. The next morning she was dizzy and couldn't remember what had happened. After calling Resident Services, she was taken to the ER in an ambulance. She had a concussion.

Hitting your head can transmit a wave of pressure through the brain that can temporarily stun the neurons. Any damage to the brain caused by a concussion cannot be detected by a CAT scan or MRI. That’s because the damage occurs on a microscopic level. For this reason, a diagnosis is based on symptoms: headache, sensitivity to light, dizziness, nausea, vomiting, and amnesia. (With most concussions, there’s no loss of consciousness.) Such symptoms can last anywhere from seconds all the way up to weeks or even months. 

People who have had concussions may also experience memory problems, have trouble concentrating, suffer from drowsiness, and/or become irritable. For old people, concussion symptoms can be subtle and easily mistaken for normal aging.

Treatment for a concussion consists of rest, avoiding physical activities while recovering, and taking medicine for headaches. Donna says she "needed brain therapy." In fact, a series of therapists came to her apartment several times a week, helping her with movement and even speech. She felt "supremely supported and encouraged." She fell in early October. We met for lunch in late December. She says she's still concerned about loss of memory. To me, she seemed like her old self: alert, engaged, good humored, and energetic. She remembered how to get to the restaurant and directed me to it.

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Have you fallen?

I got most of the following information from an article in JAMA (Journal of the American Medical Association). It was written by a retired physician, Dr. Bruce Campbell. At a visit to his doctor, he’s asked whether he has fallen in the past six months. He lies and says no. That’s what I do! Like him, I think it doesn’t count if you’ve done something like, in my case, tripping over a garden hose. (I have no trouble getting up.) I learned, in his article, why we’re always asked that question.

In the U.S., falls are reported every year by more than 14 million people over the age of 65 and are associated with about 90 percent of hip fractures. A history of one or more falls in the six months prior to a surgical procedure is associated with postoperative complications, higher levels of post-hospital care, and increased 30-day readmission rates.

The Centers for Medicare and Medicaid Services requires medical personnel to ask if you’ve fallen. It gathers this data to track the proportion of enrollees who have been assessed for their risk of falling.  This information, collected by doctors’ offices, is tied to reimbursement. The greater the proportion of patients queried, the better the reimbursement. (That’s what he wrote!)

As Dr. Campbell notes, admitting to a fall might trigger a cascade of medical tests, such a neuropsychiatric evaluation or stress test. Even his 90-year-old mother, who lived in a senior living apartment, lied about falling. When she fell and couldn’t get up, she called her son instead of the office. (She kept her phone in her pocket.) She was afraid she’d be hauled off to the hospital on a stretcher and subsequently moved to assisted living or a nursing home.

Dr. Campbell continues to lie. As will I.

Next week: What if you hit your head from a fall?

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Doctors versus AI

Researchers conducted a small study to compare diagnoses performed by doctors versus those performed by AI, specifically ChatGPT. After recruiting 50 doctors for the experiment, the researchers divided the experiments into three groups: 1) Doctors not using the chatbot; 2) Doctors using the chatbot; 3) The chatbot by itself. The three groups were given six real-world case histories and told to suggest diagnoses and explain why they favored or ruled them out. The case histories had never been published, so neither the doctors nor ChatGPT would have foreknowledge about them.

Here are the results: Doctors who did not use the chatbot had an average score of 74 percent. Those who did use the chatbot had an average score of 76 percent. The chatbot by itself scored an average of 90 percent, vastly outperforming all the doctors!

[The researchers, in a subsequent interview, said "The results were not what we expected....we thought the doctors who had access to the chatbot were going to do way better than the doctors who only had access to the usual internet—UpToDate, PubMed, Google, whatever."]

The doctors using the chatbots often were not persuaded when the chatbot pointed out something that was at odds with their diagnoses. Instead, they tended to be wedded to their own ideas of the correct diagnoses. In describing how they came up with a diagnosis, doctors would say, “intuition,” or “based on my experience.”

Researchers also found that few doctors knew how to take advantage of the chatbot’s ability to solve complex diagnostic problems. For example, they treated the chatbot like a search engine, asking questions such as “What are the possible diagnoses for eye pain?” Only a few of the doctors figured out that they could copy and paste the entire case history into the chatbot and ask for a comprehensive diagnosis.

Hey! We could try this at home!

P.S. This post marks the tenth anniversary of my weekly blogs. 

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.