Wednesday, April 10, 2019

The latest dangerous “addiction” parents need to worry about Health

When my children were little, their favorite thing to play on at the local playground was a big yellow climbing structure. There was a platform that was high off the ground, with various ladders to climb up as well as two slides (one straight and one curvy) and a pole to slide down or climb up. There were even some monkey bars leading up to it on one side. It could be a castle or a pirate ship or a space ship, and climbing it or mastering the monkey bars was a big, pride-filled milestone. It was awesome.

When they renovated the park, they took it down. “There’s nothing good there anymore,” said my youngest. “It’s all little kid stuff.” Everything in the playground now is close to the ground — and hard to get hurt on.

It made me sad.

Don’t get me wrong — as a parent and pediatrician, I want children to be safe on the playground. Between 1996 and 2005, US emergency rooms treated about 200,000 children a year for playground injuries, which is a lot. I worry especially about traumatic brain injuries (TBI) such as concussions, as they can have long-term consequences; a study just released in the journal Pediatrics showed that between 2001 and 2013, there were 21,000 emergency room visits a year for TBI’s in children 14 years old and younger.

The study showed that the number of playground TBIs seen in emergency rooms rose between 2005 and 2013 — but it’s not clear whether that’s because there were truly more of them or whether both parents and doctors were becoming more aware of and concerned about concussions. The fact that more than 95% of the children were treated and released, meaning that the injuries were minor, supports this explanation. Until relatively recently, most parents wouldn’t have brought their child to the emergency room for a head bump unless the child lost consciousness, needed stitches or otherwise seemed very unwell; head bumps were considered a normal part of childhood.

We now understand that head bumps can be more dangerous than we realized, and we are more careful at playgrounds (and in sports). That’s why the yellow climbing structure came down, I’m sure; the study found that playing on those, and swings, was the biggest cause of TBI. But as a parent and pediatrician, I think we need to be careful with being careful.

Concussions shouldn’t be a normal part of childhood, and playgrounds should be safe. But being safe isn’t just an environment thing; it’s also a learned skill. Children need to learn what and where the dangers are, and how to avoid them. They need to learn their limitations — and learn when to respect them, and when to push them.

These aren’t just safety lessons, they are life lessons. Life is full of challenge and risk. And whether it’s a broken arm or a broken heart, sometimes we get hurt as we learn to meet those challenges and risks.

So of course, let’s make our playgrounds safe. Let’s make sure there are soft surfaces beneath climbing structures and swings. Let’s make sure that equipment is maintained properly. Let’s make sure that caregivers supervise children. Let’s educate people on the signs of concussion, and on what to do if they see those signs.

But let’s not get overprotective in the process. Let’s not take down all the high climbing structures or big swings — and especially, let’s not stop our children from doing anything that might be risky. Because the risks will always be there — and we won’t always be there to watch them. It’s better they practice now, on a playground, with us nearby. y often caused by our thoughts, feelings, and resulting behaviors. And an exciting new study now demonstrates that treatments aimed at our beliefs and attitudes can really help.

When our back hurts, it’s only natural to assume that we’ve suffered an injury or have a disease. After all, most pain works this way. When we cut our finger, we see blood and feel pain. When our throat hurts, it’s usually because of an infection.

But back pain is different. There simply isn’t a close connection between the condition of the spine and whether or not people experience pain. Research has shown that a majority of people who have never had any significant back pain have the very same “abnormalities” (such as bulging or herniated spinal discs) that are frequently blamed for chronic back conditions. And then there are the millions of people with severe chronic back pain who show no structural abnormalities in their back at all.

On top of this, it turns out that people in developing countries, who do back-breaking labor and don’t have easy access to medical treatment, have much fewer incidents of chronic back pain than people in the developed world who sit in ergonomically designed chairs, sleep on fancy mattresses, and have ready access to spinal imaging, surgery, and medications.

Because there’s so little correlation between the condition of the spine and any given person’s experience with back pain, clinicians and researchers have begun looking instead at treatments that address the psychological and behavioral patterns that can lock people into years of suffering. And they’ve just demonstrated that two of these treatments work much better than traditional medical interventions alone.
What actually helps back pain

Last week, researchers at the University of Washington published a landmark study in The Journal of the American Medical Association that showed training people with chronic low back pain in either mindfulness or cognitive behavioral therapy (CBT) works significantly better than medical care alone to reduce both their disability and pain-related suffering. The researchers randomly assigned 320 adults, ages 20 to 70, to either an eight-week class in one of these methods, or to “usual care.” The subjects who attended the classes saw significantly more improvement in their pain and disability than those receiving usual care — and this greater improvement was still evident a full year later, when the study ended.

Mindfulness training teaches us to be aware of, and accept, moment-to-moment physical sensations of discomfort, while letting go of our usual negative reactions. So instead of spending hours each day thinking about how much we hate our back pain, worrying about our prognosis, and seeking relief, we learn how to be with the pain — paying attention to how it actually feels at each moment and relaxing our tendency to tense up against it, while observing our worried or distressed thoughts and feelings coming and going.

CBT takes a somewhat different approach. It helps us learn to observe and identify our negative thoughts about our condition, and replace them with more realistic ones.

Both methods help us see the functioning of our minds more clearly, and the role that anxious, angry, and frustrated thoughts and feelings about our condition play in increasing our fear and stress.

And as it turns out, it is precisely this fear and stress that maintains most chronic back pain. This explains why events such as childhood physical and sexual abuse, painful losses, and job dissatisfaction have all been shown to be risk factors for the condition.
Take action for back pain relief

The excellent news is that for most of us, chronic back pain needn’t derail our lives. CBT is available at many pain clinics, as is mindfulness training.

You might also try on your own. You could explore CBT using the book on which the University of Washington class was based: The Pain Survival Guide: How to Reclaim Your Life. Alternatively, you can try mindfulness practice by following recorded instructions. While there are many resources for these, you can listen for free to some that I recorded at

Additionally, for a comprehensive guide to using mindfulness along with rehabilitation to work through chronic back pain, you can consult a book I co-authored on the subject: Back Sense: A Revolutionary Guide to Halting the Cycle of Chronic Back Pain. Chances are good that at some point you or someone you know will have hip replacement surgery.

I can say that with some confidence because it’s a common operation that’s becoming more common all the time. An estimated 300,000 total hip replacements are performed each year in this country, and that number is expected to nearly double by 2030. The most common reason is osteoarthritis, the age-related “wear-and-tear” type of arthritis that can be difficult to treat with medications or other non-surgical approaches.

If you’ve had a hip replacement yourself, you may have experienced some things that surprised you. For example:

    Despite having major surgery on the largest joint in the body, you probably stood up and started walking on it within a day or two.
    You probably were only in the hospital for a few days.
    The improvement in the arthritic pain is usually noticeable right away.
    Despite all that, after discharge from the hospital, the physical therapy visits seemed to go on forever.

In fact, it’s routine after hip replacement surgery to have extensive physical therapy — also called rehabilitation therapy, or “rehab.” This usually consists of a series of outpatient appointments with a physical therapist. These visits usually take place two or three times a week for a month or more to help you work on strengthening, stamina, and balance.
Is home rehab just as good?

A new study calls into question the way people receive rehab after hip replacement surgery.

The researchers presented their findings at a recent meeting of the American Academy of Orthopaedic Surgeons. They described how, among 77 people having hip replacement surgery, half were randomly assigned to meet with a physical therapist 2 or 3 times a week for 2 months. The rest were instructed on particular exercises to be performed on their own at home for two months.

Here’s what they found:

    One month after surgery, there were no major differences in the individuals’ ability to function as assessed by their ability to sit, walk, and use stairs, or other measures of daily activities.
    Six months after the surgery, there was still no difference in results.
    Changing the routine physical therapy from supervised appointments to exercising at home could be accompanied by a significant reduction in the cost of care. And the convenience is an extra bonus.

Of course, this may not work for everyone. Many people who have hip replacement surgery cannot return home right away, especially if they live alone and have to climb a number of stairs right away. For them, surgery is followed by a stay at a rehabilitation facility, where they receive supervised physical therapy on a daily basis until they’re strong and steady enough to get around safely at home.

Another consideration in how post-op rehab is provided is the notion of “pre-hab” — that is, when surgery can be planned in advance (such as a hip replacement for arthritis), an exercise program prior to surgery may be useful. Those willing and able to exercise before surgery may have an easier time with home rehab.
So, now what?

This new research should be considered preliminary because it included only a small number of study subjects and the results were presented at a medical conference; they have not yet been published in a peer-reviewed medical journal. Additional research will likely be needed to confirm the findings and to identify those who are most likely to do well with self-directed rehab.

But, if the findings of this new study are confirmed, it’ll be welcome news for the thousands of people having hip replacement surgery who may no longer be asked to trudge back and forth to physical therapy appointments. For parents of teens, “addiction” is a scary word. It brings to mind all sorts of things we never want to have happen to our children, from overdoses to arrests — and so we talk to our kids about drugs and alcohol. But is there another addiction we should be worrying about, too?

The Merriam-Webster definition of addiction is “a strong and harmful need to regularly have something (such as a drug) or do something (such as gamble).” Using that definition, you could make a real argument that many teens are becoming addicted to their mobile devices.

You could make the same argument about their parents — and plenty of other people, too.

Common Sense Media recently published a report on a survey they did on 1,240 parents and teens (620 parent-child pairs). The findings are not a big surprise to anyone who, well, looks up from their phone. They found that:

    50% of teens feel that they are addicted to their mobile devices (and 28% think that their parents are too)
    27% of parents feel that they are addicted to their mobile devices (and 59% think that their teens are too)
    66% of parents feel that their teens spend too much time on their mobile devices — and 52% of the teens agree with them
    48% of parents and 72% of teens feel the need to respond immediately to text messages and other notifications
    69% of parents and 78% of teens check their devices at least hourly
    half of parents and a third of teens at least occasionally try to cut down the time they spend on their devices.

This is pretty powerful. Parents and teens are in agreement that their devices have a hold on them.

Now, I don’t want to seem to say that constantly checking Instagram is the same as shooting heroin. Clearly, it’s not. I also want to be careful to point out that clinicians are not quite ready to use the word “addiction” when it comes to technology. And there is also very limited research on the long-term effects of having our faces stuck to our phones. But there is real cause for concern.

Devices displace. It’s that simple. We only have so much bandwidth when it comes to awareness, interaction, and memory; multitasking is, ultimately, simply paying less attention to more things. And when you pay less attention, there can be consequences.

For teens, there are consequences when it comes to learning (it’s hard to lay down new memories and learn new material when you are distracted), social relationships (it’s hard to build or maintain them, and to hone social skills, when you are on your phone), sleep (which can have tremendous impacts on both mental and physical health), safety (like using the device while driving or crossing the street) and the general and important ability to sustain attention.

For parents, besides all the consequences above (which apply to adults, too), there are concerns about how devices literally get in the way of parenting. Researchers at Boston University have done some very interesting observational studies of parents and children, and found (here’s a shocker) that when parents are on their phones, they interact less with their children. Given that so much of relationship-building and cognitive development depends on interaction, the implications — which may not be fully seen for years — could be significant, even profound.

We need more research to understand all those implications. But in the meantime, the message is clear: devices need to be used thoughtfully, and with care.

Every person and every family is different — and so every approach to a healthy balance is going to be different. But there are three times when device use should be as close to zero as possible:

    When it impacts safety, like when driving or walking. This is where the zero comes in.
    When attention is important for learning or performance, like at school, doing homework, or in the workplace.
    During social gatherings, like meals or parties — or simply hanging out or having a conversation. It’s one thing to use devices to connect with people who are somewhere else; it’s entirely another to use devices when those people are sitting next to you. Our connections with other people are crucial for our health and well-being; we cannot let our devices undermine those connections.

Check out the Common Sense Media report. Talk about it as a family. Do some soul-searching. Make some ground rules. Make sure that every day, you spend time paying full attention to the world around you — and to the people you love.

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