Heart and brain got the investment; the musculoskeletal system did not [PODCAST]

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You can learn more from watching a patient walk down the hallway than from the rest of the exam. Most exams happen sitting or lying down. Narinder Singh Parhar is an internal medicine physician and founder of Jeeva Health Systems. This episode is based on his article “Musculoskeletal health may be the foundation of prevention,” published on KevinMD. After nearly 40 years in practice, he argues that medicine poured decades of investment into heart and brain prevention while leaving the musculoskeletal system behind. You will hear what a walk down the hallway reveals about cardiopulmonary reserve, fall risk, and confidence, and the two muscle groups he says everyone overlooks. You will also hear his specific activity prescription, including a backward walk that takes under two minutes. Press play for what he wants asked at every visit, and why he thinks patients are watching your health as closely as you watch theirs.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Narinder Parhar. He’s an internal medicine physician. Today’s KevinMD article is “Musculoskeletal health may be the foundation of prevention.” Narinder, welcome back to the show.

Narinder Singh Parhar: Thanks, Kevin. Good to be here.

Kevin Pho: All right. Tell us why you decided to share this particular article on KevinMD, and then talk about the article itself for those who didn’t get a chance to read it.

Narinder Singh Parhar: Yes, sure, Kevin. I have been practicing for almost forty years, and of course following the national statistics and population health, I find that we have invested very well in the acute care of coronary artery disease, as well as vascular disease, or cardiovascular disease. We have done wonderfully well in advancing coronary care, including post-myocardial infarction care, stent placement, and the different generations of stents, which have done wonderfully in preventing reocclusion. Cardiac rehab and the tobacco cessation programs did very well for prevention, along with BP control and lipid control. They all played a wonderful role in decreasing the burden of coronary artery disease, as well as cardiovascular disease.

However, I feel that we have underinvested in advancing musculoskeletal health. I think that’s an opportunity that we as a health care system could take advantage of.

Why is the musculoskeletal system so important? Well, number one, the body is a unit. No system lives in isolation or in a silo. The musculoskeletal system is actually the backbone of our mobility, our joint flexibility, our exercise, our resistance, and our muscle building, as well as our breathing efficiency and our sleep hygiene.

A person who has a weak musculoskeletal system and decreased mobility cannot participate in any exercise patterns. They cannot recover well through cardiac rehab. Endothelial function cannot be at its prime for a person who is just a couch potato. There are other side advantages as well. Insulin sensitivity is one important one, along with weight control and gastric emptying itself. These are all aspects of general health that depend on sound musculoskeletal health and the ability to perform these activities.

Kevin Pho: I think over the years, a little more attention has certainly been paid to musculoskeletal health. You hear about some of these longevity experts, and physicians as well, who really want to focus on strength training and how important it is for both men and women as they get older. But it is certainly not getting as much attention as you would like, right? So, what would you like to see happen? What would it look like to screen for musculoskeletal health in much the same way we screen for cholesterol?

Narinder Singh Parhar: Sure. Very good point. Before I delve into it, I remember reading a book by Sanjay Gupta, Keep Sharp, which said that people who want to prevent dementia or cerebrovascular disease are well advised to keep good heart health as well, because, as he said, what is good for the heart is good for the brain. I would take that statement one step further: What is good for musculoskeletal health will be good for the heart and will be good for the brain. So that is extremely important.

Now, to come back to your question, what could we do as physicians or health care providers to improve, or to help patients with this, beyond what we are doing at this time? I have a few suggestions. One is that we, or our staff, need to ask patients how much physical activity they are doing on a daily and weekly basis. I know some organizations have started doing it, especially Kaiser, which I have experience with. They check how much the person is walking, how many minutes a day, how many days a week, etc. But it’s a rather cursory interview. I think we can invest a little more in it if the physician or the health care provider, herself or himself, also asks these questions, or at least confirms that whatever answers were given to the medical assistant are correct.

Another important step I would take the liberty of recommending is that we should assess patients’ gait. We should not examine patients only sitting or lying down on the examining table. We should include the patient’s mobility in our initial assessment. What I would recommend is that the health care system make this a fifth vital sign, because mobility gives so much information, not only about the patient’s musculoskeletal health, including muscle strength and the joints. It also tells us about the cardiopulmonary reserve the person has, how much confidence the person has, and whether the person is at risk of falling.

As a medical community, we were probably taken for a ride by the narcotic industry into including pain as a fifth vital sign. But in my humble opinion, the musculoskeletal assessment with the gait review should be an important initial tool, an important vital sign, because it gives so much information that our history and the rest of our exam might miss.

Kevin Pho: So let me ask: When you ask patients how much physical activity they normally get, what counts as physical activity? And what are some recommendations in terms of how much physical activity they should be doing?

Narinder Singh Parhar: It starts with the basics. I think each of us, and all our patients, should be walking daily, brisk walking, because it’s a whole-body exercise. It doesn’t take any extra investment of finances; it comes free. Forty-five minutes a day, at least five days a week, is optimum. I would also recommend muscle preservation through resistance exercises at least three to four times a week, for even twenty minutes a day. Those are important, and I think we should emphasize that.

Third, I think, is strengthening of the spine extensors, as well as strengthening of the hip adductors. These are overlooked muscle groups that we take for granted, both as health care experts and as a general population. We think that we have this natural gift, so it will continue to serve us all through our lives even if we ignore it. And of course, sound sleep, sleep hygiene, and watching weight are all important things.

Kevin Pho: In the exam room, especially in a busy primary care visit, what are some simple ways to assess a patient’s gait?

Narinder Singh Parhar: Well, again, a very interesting question. I think, as AI comes to help us, a short video taken in the hallway by a medical assistant, watching the patient walk forward and, if possible, backward, should be inserted as one of the vital signs to be assessed by the physician or the health care provider.

Kevin Pho: So if a patient is not getting enough physical activity, or there are issues with their gait, tell us some simple recommendations that you would give that particular patient to improve the amount of physical activity they do. Is it simply telling them to do more? What are some of the concrete, specific things we can tell patients to do?

Narinder Singh Parhar: Well, I think patients not only listen to us, they also watch us. They watch how healthy we are, how healthy our posture is, how we walk, whether we are maintaining our weight, and whether we look healthy enough. The point is that as health care providers, doctors, and nurses, we should pay extra attention to our own health, not only for our patients’ sake but for our own sake. There is so much riding on our health to sustain the health care system.

The other thing I have been doing, and I’m not practicing now, but I can definitely recall what I was doing: In addition to watching patients walk in the hallway myself, I would also show them the benefits of a two-minute retro walk exercise. There is data that retro walking helps engage muscle groups that we normally do not engage when we just walk forward. Retro walking takes just thirty steps backward, which takes less than two minutes, on a daily basis, or once or twice a day. That is a great initial step that I recommend to my patients.

I would also just talk with them: How do you walk? Where do you go for walking? Is there any difficulty? How could we help? Do you need a physical therapy assessment or an occupational therapy assessment? Is there any joint pain that is hindering your mobility? Is there any pulmonary issue that is restricting your ability? Do you need an asthma medication refill, or are you having a problem with the cost of the medicine, etc.? All those things do help.

Kevin Pho: It sounds like just by observing a patient’s gait, both forward and backward, you can potentially uncover so many things, as you mentioned, like asthma, pulmonary issues, and problems breathing. It is not just musculoskeletal; it goes beyond that.

Narinder Singh Parhar: Exactly.

Kevin Pho: Now, if a person has trouble with their gait from a musculoskeletal standpoint, what do you often recommend as a next step? Would it be things like physical and occupational therapy?

Narinder Singh Parhar: Sure. We definitely must take advantage of our paramedical disciplines. They are very good at it. They have studied these systems more than a medical physician or medical doctor has. We are so occupied and burdened by the pharmacotherapy and the details of the histopathology. We have limited time and limited energy, and naturally our other patients are waiting for us as well. So utilizing physical therapy, occupational therapy, and the staff is very appropriate.

Kevin Pho: We’re talking to Narinder Parhar. He’s an internal medicine physician. Today’s KevinMD article, we’ve talked about the importance of musculoskeletal health. Narinder, as always, we’ll end with your take-home messages to the KevinMD audience.

Narinder Singh Parhar: Again, I think we need to pay the same respect to musculoskeletal health as we have paid, and are paying, to cardiac health and brain health, as well as to invasive procedures such as endoscopies, coronary cath, and vent management. We take pride in performing those procedures and seeing the progress made. We should start paying the same amount of attention and respect to the optimal and enhanced health of the musculoskeletal system and mobility.

Kevin Pho: Narinder, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Narinder Singh Parhar: Thanks, Kevin. Thank you very much.

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