November 25, 2014

Watch Your Back

by Carl Ellenberger, MD

Although this post has little to do with music, the odds are good that some musical readers will find it useful. 

Chronic low back pain is the most common cause of disability and the largest category of medical expenditure in the US healthcare system. The system's response to it is a good example of what is wrong with the system. 

Treatment consumes about $100 billion a year in the US, 9% of total health care costs, not counting the cost of lost work. The fact that more than 200 cures are currently promoted amply shows that only a few can be proven slightly better than no treatment at all -- and only in selected cases.

Most back pain (80-90%) in otherwise healthy people occurs in episodes naturally limited to less than a few weeks that don't need medical attention regardless of severity. When pain remains for more than 3 months, it is called "chronic." That's what we are talking about here. 

If you have had cancer, tuberculosis, HIV, or certain other chronic diseases this doesn't necessarily apply to you. 

In an earlier post I wrote, "...more health problems than you might think can be solved by better understanding than by pills, injections, or surgery." Back pain is one.

So if your back pain is chronic, before having another injection or operation read Watch Your Back by Richard A. Deyo, MD, Professor of Evidence-Based Medicine at Oregon Health and Sciences University who writes with the authority of broad clinical and research experience. Importantly, Deyo does not promote any particular procedure. He writes in a lively style for the general public. 

You may need to revise your thinking about this problem; doing so may change your thinking about other medical problems. Some conventional rules don't apply. For example, when you have pain, you should continue, without fear of harm, the activity that makes it happen, not try to avoid pain by resting. 

A cause in the spine may not be found even by MRI, though if you are an adult, MRI may show more than one abnormality related to normal wear, such as a bulging disk. Know that if you submit to an MRI, you are twice as likely to submit to surgery. If you submit to surgery you are ten times more likely to have more surgery within ten years. Eighty percent of post-operative patients continue to need pain killers, including opioids (aka narcotics), indefinitely.

Deyo argues persuasively that the responsibility for treating low back pain is yours, done by you, not to you, guided by 'providers' who are not invested in what they provide. A typical spinal fusion operation, a current fad done for pain with increasing frequency, distributes its reimbursement of >$100,000 to many "providers" and manufacturers (think $500 screws) but cannot be proved more effective for pain than no treatment at all. Fusion may be necessary to stabilize your spine after an injury. 

Effective treatment involves a long and difficult life-style change but is your best chance of avoiding a lifetime of disability, depression, and reliance on opioids. This treatment changes the "pain module" of the brain, not anatomy of the spine, by means of cognitive-behavioral and exercise therapy. The concept is consistent with new thinking about the brain and its plasticity--the same plasticity that enables learning of a Beethoven sonata and causes dystonia in rare instances.

I hear you saying, "That's easy for you to say, but you haven't experienced the terrible pain that I have every day. It can't be "all in my head." There must be something terribly wrong where it hurts." You're the doctor. Do something! Deyo reminds us that acute pain is a protective sensation to call attention to the location of an injury. When pain becomes chronic, that simple relationship dissolves, the brain continues to falsely signal pain even after the original injury has healed, and the treatment becomes different. It becomes useless to keep trying to repair the original stimulus that created the pain. (That's like changing golf clubs after you have hit a bad shot.) Therapeutic efforts must turn to ways to change networks in the brain, as they must to treat chronic headache or chronic pain anywhere.

So it is not unreasonable to suspect that the epidemic of low back pain in the US has in one sense been created, at least in part, by the health care system. After all, $100,000+ for a back operation provides work and profits for many people, usually excepting the victim of the pain.

Deyo writes:

"...every system is perfectly designed to get the results that it gets. If our health care system generates high costs, promotes ineffective care, and creates avoidable complications, it's because we've inadvertently designed the system to get exactly those results.

In care for back pain, we do this by performing tests when they're unlikely to help and responding to alarming but meaningless results. We do it by prescribing medications and procedures with proven risks but unproven benefits. We do it by by expecting a quick fix from a probe, a pill, or a procedure when real benefits require harder lifestyle changes. We do it with unrealistic expectations of a pain-free life. We do it by responding to financial incentives for more rather than better care. And we do it by ignoring and underfunding the treatments that appear to be most helpful.

For back pain, here are the results: steadily increasing use of imaging tests, opioids, injections, and surgery. Costs that are rising faster than the rest of medical care. And at a population level, worsening patient function and work disability. We've perfectly designed our health care system to produce these results.

It's easier to understand this situation if you remember that the back business is indeed a business. This is the story of too much medical care today. In a for-profit health care system, the first concern is the bottom line rather than the patient's welfare. And too often it follows a business ethos: caveat emptor -- buyer beware."

Full disclosure: I wrote the guideline for use of MRI in low back pain for the American Academy of Neurology in 1994. It recommends limiting MRI to patients who have had pain for over 7 weeks. By then pain has gone in almost 90% of cases. But for some of them knowing for the rest of their lives they have a degenerated, bulging, or herniated disk may not make their lives better. A herniated ("slipped") disk is not like an inguinal hernia. You don't have to repair it.

November 2, 2014

ReJoyce! Singers in the back row stopped texting.

Memorable experience last Sunday afternoon in Carnegie Hall: Alcina. A breathtaking performance of Handel's last (of dozens) opera by The English Concert conducted by Harry Bicket. (Do you remember? That's the same group who attracted an audience of ~200 in Elizabethtown when we had to paper the house a few years ago.) 

Sunday was one of the series Joyce DiDonato curated for this season in Carnegie. Joyce as Alcina and a small cast of others whose names you might not recognize (see Tony Tommasini's review) delivered some of the best singing I have ever heard. 

Alas, most human beings have the misfortune to live entire lives without hearing a Handel opera. 

Alex Ross wrote a wonderful profile of Joyce last year. 

She sang the National Anthem at the last World Series game. More Kansans were familiar with the singer from "Staind" who forgot the words (maybe his first waltz?) before game 5. 

Do Joyce and Stained represent the bipolar state of music in America?

Did I mention DiDonato's Juilliard commencement address?

October 6, 2014

Flute Flamingo and Gretna Semiotics

You have heard stories about patients in hard times paying doctors with a chicken or a head of cabbage. In my view that's a better system than the Byzantine one in the US under which we spend part of our fee to justify it to the insurance company and the insurer tries to find reasons not to pay.

In Gretna, however, we bring humor and sophistication to the exchange, not just farm produce, and cut the insurers out of the transaction. Here, for example, is payment for a comprehensive neurologic "Evaluation and Management Service," E & M 99206.xxxxx. (Don't bother with 12 pages detailing what the service entails. If any of its required parts, say "one fact each about past, family and social history," are not properly documented, the hapless doctor can go to jail.)

Flute (piccolo) Flamingo, parts contributed by other instruments

The artist is my neighbor, Max Hunsicker, a drummer and musician who has has introduced generations of school children to the joys of music and Broadway plays and shows. One of Max's many talents is fashioning a flamingo for any occasion: to advertise the annual homeowners meeting, the beginning of the school year, or to mock the "Shitauqua," a sewage pumping station that sprouted last Spring to greet drivers as they emerge in our Shangri-La out of the long tunnel of trees on route 117. 

Any resident may awaken to find a pink flamingo nailed to a tree in his yard. Ours is a pair, one playing a piano, the other a flute. When I broke my leg, a flamingo appeared on a pair of crutches. The practice has gone on for over 20 years, but the flamingos have only recently achieved three-dimensional form.

We presented another member of the musical flamingo family to Susan, another neighbor, to reward her for her fine service as our board president.

September 9, 2014

Bassoons, again

The Wedding-Guest here beat his breast,
For he heard the loud bassoon.
. . . from Coleridge’s Ancient Mariner
"Coleridge didn’t know much about the bassoon . . . or he wouldn’t have said it was loud. The bassoon’s liability as an orchestral instrument is that it is quite soft, much softer in volume than its size would suggest. . . . But bassoonists the world over are grateful to Coleridge for including them in his stanza."

I have known many bassoonists, This one, the fictitious Paul Chowder in Nicholson Baker's Traveling Sprinkler, is a hoot:

"My bassoon was a Heckel bassoon, made of maplewood, stained very dark, almost black, with a nickel-plated ring on top. I loved it because it looked like a strange undersea plant, something that would live in the darkness of the Marianas Trench, near a toxic fumarole. My wonderful grandparents bought it for me, and I performed Rimsky-Korsakov’s Scheherazade on it, and Ravel’s Bolero, and Stravinsky’s Firebird Suite, and Vivaldi’s A minor bassoon concerto.

People often confuse the words “bassoon” and “oboe….” I think it’s because the word “oboe” sounds sort of like a sound emanating from a bassoon: oboe. But the two instruments look very different. The oboe is small and black and your eyes pop out staringly when you play it, and it’s used all the time in movie soundtracks during plaintive moments, whereas the bassoon is a brown snorkel that pokes up at an angle above the orchestra. You almost feel you could play it underwater while the violists and oboists gasp and splutter.

Hindemith, a composer, outraged me when he wrote that the bassoon, “with its clattering long levers and other obsolete features left in a somewhat fossil condition,” was due for a major overhaul. I had to admit, though, that the keys did make a lot of noise. There’s no way to play a fast passage without some extraneous clacking. Listen to Scheherazade—you’ll hear all kinds of precise metallic noises coming from the bassoonist.

I put in thousands of hours of practice, shredding my lips, permanently pushing my two front teeth apart. And then I decided I wasn’t going to be a musician, because I wasn’t that good, and my jaw was hurting badly and I had headaches from too much blowing. I was going to be a poet instead. I sold my beloved Heckel to Bill, my bassoon teacher, for ten thousand dollars. Suddenly I felt free and very rich. I quit music school and flew to Berkeley, California, and took a poetry class with Robert Hass, who was a good teacher.

Selling my bassoon was one of the biggest mistakes I’ve ever made. I’ve regretted it a thousand times since. And here’s the strange thing. I’ve written three books of poems, and I’ve never once written a bassoon poem. I have never used the word “bassoon” in a single poem. Not once. I guess I was saving it up, which is not always a good idea.

August 28, 2014

Rachmaninov: All-Night Vigil (Vespers)

There may be a reason you never heard--or heard of--Rachmaninov's Vespers, and for the unusual difficulty I had finding out about it to prepare for my pre-concert talk on Sept 7, when Choral Arts Philadelphia will sing Vespers in the Playhouse by candlelight. Inna Lobanova-Heasley, a native Russian and singer with Choral Arts explains:
During my first 24 years of life in the Soviet Russia, having studied classical music and its history at a full-time music school for eight years, I had no idea about the existence of the Vespers or any other sacred music by any other composer whatsoever! This is how well this information was locked away from public eye in the Soviet Union.  
(Link to blog post with musical clip below)
We talked about how Christianity was brought to Russia almost two millennia ago, its liturgy, primarily by St. John Chrysostom, entirely in song (June 29). Though Rachmaninov avoided affiliation with the established church, he was not an irreligious man and church music and ritual were powerful influences on his life. "Vespers" is an English translation of the original Vsenoshchnoye bdeniye, literally "All-Night Vigil," music for a night-long service celebrated in Russian monasteries and, on the eves of holy days, in Russian Orthodox churches.

The text contains Russian Orthodox versions of Latin hymns familiar to Westerners, including the Gloria in excelsis, Ave Maria, the Magnificat and the Nunc dimittis. As in the Latin Vespers service, the source of most of the text is the Book of Psalms and the Gospels. Several sections come from age-old Znamenny chants, traditional monophonic songs known from the first consistently identifiable znamenniy (signs) by which Russian sacred music was notated, the chants dating back at least to the fifteenth century and probably earlier. Others are based on what the Russian church calls Greek chant, a seventeenth-century refinement involving the use of one-note recitatives and simple melismas. Two are traditional Kiev chants, with music alternating, in the style of Ukrainian folk music, between recitative and melodic parts. Finally, two songs are designated as troparia, examples of an ancient type of poetic invocation used in Eastern and Russian Orthodox services. (Nick Jones)

Rachmaninov wrote the Vespers in 1915 when at the height of his powers at age 42 according to the church tradition of unaccompanied voices. After his escape from the revolution in 1917 with his family on an open sled to Helsinki, he felt that he had lost some of his creativity. He became a touring virtuoso pianist playing is own compositions (like "Rach 1, 2, and 3" concertos), and living in Hollywood, probably experiencing new kinds of All-Night Vigils.

Notes: This concert will NOT last all night! Inna Lobanova-Heasley's lovely blog post is here.

August 11, 2014

"My Music"

One time I started listing what Leonard Bernstein meant by "hardening of the categories": rock, classical, pop, country-western, jazz…. A long list, maybe an artifact of recording-era catalogs. 

Some of our patrons come for only one concert each summer, the one in their category.

One determinant of your category is when you grew up. We can predict the age of the audience at Gretna Theater's "retrospectives: music of the '40's, '50's," etc. (disregard the roaring '20's background at intermissions), and maybe those attending our August 30 Tierney Sutton sings Joni Mitchell (music of the '70's, '80's; category: "pop/rock/jazz"). That's because, according to psychologist Dan Levitin, 
Fourteen is a sort of magic age for the development of musical tastes. You’re in the ninth grade, confronting the tyrannies of sex and adulthood, struggling to figure out what kind of adult you’d like to be, and you turn to the cultural products most important in your day as sources of cool — the capital of young life. Musical tastes become a badge of identity in social contexts framed by pop culture.
I don't know the science of that assertion but it held true for me. As a child I raced through categories. Home sick from first grade I called in a request to local AM radio for a gospel song, Up Above My Head. Next I marched to the Cities Service Band of America every Monday night after we finally got FM. I liked broadcasts of Marian McPartland and the Oklahoma City Symphony and the Boston Pops and Leroy Anderson. I wish my parents had listened to the Met Opera on Saturday afternoons.

At about age thirteen, after hearing my father play them since I learned to walk, I invaded his collection of "78's." Schubert, Beethoven, Stravinsky, Sibelius were his badges of identity, and thus became mine. An identity like his was my goal.

Millennials speak of "my music." If it fits into a category ("genre" on iTunes), they may not know which, but they can easily find the most popular songs, the sources of cool. Many avoid the classical genre ("your music," they say), as some parents, schools, and even churches have. What will they will listen to when they mature?

Like arteries, categories start hardening early in life. I try to keep mine open. 

"Music, Mr. Gershwin," said Alban Berg, "is music."

July 27, 2014

Music vs. Alzheimer

by Carl Ellenberger, MD

"I hope (with no evidence) that playing the flute (actually practicing hard and thoughtfully) every day improves my physical and mental health and may delay (for how long?) Alzheimer's or vascular disasters." (CAN MUSIC HEAL? July 6)

That hope made sense to me in several ways partly because music is a language and multilingualism has been found in studies to delay Alzheimer's Disease.

My hope is also supported by a study I just stumbled upon by psychologists at the University of Toronto. After testing middle to older-age adults, they concluded:
Musicians outperformed non-musicians on [several transfer tasks] and on a composite measure of cognitive control. The results suggest that sustained music training or involvement is associated with improved . . . cognitive functioning in older adults.
("Transfer" means the transfer of skills learned in one task, like playing the flute, to others like, say, building a birdhouse, though they didn't test those particular tasks.)  

The article is understandable by anyone without specialized training. It reviews evidence supporting other benefits of playing music at all ages. It is a good example of what I said (July 6) about the difference between hopes, aims, claims, programs, unequivocal beliefs, ultimate goals, and evidence-based science--when you talk about the reasons for playing and listening to music. 

It isn't, however, the 'final answer' to any question, just one small piece that needs to be confirmed in the mosaic of understanding music in the brain, which is one only aspect of brain function. It points in the direction of more experiments.

Even more accessible to the general reader is Secrets of the Creative Brain by Nancy Andreasen in The Atlantic (July/August). In a wonderful article she mentions a 2007 study that found that orchestral musicians have a more active Broca's area of neocortex, one of the areas associated with language. Creative people more likely have mood disorders and families with schizophrenia.