Fit for Duty podcast: Episode 8.

(0:00)

Hi, welcome to episode eight of Aetna International’s Fit for Duty podcast. At Aetna, we know that organisations, whether they’re large or small, recognise that their future growth and success depend on their people. So, Fit for Duty brings you insights on some of the biggest health and wellbeing challenges impacting individuals, workforces and organisations around the world. We’re here to help inform, inspire and support people to drive healthier behaviours, better health outcomes and improved cost containment at an individual and corporate level. Through this podcast, we bring you valuable insights and actionable guidance from some of our most well informed medical corporate wellness and health tech experts. I’m Lorien Norden, Global Content Marketing Lead for Aetna International, and today I’m joined by Dr Sneh Khemka, Vice President of Population Health Solutions and vHealth here at Aetna. In this 35 to 40 minute podcast, we talk about musculoskeletal conditions, which are the second largest contributor to disability in the world, with low back pain being the single biggest cause. We discuss the broad range of conditions in the category, the value that primary care brings to the diagnosis process and effective treatment of conditions, and I ask Sneh for his opinion on procedures like laser spine surgery and key preventative steps individuals can take to protect the health of their spine. We hope you find our discussion not only interesting but valuable. Make sure you subscribe to the podcast. And don’t forget, you can follow international on LinkedIn for all the latest news and articles. I hope you enjoy the episode.

(1:39)

I’m really pleased to be joined again by Dr Sneh Khemka, who’s the Vice President of Population Health Solutions and vHealth here at Aetna. Now Sneh, could you please give our listeners a bit of background on yourself.

(1:52)

Yes, I’m a surgeon by background – I specialised in cancer surgery. And then I moved really into the world of the business of healthcare and public health. So I was awarded an Honorary Degree in Public Health, and I’ve be working in the health insurance and health services industry for the last 15 to 20 years, most recently with Aetna International and at Aetna International I look after the population health and vHealth teams. And what we do is largely use data and analytics to understand better what is going on with people and to give them tailored services, a lot of those services are delivered virtually hence the vHealth, and it’s about giving people primary care, chronic disease management, access to mental health services, wellness services, and those types of things. So we operate in a number of countries around the world, with some very interesting businesses and it’s a privilege to be here with you again today Lorien.

(2:47)

Well thank you. And could you also perhaps give us a little known fact about yourself, Sneh.

(2:53)

So some people may know that I also work as a radio doctor, which sounds a bit like Frasier. And it is a bit like that. So there’s a radio station here in London called LBC, which is very popular. I do a weekly call in show live, and I take the questions live so we get about 2 million listeners and about 700 people call in, I take about 30 of those callers’ questions and I answered them live on air. And the topics ranged from lumps and bumps to cancers to mental health issues, all sorts of things. And as I’ve been doing for eight years, it’s great fun, and lots of people recognise my voice from the radio, luckily not my face.

(3:32)

But that’s certainly going to keep you on your toes, isn’t it? So, I wanted today to talk to you about musculoskeletal conditions and disorders. So as a bit of background, musculoskeletal disorders (MSDs) the category comprises of more than 150 diagnoses which affect the body’s muscles, bones, joints, connective tissues like ligaments and tendons. And I think virtually everyone will experience back pain at some point in their life, but some will develop chronic conditions like osteoarthritis, which cause persistent pain and can limit mobility, dexterity and functional ability. Now in our recent discussion Sneh on mental health, we touched on research published by Drinkaware and Opinion on the increase of alcohol consumption among certain segments of the population during lockdown. And the organisers of World Spine Day state that lockdown restrictions during the pandemic have resulted in a lack of physical activity, which has made people more susceptible to spinal pain and injury. So, the world spine day theme this year is ‘Back on Track, with the aim of raising awareness of the importance of good spinal health. So, as an organisation we are nicely aligned there. So, could I start by asking you, as I said, you know, virtually everyone is going to suffer from some form of back pain or other at one time or another. And as the MSD category is so incredibly broad, are there threads that tie the various conditions together?

(5:08)

Well, the real thread is the skeletal system, or your skeleton. So, you have over 200 bones in your body. And as the old rhyme goes: the hip bone is connected to the thigh and knee bone and all that sort of stuff. So, the whole system is interconnected, so low back pain is not just caused by bone problems. And that’s why we put it together as musculoskeletal – so the muscles, the tendons, the ligaments, the fascias, and then the bones themselves and where those muscles and tendons are attached to all are very closely interwoven. So, if you have something wrong with your back, that will often affect your legs or even your arms. If you have something that’s wrong with your gait and how you walk, that will often affect your hips and your lower back. And so, the whole thing is very closely intertwined. And it’s quite a complex set of things to get under the bonnet of, but low back pain is definitely one of the most common problems that come out of the musculoskeletal range of conditions that we see.

(6:21)

Are you aware of any uptick in low back pain or other MSDS as a result of lockdown?

(6:28)

Yeah, so, as people have been working from home, and especially if you’re an office based worker, which many of us are these days, you will be used to sitting at your desk for quite a long time during the day. Now, usually in the workplace, people have had ergonomically designed desks and chairs, so that they have appropriate seating. People haven’t afforded themselves that luxury at home so much. So, people are working from their bedrooms or from fairly informal places, and the chair or the table may not be at the right height, people often nestling their phone into their ear rather than using headphones, and so that same structured working environment hasn’t necessarily translated to the home environment. Which means that there has been an uptick in musculoskeletal issues, mostly related to posture, being increasingly sedentary and having the wrong positioning when you’re in front of your computer screen for extended periods of time. So, I don’t know the stats, Lorien, but I do know that there has been an uptick. As I mentioned, part of that is decreased activity. So, as we’ve been locked down and not going out for as much exercise as before, people have found that their issues have slightly worsened during this time.

(7:49)

And what are the two or three conditions that people should be, you know, especially focused on in terms of taking steps to help prevent them?

(7:58)

Well, I wouldn’t really focus on two or three conditions as this is very individual. I mean the common ones are obviously neck pain, low back pain and often lower limb issues such as plantar fasciitis. And by the way, plantar fasciitis is essentially where the fascia, which is the connective tissue in the lower limbs, gets tightened because you’re sitting for long periods of time and it could cause foot pain and heel pain. So those are the most common sorts of things that we see. But the spine, Lorien, is poorly designed. So interesting fact is that all mammals really have very similar spines – all mammals have got exactly the same number of vertebrae in their necks. Doesn’t matter if you’re a human being a mouse or a giraffe, you have the same number of vertebrae in your neck. Apart from if you’re a sloth or a manatee, because they have a different number of vertebrae, but it’s just an interesting fact. But in humans, where we are upright on two legs all the time, it means that we are putting an unusual strain on our lower backs. The way that we are structured means that we are actually poorly programmed, which is why so many people get lower back pain. And the way that our vertebrae and our nervous system interact with each other, means that we are quite prone to spinal problems as a race, as a species, unlike some of our other mammal colleagues who are either on four limbs or use their hands a lot more to walk, such as you know monkeys and things like that. So human beings are particularly susceptible to these low back pain issues.

(9:45)

So then, when we think about back pain and how prevalent it is and treatment, could I cast your mind back to a piece that you wrote recently for International Investment in which you said that primary care is sometimes seen as an unwanted gatekeeper, a place you have to go before you can get through to the specialist you think you might need. So, first of all Sneh, how can an individual know that they need to seek treatment? Absolutely. And secondly, why is it so important for individuals to make a primary care physician, also known as a GP or family doctor, their first port of call if they are concerned about their back health?

(10:27)

Okay, well let me try and tackle that in two ways. So, when do you need to go and see someone? Well the general rule of thumb with musculoskeletal conditions is that if the condition is persisting, especially beyond a period of three or four weeks, if it is interfering with your daily activities enough to feel you need to change or limit your daily activities, so you can’t walk as much if you’re unable to do your bra strap up or get dressed properly or unable to lift the kids properly, whatever it may be, it is interfering in that way. Or if you suspect that you have some sort of impingement of the nerve and that is often diagnosed by either a loss of function meaning you can’t move something properly, a loss of sensation meaning you’re numb in one area, or hypersensitivity meaning that you’re getting pins and needles or pain in a particular area. So, if you’re getting a nerve problem, then that usually requires fairly urgent medical attention, but the rule of thumb is if it’s going on and not resolving and if it’s interfering with your daily activities, that’s usually a good time in which to say right I need to go and see the GP. So, the second part of the question is, why the GP or the primary care physician, rather than straight to a specialist? And that delves right to the heart of how you deal with musculoskeletal conditions. Sometimes, but only sometimes, do you need a surgeon to get involved and to put a scope inside your knee or to do an MRI and your back or whatever it is. Most of the time musculoskeletal conditions are self-limiting, and with the right physiotherapy with the right painkillers with the right muscle strengthening activities, and other changes, you can usually get on top of it. So if you don’t go via primary care system, you go straight into a specialist, you are more likely to get investigated, prodded, poked, operated on, than if you go via the GP and you give it some time for it to settle. So, personally, I always go via primary care and I’m always very cautious about receiving interventional care, such as surgery, it’s really my last port of call, and I only want to see the specialist when other avenues have failed. And that is what I advise to all of the listeners of this show.

(12:47)

So, in terms of thinking about opioids, for example. So, in the treatment of back pain, opioids have been a particularly big factor in the ongoing opioid epidemic, particularly in the US but not limited to that country by any stretch of the imagination. So aside from the significant risk of addiction, why are opioids not the right treatment for back pain?

(13:13)

Well the simple answer to that is that the only deafen symptoms, rather than dealing with the underlying cause. As with any painkiller, it’s there to alleviate symptoms rather than to cure and to get rid of the originating problem. And so, painkillers do play a role. But they are not the only thing and often it is easy for the medical fraternity to brush someone off who’s got long term pain that they can’t understand properly, and give them painkillers and hope that, you know, it’ll settle with painkillers. Now the opiates scandal, and they call it a scandal advisedly, has been one of the biggest scandals of the medical community which we’ve actually known about for a long time, but it only recently surfaced in the public domain. Opioids are very, very strong drugs. They act in a way which causes them to be addictive with quite a significant side effect profile and causes decreased life expectancy, early death, and all sorts of psychological problems. Now what has happened in the medical industry is because in previous models, the pharmaceutical industry was able to push quite hard to doctors to prescribe these things, it became part of the normal pattern. And so, for doctors it became a knee jerk reaction to reach for the opioids and prescribe them for patients who didn’t actually need them, rather than getting to the root of the problems. And if there’s one revolution that really is to be had in dealing with musculoskeletal conditions, it is about going away from opioids especially, but generally painkillers and things that deafen symptoms and going more to the heart of finding out why something is happening and trying to deal with the root cause of it. Now you can’t do that in every circumstance, but certainly the Cecil had tipped completely the wrong way, and we’re now beginning to see some redress of that.

(15:12)

Well that’s certainly good news to hear. I wanted to draw your attention to a book that was published in 2017 by a US journalist and author, Cathryn Jakobson Ramin, and her book Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery explores the $100 billion dollar per year industry that she describes as mostly a hoax. And this was inspired by her own experience with debilitating back pain, and failed laser spine surgery. So, some people have called procedures like laser spine surgery a hoax. But is there a place for these and other expensive invasive procedures?

(15:57)

Well yes absolutely. I mean I haven’t read the book. And I think it may be a little bit too far to call it a hoax, I genuinely don’t believe that the majority of the medical industry is going in to try and con people and to give them a hoax. I do think that people, you know, the industry is working in good faith. Of course, trying to make money as it goes along, but working in good faith to find different therapies and treatments which really help. Now of course, you will get the odd charlatan who is a hoax. But I think that’s fewer rather than more common. And you obviously want to avoid those people. There are a few things which have been part of the common vocabulary of treating back pain, which I do fundamentally disagree with. And one of those is opioids, as we discussed. Another of those things is facet joint injections. So injecting steroids into the facets of the vertebrae to relieve back pain symptoms. In the vast majority of circumstances that is an unwarranted treatment. It is only in very few select cases the evidence exists that that is an effective therapy. But if I’m being sceptical and conspiracy theorist about this, it is an easy way for doctors and for hospitals to make money to give these injections, and then give the patient temporary relief. But it’s only another deafening type of symptom relief and rather than dealing with the underlying cure. So, I’m rather against that. But if you come to something like spinal discectomy, which is quite a commonly for procedure. Sometimes that is hugely necessary. So, what happens in that is your vertebrae, which are bones, they sometimes compress and when they compress they squash against each other. Sandwiched between the vertebrae is the nuclear pulp nerve tissue. Now that pulp is a soft tissue. And if you think of squeezing a sandwich then the fillings pour out of the sides. And when this pulse comes out to the sides, it can then hit the nerves that run along parallel to the vertebrae. When it hits those nerves, you get paid. That’s where sciatica comes from that’s where all that referred nerve comes from. Now my way to deal with that really in some circumstances, is to cut out the offending material, so it doesn’t rub against the nerves and that’s the only thing that gives people relief. So, there’s definitely room for surgical intervention in osteoporotic older individuals, where their spinal bone structure is collapsing, putting in spinal rods and stents is often the only thing that will alleviate their pain, but unfortunately in medical practice I’ve seen spinal rods and stents being used in very young patients, where it’s completely inappropriate. So, all of these therapies have a place, but it’s about choosing the right surgical candidate, the right patient, making sure the patient is getting what they need, and not getting what they don’t need, just because of some economic driver for the hospital or the doctor.

(18:58)

Yeah, I think I understand that for some, as you said, if you’re being sceptical about it, the back surgery industry does have a bad reputation. But when we look at organisations such as the North American Spine Society, they have nine tips for keeping the spine healthy. So, I’d be interested to get your take on these. So, get regular exercise, don’t smoke, maintain a healthy body weight, keep your core strong, use proper body mechanics, have good posture, reduce stress. keep your bones strong and healthy and don’t be a weekend warrior. So, of course, prevention is always preferable to cure, but what steps do you think individuals should be taking first and foremost, to prevent back problems?

(19:50)

Well I like all of those but in particular, don’t be a weekend warrior, which is interesting. So, the DIY industry is probably responsible for more back pain in otherwise healthy individuals as people become weekend warriors and go about their houses lifting heavy pieces of furniture and straining themselves and causing all sorts of injury. I think all of the tips that you just read out, those nine tips, are exactly right. I’ll just focus on a couple. One is about smoking. So, not surprisingly, we know that smoking is bad for you. But, smoking actually has a very unusually poor correlation with back pain. Daily smokers and former smokers have significantly higher chance of suffering from chronic back pain than non smokers, and the risk is higher, the more you smoke. So it’s about when you started smoking and how much tobacco you consume. That is really very closely correlated with how much back pain you get. The other thing that smoking does is it causes sort of neurochemical imbalances in the brain, such as dopamine. And so, if you get pain, it makes your pain worse. You cannot control pain in the same way you could normally if you’re a nonsmoker because of the effects that it has on the chemical balances. So, smoking is a real no no for back pain. And the first thing that I concentrate on is about muscle strength. So, the body is designed so that the skeleton takes some of the strain, but the muscles, ligaments and tendons to some of the strain. So, if you don’t have good core musculature. It means that your bones are going to be taking a lot more strain than they should, in fact they’re taking the strain that the muscles should have. And because of our sedentary lifestyles, rising labour rates of obesity, increasing age, all of those things, we are finding more and more people are getting back pain because their muscles are not dealing with things as they should in daily living. So those are probably the three things that I would concentrate on, Lorien.

(21:58)

Absolutely. And I also wanted to talk to you a little bit about stress. I mean obviously our last podcast, we were we were talking a lot about mental health and the intertwined nature of how your mental well being impacts your whole being. So, what can you tell me about in terms of stress and its impact on MSDs.

(22:23)

Well, the two highly interlinked. Stress causes musculoskeletal disorders and musculoskeletal disorders cause stress. So, when you’re getting pain from a part of your body, the natural physiological response is to release steroids into the bloodstream from your adrenal glands, and the adrenal glands produce adrenaline and cortisone and things like that. Now, those hormones cause stress, they are stress hormones, they cause your blood vessels to constrict, they cause your blood pressure to go up. And they cause all of those symptoms of stress. So, one leads to the other. And in reverse, if you have stress or anxiety or irritability or mild depression, that also means that you are more susceptible to pain and musculoskeletal conditions forming, because the way that you function physiologically starts to change. And so, the two are very closely interrelated. And the problem is that when you get one, you often get the other one and it’s hard to get on top of them both. The prevention again comes from balance, it comes from maintaining healthy weight, maintaining regular exercise and all those boring things that we doctors tell you about all the time, and very hard to put into practice. But if you do have musculoskeletal conditions. There is nothing better that you can do for yourself than regular exercise, maintaining a healthy weight, good diet and trying to decrease your levels of stress.

(23:56)

And it’s been observed that MSDs are increasingly cropping up in younger workers. And Guy Osmond of the Osmond Group has even predicted an oncoming, ergonomic tsunami. So is the issue here how younger workers interact with technology do you think?

(24:15)

It’s a good question. I don’t know the answer to that, so I haven’t seen this work and I haven’t seen the statistics around younger people as a demographic. What I do know from the statistics that I’ve seen is that as the world ages, especially in Western societies, back pain and musculoskeletal conditions are becoming much more common, because it is associated with age. What I didn’t know about was the ergonomic crisis that’s going on in young individuals. What I would postulate, is that the way that we interact with technology devices significantly more than we did even, you know, five or 10 years ago is probably changing our posture. So, I think computer screen time and sitting at desks. You know, you go into an office or use to go into an office and spend eight hours in front of a screen and have probably half an hour walking around for lunch — that’s not a natural state of being. It really isn’t. And so, if the world is moving more towards that that doesn’t surprise me at all. Interacting with mobile phone devices, I’m sure there are lots of people who are, you know as I mentioned before, nudging it up between their shoulder in their ear on regular occasions for protracted periods of time. Looking at when you’re in bed or sitting down, probably not in an ideal posture. So it wouldn’t surprise me if this gentleman has found something truthful there, it may well be a threat.

(25:38)

Well thank you ever so much for your time. As always, I’ve thoroughly enjoyed it and I hate those that are listening have had some really valuable insights that they can take away with them and action as well. So, I hope to speak to you again soon. Thank you again Sneh.

In our next episode of Fit for Duty, we’ll be building on last year’s proprietary research and revisiting the gulf between employer and employee perceptions and expectations of corporate health and wellness. And how businesses often fail to recognise and manage the health priorities of their workforce. This year, we explore how COVID-19 and related lockdown has impacted employer and employee priorities, and uncovered the ways in which corporate well being responsibilities have shifted as a result. For those who don’t know us, Aetna International is a global health and wellness benefits provider. But we’re more than just an insurance safety net, our skill lies in delivering the tools, the services and the resources that help drive healthcare costs down and people’s physical and mental health and well being up. And that’s something that’s important to our corporate clients and self funded members alike. And that’s why we serve almost 900,000 members around the world, from Shanghai to Seattle. Ultimately, we believe that when people thrive, their work and personal endeavours thrive too. For more information about us, you can visit aetnainternational.com.