USA: Mount Sinai PACS clinic and Dr Putrino

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New video from Medinger. This time in conversation with dr. David Putrino, a British physiotherapist who is the director of rehabilitation innovation at Mt. Sinai in New York and now works with long haulers.

10 minutes in he says he was discussing the symptoms of his Long Covid patients with a colleague with background from the Navy. The colleague said the symptoms reminded him of "hypocapnia" that they've seen in airforce pilots who "have been pulling a lot of Gs" and he wondered if the patients' Co2 levels were low, which they turned out to be. He says further that patients improved a bit with a breathing programme and that this helped them get ready for rehabilitation.
More about the breathing programme here https://stasisperformance.com

dr. Putrino then goes on to talk about what sounds like PEM in his patients and that they are slowly increasing exercise tolerance with "autonomic condition therapy", but within the energy envelope and patients can assess themselves where their limits are. He believes that those who have improved, have improved due to their program, but also mentioned a patient who improved, then had a severe flare after 5 months.

Towards the end he says he'd like to see more research into traditional Chinese medicine in Long Covid.

No mention of ME in this video.

https://www.youtube.com/watch?v=f0ehpsv-2TE

 

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That was a really nice podcast. Very interesting to hear about dr. Putrino's work.

Here's a transcription of what is said between 26-33 minutes into the podcast (hope I got most of it right):

Amy Proal
Overall, I can understand how when a clinician first sees a patient like this. On standard blood works, there’s not much that seems wrong. Overall it just seems like - hey look, you gotta jump back in, you gotta get back up. You don’t feel well..

That they would just recommend exercise. I can understand why that would be the case. But it isn’t really.

You mentioned Post Exertional Malaise which is also a common symptom of another diagnosis; Myalgic Encephalomyelitis - ME/CFS, and I’ve worked to study for several years now and which patients; their exercise actually provokes symptoms. So they have to be very careful in the way that they exert themselves.

Have you seen that and is that part of how you pace? Can you go into that a little bit more?

David Putrino
Yes, absolutely. We see a lot of symptom provocation and exacerbation in response to exercise. So much so that in our training, because we’ve trained around 700 clinicians now around the country on just the fundamentals on autonomic rehabilitation.

We point out that even… because everyone wants functional testing. They want to say how do I know when a patient is getting better.

And even something as simple as the six minute walk test, which is a self-paced walk-down-the-hall for six minutes, and the clinician just tracks over the six minutes period how long the patient walked. We have to tell clinicians that that is too high level of exertion for most of the patients that we see.

And we’ll often get the cowboy, you know:
- No, no, I did it with all my patients and they were fine

and I was like:
- Yeah, they completed the test, right?

- Yeah, no problems, no problems completing the test

and I was like:
- Did you check in on them two days later?

- No, why would I do that?

- Because I’m expecting that you have a fundamental understanding of the literature for the conditions that you’re treating, and you understand that when we talk about post exertional symptoms, that’s different from exercise intolerance, which is different from fatigue. And so with post exertional symptoms you need to be tracking your patients for up to two days, some patients will even say three days, because that’s when things arise.

So this idea of you're deconditioned, we just need to push you through with exercise is a disaster.

It’s inappropriate because these patients don’t look like patients in need of pulmonary rehabilitation or cardiac rehabilitation.
Their heart is fine, it is within normal limits. Their lungs are fine, within normal limits. They don’t have pulmonary function test that looks out of order.
So why would you refer them on for what looks like pulmonary rehabilitation?

They are reporting symptoms that are consistent with dysautonomia. There’s 20+ years of literature saying that if you work patients too hard with dysautonomia, they will worsen. If you exercise patients too hard in ME/CFS, they will worsen. Of course, ME/CFS has had a lot more controversy than dysautonomia around the point of exercise unfortunately, because bad science and the dissemination of bad science.

But the reality is hopefully there are enough people, there are enough patients speaking up now, that these doctors will listen when they’re told exercise as though these patients are deconditioned is not the answer.

I was incredibly discouraged to see the NIH funding high-intensity interval training for long covid patients. Now granted it was for a subset of long covid patients that had PICS, Post ICU syndrome, but I’ve seen some of these patients and if anything you need to be even more careful with this patient population.

So I think that we have a lot of work to do in terms of changing the culture from the top level. I think that all of these patient led groups have been doing a phenomenal job of being heard. I think it’s time for them to sit in on NIH study sections and have a voice, because clearly when I see HIT-training being recommended as a clinical trial for long covid patients, I see the potential for harm and I know for a fact that that grant would not have been funded if there were a patient representative sitting in the room saying: hi guys, that’s gonna kill some people. Don’t do that.

That’s a meandering thought process for fatigue...

Amy Proal
No, that’s an extremely valid view.

Because with the ME/CFS as we've explained already I work on, all of us researchers that are already working on that diagnosis know that it confuses the community.

It takes away from valuable time that can be spent on research and discussions on what actually matters and this idea that we’re just gonna have patients exercise without really reading, like you said, this existing literature on this.

There have been plenty.. in ME/CFS there’s a trial called the PACE trial that concluded that patients can benefit from graded exercise, but there are many faults with that study. I have signed many letters that have pointed out the faults with that study. So have many other scientists.
We’ve been doing this for years. And part of that is that we’re not listening to patients enough, like you said.

Patient reported feedback should be a high level of evidence. Right now in evidence based medicine, it’s low on this evidence pyramid, which I’ve always disliked. I think patient reported feedback should really be one of the primary sources for hypothesis and the research in clinical work that we conduct.

And the fact that your group is doing that is an exemplary example of how this can work and I agree that institutions like the NIH and whoever that are doing this and probably coming up with the more conservative and standard approach in the beginning, I hope they will stop and be listening to feedback from groups like yours over time to adjust the programmes and things that they are funding because I agree, we should have learned by now that probably just making someone exercise alone without thinking through the way that you approach, it does not work.

ETA: weird, I tried to quote the post with link to the podcast, but it didn't show. Anyway, I was referring to the post just above this one and here's the podcast:

https://www.youtube.com/watch?v=36fsT-1pyBk

 

https://twitter.com/user/status/1498343266781052929

 

I'm assuming there was suspicion of his 'leanings' from other areas? Because there is a very outside chance that this could be taking the mick out of the medics who have pushed/invented these terms rather than look into physical conditions

 

LOVE this.

As summary of succinctly what someone who has a brain looking and wondering what on earth has been going on for the last number of years the following line seems to encapsulate exactly what it is (and of course could be extrapolated to the other misguided ideas of how other symptoms could be fixed using generic presumptions):

"I see the potential for harm and I know for a fact that that grant would not have been funded if there were a patient representative sitting in the room saying: hi guys, that’s gonna kill some people. Don’t do that."

 

Well I take back my previous comment in a way. How can someone who ignored a 60% drop-out and didn't investigated why most people didn't finish the programme then say the phrase about patient input so you don't kill people with a straight face? One's talking the right talk and then the paper re the drop-outs isn't walking the talk at all

 

Dave Tuller: "Dr Putrino discussions long Covid, post-exertional malaise, ME/CFS, etc."

Trial By Error: Interview With Mt Sinai’s David Putrino

https://www.virology.ws/2022/05/12/trial-by-error-interview-with-mt-sinais-david-putrino/

 

Very interesting interview @dave30th A breathe of fresh air!

 

Post copied from the Long covid in the media and social media thread

Anyone not yet blocked by Sharpe, Wessely and the rest want to clue them in on what actually matters in ME? Tag them in on this? Maybe Greenhalgh and a few more? Putrino has been at this for 2 years and understands this better than all of them combined. And didn't even start that strong, had some early assumptions that he managed to falsify. Because it is possible to learn from experience, it just takes a scientific mind free of excessive bias. Oh, and actually listening to patients for useful information. That helps a whole lot when technology isn't useful.

I am firmly in the opinion that informing people of things they don't understand is not harassment. But maybe I'm just weird like that.

https://twitter.com/user/status/1525172494709182464

 

What exactly is this autonomic rehabilitation Putrino keeps on talking about? It's always mentioned but never really explained (that I've seen).

 

I'm pretty sure I've heard a description in one of the interviews he's given. I believe it was the one referred to here:
https://www.s4me.info/threads/usa-mount-sinai-pacs-clinic-and-dr-putrino.23051/#post-384939

 

Thanks for posting, @Kalliope. I'm only partway through the transcript of that video and he's described a lot a of standard dysautonomia treatment but also something that's new to me:

So no RCT there or much discussion of the benefits except to say it was 'really helpful'. I don't know if I've ever had my CO2 levels measured and I've certainly never been offered breathwork.

 

Putrino's general approach is certainly sympathetic.
I think we need to know more about the physiology before starting treatments though. If there is a lowish CO2 that might be a useful compensatory response so not something to try to reverse.

 

I don't know. In practice, this is the kind of thing that I might be tempted to try, because I could have died of old age before we know more about the physiology.

 

From the little I have yet to find out on this online is that he works in a multidisciplinary team which incudes psychiatry, (and ACT is not the acronym I would have chosen for Autonomic Conditioning Therapy). I understand they approach amalgamating various disciplines including physiotherapy. I think he is a good communicator around current issues related to pwME/LC and interested to see how this develops.

The “breathwork” is an updated term for simple deep abdominal breathing exercises to correct any hypocapnia (from whatever cause) and from my perspective does not require a breathwork “coach”.

Box breathing may be an addition for lung rehab from covid effects to get full inflation of lungs and there is an interplay between the distress of breathlessness due to respiratory illness and often physiotherapy and psychology work together within this context with good results (From a liaison psychiatry perspective).

There are a myriad of ways of doing breathing and relaxation to lower any excess sympathetic drive that are easily accessible online etc and are free and suitable for any sociocultural group without any hyping and amplification that I see around. I used to teach deep breathing/relaxation to many of my patients in MH and later Mindfulness Based Stress Reduction techniques (we had a different approach on observing the breath once abdominal breathing established rather than focusing on any thinking, counting etc - as the most simplest coping strategy when overstimulated with internal and external information)

I suspect a lot of this is based on psychological treatments based on observing the effect of breathing on the body (Somatic Therapy) and often do require a professionally trained therapist. This is used for the treatment of trauma in the MH sphere.

I am still trying to find out if they are using vagal nerve stimulators which have no scientific trials that meet the standard of evidence that I would require to consider their usage.

 

According to this tweet/thread, the goal is to challenge the ANS in order to change its behaviour.

 

I can't even be sure by that whether he means people with E are apparently 'overbreathing/pushing out too much CO2 (apparently it causes alkaline blood)' or the opposite?