Studies Could Ease Fears of Medicines for ADHD

Ritalin, Adderall and other drugs widely used to treat attention disorders didn't increase the risk of serious heart problems in a major study published Monday that could help ease concerns about the heart-related safety of the medicines.

The drugs, including Shire PLC's Adderall, Johnson & Johnson's Concerta, and Novartis AG's Ritalin, as well as generic versions, are associated with modest increases in blood pressure and heart rate. They are also known to be highly effective in managing ADHD symptoms, with more than 80% of patients responding to the medicines, researchers say.

The findings, from an analysis involving nearly 500,000 adults, come on the heels of a separate study that reached a similar conclusion about the medications' effect in 1.2 million children and young adults. The results don't completely exonerate the drugs, which have other side effects that include a slowing of growth in children and anxiety. But researchers and doctors who treat the condition—known formally as attention deficit-hyperactivity disorder, or ADHD—said that together the reports should generally allay worries about heart risk that have stirred confusion among doctors and patients for several years.

"We don't see any evidence they're increasing risk," said Laura A. Habel, a research scientist at Kaiser Permanente at the big health plan's Northern California operation in Oakland and lead author of the latest study. But she added that the study didn't go as far as to prove the drugs are safe.

About 2.7 million children are prescribed medicines for ADHD, mostly to help control impulsive behavior and an inability to focus and pay attention. More than 1.5 million adults also take the drugs, researchers said. Growth in the medications' use among adults has outpaced that in children during the past decade.

Fears about potential heart risk for ADHD medicines were sparked in 2005 by reports of about a dozen deaths from sudden cardiac arrest among young users of Adderall. The reports prompted the Canadian government to temporarily remove Adderall from the market, though it later lifted the suspension after it was determined that the patients who had died had heart defects or other underlying heart disease.

In the U.S., the Food and Drug Administration held advisory panels to discuss the matter in 2006. The agency subsequently required an update to product labeling to mention cardiac risk. The American Heart Association in 2008 urged that children being considered for ADHD drugs undergo a thorough heart exam, possibly including an electrocardiogram, before taking the medicines.

"Many patients and families stopped using the medicine," said Victor Fornari, director of child/adolescent psychiatry at North Shore-LIJ Health System in New Hyde Park, N.Y. The issue of whether the drugs cause heart problems still "comes up every single day" in discussions with parents of children with ADHD and adult patients, he said.

At the Mayo Clinic, in Rochester, Minn., cardiologist Michael Ackerman said he knows of students who stopped taking the medicines and went from "high-functioning, straight-A students to F students" after doctors became concerned that the drugs "could kill their patients."

Both doctors, who weren't involved with the research, said they hope the new findings provide reassurance to doctors, patients and parents of children with ADHD that the risk of the medicines, especially in otherwise healthy people, is very low.

"The consequences of failure to treat ADHD far outweigh the risk of untreated ADHD," Dr. Fornari said. Children with untreated ADHD usually don't do well in school and adults often can't function in the workplace.

Both the new study, published online Monday by the Journal of the American Medical Association, and the earlier one, published last month by the New England Journal of Medicine, were funded by the FDA and other U.S. agencies to get a clearer picture of the risk associated with the medicines after the 2006 advisory panel hearings.

The study in JAMA compared about 150,000 adult users of ADHD medications between 25 and 64 years old to nearly 300,000 nonusers. Researchers reviewed medical records from four health insurance plans to look at the number of serious cardiovascular events such as sudden cardiac death, heart attack and stroke among both groups.

The study found there were 1,357 heart attacks, 296 cases of sudden cardiac death, and 575 cases of stroke among all patients. The rate was similar among users and nonusers of ADHD drugs, which suggests the drugs didn't increase risk of developing serious cardiovascular problems.

The earlier study, by the same research team, reached a similar conclusion among patients 2 to 24 years old.

Patients evaluated in the studies weren't randomized and the average duration of treatment was relatively short, prompting researchers to say that a potential for increased risk associated with the medicines was possible.

"Even though we can't rule out increased risk," said William Cooper, a pediatrician at Vanderbilt University, Nashville, Tenn., and lead author of the earlier paper, "the absolute magnitude would be low because the [serious] events are so rare."

Despite the findings, the FDA said Monday that patients treated with ADHD medications should continue to be monitored for changes in heart rate or blood pressure as well as for other side effects that include decreased appetite, weight loss and trouble sleeping. The agency also said the drugs "should not be used by patients with serious heart problems, or for whom an increase in blood pressure or heart rate would be problematic."

Mason Turner, regional director of mental health outpatient operations for Kaiser Permanente Northern California, said that with low doses, careful monitoring of blood pressure and other measures, and consultation with a cardiologist, even patients with heart risk who also have significant ADHD symptoms can be effectively treated with the medicines.

Dr. Turner also said strategies that don't involve taking drugs can help some patients. Among these are educating patients to better organize their lives or to ask at school or work for assistance in helping with detailed assignments and projects. That "can mean the difference between doing well or doing poorly," he said.

By Jennifer Corbett and Ron Wilson, The Wall Street Journal 

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

Vitamins and Other Supplements: An Update

We are often asked about various vitamins and supplements and when important information becomes available, we try to make blog posts to update everyone.  We’ve also decided to summarize some of our thoughts about supplements and this is the result of that effort.  As always, the opinions expressed here are general recommendations and we always encourage a conversation with your physician before you make any changes to previously recommended treatments.

Multivitamins

There is general agreement among physicians that a well-balanced diet provides adequate vitamins and minerals required to maintain health and prevent diseases. Over half of Americans report that they regularly take dietary supplements in an effort to improve their health.  Unfortunately, no studies have documented any benefit from multivitamin supplementation in healthy adults and safety concerns have been raised.

Specific vitamins and supplements

We do not recommend routine supplementation with vitamins A, C, E, folic acid or beta-carotene.

Taking antioxidant vitamins (such as vitamin C and vitamin E) has been promoted as beneficial in prevention of colds, heart attack, stroke and cancer. Unfortunately, none of these illnesses are prevented by taking vitamins. And worse yet, evidence has accumulated that antioxidant vitamins can be harmful. 

A remarkable study from Norway published in the New England Journal of Medicine in 2006 rebuffed prior theories that heart attacks could be prevented by antioxidant vitamins and was among the first to raise concerns that these might actually increase heart attack and stroke risk. 

Supplemental beta-carotene, vitamin A and vitamin E may increase risk of death according to a recent JAMA review.  

A study published in the Proceedings of the National Academy of Sciences demonstrated that taking supplemental vitamin C and vitamin E eliminated one of the major benefits of exercise in healthy men (in this case, the body’s ability to respond to insulin). We described this study in detail in a prior post.

There is no evidence that vitamin E is effective in preventing Alzheimer’s disease or other types of dementia.

A recent review of 67 studies (involving over 230,000 participants) concluded that vitamin C (alone or in combination with other vitamins) did not lower mortality. The same review concluded that vitamin E supplementation (as well as supplementation with vitamin A and beta-carotene) may increase mortality significantly.  

A recent study published in the Archives of Internal Medicine also concluded that the “more is better” approach is not necessarily the best.  They concluded that for adult women, multivitamins, vitamin B₆, folic acid, iron, magnesium, zinc and copper all increased mortality in and that calcium supplementation decreased overall risk.

A study published in the Journal of the American Medical Association this month also concluded that men who took 400 IU of vitamin E were 17% more likely to develop prostate cancer over 7 years than were those who did not take vitamin E.  An earlier study concluded that vitamin E supplementation increased the risk of death in men.

Earlier studies in smokers found that beta-carotene supplements increased lung cancer risk and the trace mineral selenium has been linked to an increased risk of non-melanoma skin cancer in women and men.

The exceptions

Deficiencies of vitamins B₁₂ and D are linked to many health problems and when low levels are found in lab testing, we often recommend supplementation.  Also, most American adults should probably take a calcium supplement. 

It is very clear that vitamin D is important for bone health (to prevent osteoporosis). Recently, data have suggested that adequate vitamin D levels may also decrease the risk of falling, and prevent colon polyps and cancer and heart attack and may facilitate weight loss in those who are overweight. We’ve reviewed this data and while it’s unlikely that vitamin D is magic, it does seem to be important. Over-the-counter vitamin D supplementation is reasonable for average-risk patients who have a mild vitamin D insufficiency, but a much higher dose (prescription strength) supplement is probably more appropriate in patients at risk for osteoporosis or those with severe deficiency.

Low levels of vitamin B12 can cause anemia and damage to the brain and nerve cells. Symptoms of nerve damage may be present before anemia. They can include numbness or tingling in the fingers and toes, poor balance and coordination, forgetfulness, depression, confusion, difficulty thinking and concentrating, impaired judgment and poor control of impulses, a decreased ability to sense vibration, ringing in the ears (tinnitus), and dementia, a decline in mental abilities that is severe enough to interfere with daily life.

The Bottom Line

With the few exceptions above, vitamin supplements are unnecessary and potentially harmful.  A well-balanced diet coupled with daily exercise is the closest thing to a magic pill for good health.

Written by: Drs. Martin, Schrader and Yates

Parents Urged Again to Limit TV for Youngest

Parents of infants and toddlers should limit the time their children spend in front of televisions, computers, self-described educational games and even grown-up shows playing in the background, the American Academy of Pediatrics warned on Tuesday. Video screen time provides no educational benefits for children under age 2 and leaves less room for activities that do, like interacting with other people and playing, the group said.

The recommendation, announced at the group’s annual convention in Boston, is less stringent than its first such warning, in 1999, which called on parents of young children to all but ban television watching for children under 2 and to fill out a “media history” for doctor’s office visits. But it also makes clear that there is no such thing as an educational program for such young children, and that leaving the TV on as background noise, as many households do, distracts both children and adults.

“We felt it was time to revisit this issue because video screens are everywhere now, and the message is much more relevant today that it was a decade ago,” said Dr. Ari Brown, a pediatrician in Austin, Tex., and the lead author of the academy’s policy, which appears in the current issue of the journal Pediatrics.

Dr. Brown said the new policy was less restrictive because “the Academy took a lot of flak for the first one, from parents, from industry, and even from pediatricians asking, ‘What planet do you live on?’ ” The recommendations are an attempt to be more realistic, given that, between TVs, computers, iPads and smartphones, households may have 10 or more screens.

The worry that electronic entertainment is harmful to development goes back at least to the advent of radio and has steadily escalated through the age of “Gilligan’s Island” and 24-hour cable TV to today, when nearly every child old enough to speak is plugged in to something while their parents juggle iPads and texts. So far, there is no evidence that exposure to any of these gadgets causes long-term developmental problems, experts say.

Still, recent research makes it clear that young children learn a lot more efficiently from real interactions — with people and things — than from situations appearing on video screens. “We know that some learning can take place from media” for school-age children, said Georgene Troseth, a psychologist at Peabody College at Vanderbilt University, “but it’s a lot lower, and it takes a lot longer.”

Unlike school-age children, infants and toddlers “just have no idea what’s going on” no matter how well done a video is, Dr. Troseth said.

The new report strongly warns parents against putting a TV in a very young child’s room and advises them to be mindful of how much their own use of media is distracting from playtime. In some surveys between 40 and 60 percent of households report having a TV on for much of the day — which distracts both children and adults, research suggests.

“What we know from recent research on language development is that the more language that comes in — from real people — the more language the child understands and produces later on,” said Kathryn Hirsh-Pasek, a professor of psychology at Temple University.

After the academy’s recommendation was announced, the video industry said parents, not professional organizations, were the best judges. Dan Hewitt, a spokesman for the Entertainment Software Association, said in an e-mail that the group has a “long and recognized record of educating parents about video game content and emphasizing the importance of parental awareness and engagement.”

“We believe that parents should be actively involved in determining the media diets of their children,” he said.

Few parents of small children trying to get through a day can resist plunking the youngsters down in front of the screen now and then, if only so they can take a shower — or check their e-mail.

“We try very hard not to do that, but because both me and my husband work, if we’re at home and have to take a work call, then yes, I’ll try to put her in front of ‘Sesame Street’ for an hour,” Kristin Gagnier, a postgraduate student in Philadelphia, said of her 2-year-old daughter. “But she only stays engaged for about 20 minutes.”

In one survey, 90 percent of parents said their children under 2 watched some from of media, whether a TV show like “Yo Gabba Gabba!” or a favorite iPhone app. While some studies find correlations between overall media exposure and problems with attention and language, no one has determined for certain which comes first.

The new report from the pediatrics association estimates that for every hour a child under 2 spends in front of a screen, he or she spends about 50 minutes less interacting with a parent, and about 10 percent less time in creative play. It recommends that doctors discuss setting “media limits” for babies and toddlers with parents, though it does not specify how much time is too much.

“As always, the children who are most at risk are exactly the very many children in our society who have the fewest resources,” Alison Gopnik, a psychologist at the University of California, said in an e-mail.

Published: October 18, 2011 - New York Times online

By BENEDICT CAREY

Painful Shingles Can Strike More Than Once

Having shingles can be a miserable experience. Now, to make matters worse, the long-held notion that people can only get shingles once in their lives appears to be false, according to a study in the journal Mayo Clinic Proceedings this month.

It's estimated that 1 in 3 Americans will get shingles at some point, with one million new cases reported a year in the U.S. It typically starts with itching, tingling or numbness, then develops into a painful rash that blisters. It often hits people who are elderly or already suffering from another illness or trauma, and the residual nerve pain can last for months.

The incidence rate has been rising around the world, in all age groups, though it isn't clear why, says Rafael Harpaz, a medical epidemiologist in the Centers for Disease Control and Prevention's division of viral diseases. More than half of cases occur in people over age 60, when the risk of complications also rises steeply. Women are slightly more likely to contract shingles than men.

The CDC has urged all Americans age 60 and older to get the shingles vaccine—whether they've had shingles or not. But supplies of the vaccine are on back order in some areas. Merck & Co., the only company that makes it, has encountered frequent supply problems since the vaccine was approved in 2006.

Shingles is caused by the Varicella zoster virus, or VZV, the same virus that causes chicken pox, and it only strikes people who have had chicken pox in the past. Like other herpes viruses, VZV never fully leaves peoples' bodies. It can lie dormant for decades in the nerve roots in the spinal column, until it suddenly replicates and travels down the nerves to cause shingles. This frequently creates a striped rash that follows the pattern of nerves on the back or chest.

Exactly what prompts the virus to wake up is unknown, but it seems to occur when the immune system, which has kept it in check for years, becomes weakened due to age, illness or treatments such as chemotherapy. Emotional stress can cause recurrences of other herpes viruses, and the CDC is investigating whether it can spark shingles as well.

For the new study on shingles recurrence, researchers at the Olmsted Medical Center in Rochester, Minn., examined medical records of nearly 1,700 patients who had a documented case of shingles between 1996 and 2001. They found that more than 5% of them were treated for a second episode within an average of eight years—about the same rate as would typically experience a first case.

That a recurrence is so common is more of a surprise to virologists and other scientists than primary-care physicians, who have seen it in their practices, says Barbara Yawn, director of research at the Olmsted center and the study's lead author. "I've gotten calls and emails from some saying, 'Thank you. Now they will believe us.'"

The Olmsted researchers found the people most likely to have a recurrence were patients whose pain had lasted more than 30 days with their first shingles episode.

It's possible that some subgroups of the virus are more prone to recurrence, says Dr. Yawn. In their next study, her team is monitoring new episodes of shingles and the CDC will analyze samples of those that recur to look for genetic patterns. The earlier studies were funded in part by Merck and the National Institutes of Health, while the new study is funded by the CDC.

Some shingles cases are mild, causing only a minor rash. But some patients develop sharp, stabbing nerve pain that can make the affected area extremely sensitive. "Sometimes people say they can't stand to have anything touch the rash area, even clothes," Dr. Yawn says.

In some cases, the nerve pain is the only symptom for days. Patients have been hospitalized with what was thought to be heart disease or appendicitis until the telltale shingles rash appeared. "Sometimes the rash never develops—that really confuses doctors," says the CDC's Dr. Harpaz.

Nerve pain that lingers for more than a month is called postherpetic neuralgia, or PHN, and it can last for years in some patients. While antiviral medications can shorten the duration and severity of shingles episodes, PHN is harder to treat. Some patients get limited relief from opiates, antiseizure medications and antidepressants, but many elderly people can't tolerate the side effects.

In rare cases, shingles has other serious consequences. Blisters can become infected. A rash on the face can spread shingles into eyes, which can lead to loss of vision, sometimes permanent. A rash around the ear can cause a complication known as Ramsey Hunt syndrome, which can include deafness and weakness of the facial muscles.

A big unknown is whether people who got the chicken-pox vaccine as children will be susceptible to shingles in later years or protected from it—or even vulnerable to full-blown chicken pox if their immunity has weakened. Since the chicken-pox vaccine was only approved in 1996, it will be several decades before the first generation of Americans to be widely vaccinated reaches the typical shingles years.

"It's quite plausible that rates will come down dramatically as those kids become older adults," says Dr. Harpaz, though he notes that some people who got the chicken-pox vaccine may unknowingly harbor the actual virus because the vaccine doesn't prevent 100% of cases, and some people may have had a mild, unnoticeable case before they were vaccinated.

The shingles vaccine, known as Zostavax, doesn't eliminate all cases. Studies show that it cuts the risk of shingles by about half in people over age 60. The cases that do occur in vaccinated people tend to be milder.

If it's possible to get shingles more than once, why does a vaccine work at all? Eddy Bresnitz, Merck's medical director for adult vaccines, says that unlike most vaccines, which prime a person's immune system to ward off a virus the first time it invades, Zostavax boosts the immune system's ability to keep the preexisting herpes infection in check, even though it never fully disappears.

To date, less than 11% of Americans over age 60 have had the shingles vaccine, partly because the shortages have frustrated public-awareness efforts and partly because of cost. Zostavax, which ranges from $140 to $400, is one of the most expensive of adult vaccines, and only some Medicare Part D plans cover it.

Dr. Bresnitz says Merck is building a new plant in North Carolina and expects to have more Zostavax available in coming years. It uses the same raw materials as the chicken-pox vaccine for children, to which Merck gives first priority.  Side effects are usually limited to mild irritation and tenderness around the injection site.

Public-health experts urge Americans over 60 not to wait until they are very old or ailing to get the vaccine. Once people have compromised immune systems, they are no longer eligible, due to the risk that the vaccine could cause shingles rather than prevent it.

By Melinda Beck, The Wall Street Journal

From Dr. Yates:  We've discussed this vaccine and recommend that our patients over the age of 50 consider being vaccinated earlier than the recommendation from the CDC, particularly if they've had shingles previously.  Certainly, with a few exceptions, anyone over age 60 should be vaccinated and we can arrange vaccination in our office.

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

The Autism Vaccine Hoax - The Wall Street Journal.

Twelve years late, the media and medical community may finally be digging a grave for one of the more damaging medical scares in history. We're speaking of the vaccines-cause-autism panic, the burial of which cannot come too soon.

The British Medical Journal this week published an article and editorial explaining that the 1998 study that provoked the vaccine scare was an "elaborate fraud." That study, published in the (once) respected journal "The Lancet," was by British doctor Andrew Wakefield and other researchers, who claimed that the widely used measles, mumps and rubella vaccine was linked to autism. Around the same time, U.S. parents and opportunistic lawyers latched on to a related theory that vaccination shots containing a mercury compound called thimerosal caused autism.

Despite broad evidence even in the 1990s that these claims were unfounded, the medical community was slow to push back. Nervous public-health groups inspired a panic by rushing to get thimerosal out of vaccines. The Lancet stuck by its article, the media sensationalized the story, and Congress joined the cause celebre. Maine Senators Olympia Snowe and Susan Collins went so far as to kill a vaccine liability provision so that parents could bring thimerosal suits. Indiana Republican Dan Burton was especially irresponsible in raising public fears.

By 2004, Britain's immunization rates had dropped to a low of 80%; the rates have recovered only slightly. The Centers for Disease Control says that in the U.S. 40% of parents have delayed or declined at least one of their children's shots. This has led to the needless re-emergence of once-conquered diseases.

Measles is now endemic in England and Wales. California recently suffered a whooping cough outbreak that sickened 7,800 people and killed 10 babies. As Paul Offit, the chief of infectious diseases at the Children's Hospital of Philadelphia and one of the few who stood up against the autism scare, writes in his new book "Deadly Choices," the victims of this "war on science" are children.

Researchers have all the while continued to churn out studies disproving the vaccine-autism link. Vaccine courts have struck down thimerosal claims. Yet it is only recently that professional journals and media have rediscovered a responsibility gene.

It took the Lancet until last year to offer a full retraction of the 1998 study, and that came only after Britain's medical regulator had ruled that Mr. Wakefield had acted "dishonestly and irresponsibly." The British Medical Journal's article is the first in-depth look at Mr. Wakefield's abuses. By journalist Brian Deer—who has investigated Mr. Wakefield for years—the article reports that the doctor grossly misrepresented the cases of 12 children to support his theory, and that he worked with plaintiffs attorneys to exploit the panic for financial gain.

This is a start, but the health community and media have a long way to go to restore public trust in immunizations. They also bear some responsibility for the dollars that have been diverted from research into finding the real causes of the terrible affliction that is autism. Let's hope they now broadcast the vaccine truth as much as they encouraged the vaccine panic.

From The Wall Street Journal

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

Patients in study who knew they were taking placebo still felt better

Doctors surprised that sugar pills had effect anyway

Take two sugar pills and call me in the morning. That could become the new mantra of doctors everywhere if a new Beth Israel Deaconess Medical Center study showing the power of the placebo holds water in the real world.

The researchers got some astounding results when they gave placebos — gelatin capsules filled with nondigestible cellulose — to patients suffering from irritable bowel syndrome for three weeks. Nearly 60 percent reported an improvement in their symptoms compared with 35 percent of the patients who took nothing beyond their usual treatments.

But here is the kicker: The placebo takers knew they were popping the equivalent of sugar pills, yet they still said they experienced less abdominal pain, constipation, or loose stools during the study.

In previous studies demonstrating the placebo effect, patients were told they would be given a medication or a sugar pill, that there was a possibility they could be on a real drug.

“There are some things going on that we don’t quite understand,’’ said study author Dr. Ted Kaptchuk, an associate professor of medicine at Harvard Medical School. “We know that placebos represent some kind of self-healing capacity; it could be that taking a pill triggers a sort of unconscious conditioning in our body to begin the healing process.’’

It could also be that the patients were simply helped by seeing doctors who were sympathetic to their symptoms. After all, 35 percent of the study participants who did nothing other than check in with the doctor during the study reported an improvement in their symptoms.

Kaptchuk emphasizes that placebos work best for conditions during which people appraise how they’re feeling; think mood disorders like depression or chronic pain conditions like IBS, fibromyalgia, and osteoarthritis. These are subjective measurements, not objective lab findings that can be quantitatively measured. “I don’t think placebos will improve cholesterol or hypertension,’’ he said, “or shrink a tumor.’’

But they can make people feel better — at least in this small study of 80 volunteers, all of whom were eager to participate in a mind-body experiment. That’s how the study was described in an advertisement to recruit participants, so it might have been biased in favor of those who believe in the placebo effect.

Kaptchuk said the findings need to be replicated in a larger experiment, which he and his colleagues are now planning. Most likely, the high effectiveness rate — better than some prescription medications for irritable bowel syndrome — will drop somewhat with a larger pool of individuals.

If placebos turn out to help even when patients know the pills are fake, it would surmount an ethical dilemma for physicians. Some doctors lie to patients, making them think a placebo is real medication to foster belief in the pill’s healing power. The American Medical Association and others discourage this practice, because it denies patients informed consent.

“We were looking for an honest strategy for dispensing placebos to patients, and I think we showed it can work,’’ Kaptchuk said. Perhaps that will get doctors to stop giving what he calls “impure’’ placebos to patients, such as antibiotics for a cold or vitamins for tension headaches.

About half of 679 American physicians surveyed in a 2008 British Medical Journal study that Kaptchuk co-authored reported giving placebos to their patients, with the vast majority dispensing something other than a sugar pill. Ninety-five percent of doctors who prescribed placebos told their patients they were prescribing “medicine.’’

By Deborah Kotz, The Boston Globe

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

Getting Fit Without the Pain

Athletes over 50 usually hire a physical therapist after a problem, often an injury if not surgery.

But more older people are starting to hire physical therapists before they get hurt to fill the role of personal trainer.

Before he began training for a marathon, 62-year-old veteran runner Joseph Goldberg consulted with a physical therapist about the shin splints that had developed whenever he'd run more than eight miles at a stretch. She diagnosed an imbalanced gait, ordered custom orthotics for him to wear in his shoes and prescribed exercises to strengthen his hips, a corrective proven to reduce leg-related ailments. "I finished the marathon without injury," says Mr. Goldberg, a Virginia attorney.

By fitness-training standards, physical therapists who specialize in sports medicine are extraordinarily highly educated in the science of preserving, restoring and improving human function. Most have master's degrees, and the profession is pushing its members to obtain doctorates as a matter of course by 2020.

But while physical therapists have become fixtures on the sidelines of professional and college sports, their health-preserving skills are little known among recreational athletes. "We're the best-kept secret in sports medicine," says James Glinn, a physical therapist who runs a set of clinics called Movement for Life, based in San Luis Obispo, Calif.

Word is getting out, as Jane Esparza can attest. The owner of a speakers bureau, Ms. Esparza encountered intensifying levels of knee pain as she entered her 50s. Her doctor told her that losing weight and getting fit would help.

But the trainers she interviewed paid less attention to her knee pain than to her excess weight. All of them, she says in an email, responded with some variation of "We'll whip you into shape."

Then she learned about a fitness clinic near her Virginia home called Body Dynamics, run by Jennifer Gamboa, who holds a doctorate in physical therapy. Following a thorough study of Ms. Esparza's needs and limitations, a Body Dynamics physical therapist worked one-on-one with her for eight weeks, leading her through exercise routines that improved fitness and built confidence without straining her knees. Then she was handed over to a Body Dynamics personal trainer, who continued the regimen that the physical therapist had crafted, with an easy-does-it emphasis.

After 18 months, "I've lost weight," Ms. Esparza says. "My blood pressure has gone down. My cholesterol has improved. I breathe better. My strength and balance are improved. And the pain I lived with daily in my knees has greatly improved. Some days I'm almost pain free."

"What physical therapists are very good at is identifying barriers to exercise-knee injuries, chronic ankle pain-and building a program around them that creates incremental improvements," Dr. Gamboa says. Half of people who start an exercise program drop out within six months, partly because of "fear, discomfort and lack of confidence," she says.

Physical therapists often charge far more than $100 an hour, well above the cost of a personal trainer. Insurance companies tend not to cover the cost of physical therapy without a physician's referral; referrals are often limited to patients recovering from injuries, accidents or surgery. After receiving a fitness program from a physical therapist, many patients will, like Ms. Esparza, hire a personal trainer to implement it. But prevention is where many physical therapists say their profession could make the most difference.

A large percentage of aging athletes eventually suffer sprains, strains, overuse injuries and joint pain, and as part of their recovery they go to a physical therapist who focuses on resolving inflammation, restoring flexibility and developing a more-efficient and balanced program.

A proactive visit to a physical therapist can reveal the muscle imbalances and inefficient movement patterns that cause injury. The therapist can provide a regime that corrects those problems while enhancing endurance, balance, strength and weight control.

The American College of Sports Medicine says that it has certified hundreds of physical therapists and that it has no official position on whether injured athletes should seek help first from a physician or physical therapist.

Even so, fitness trainers shouldn't attempt to treat, and certainly shouldn't ignore, sports injuries, says Diane Buchta, spokeswoman for IDEA, a trainer organization. "We must refer those clients to a physician," she adds.Of course, many personal trainers specialize in treating the aging population. But the credentials of personal trainers can range from doctorate-level academic degrees to little or no certification at all. To address that problem, officials at IDEA recently established FitnessConnect, an online directory of more than 100,000 trainers with verified credentials.The American College of Sports Medicine says that it has certified hundreds of physical therapists and that it has no official position on whether injured athletes should seek help first from a physician or physical therapist.

Physical therapy "is largely built on the sciences of anatomy, biomechanics, exercise science and movement analysis," Carl DeRosa, a doctor of physical therapy at Northern Arizona University. That combination, he says, provides "a comprehensive and efficient 'start-to-finish' service to recreational athletes."

In five states, a physician's referral is required for patient visits to a physical therapist. Elsewhere such restrictions have been eliminated, and physical therapists are allowed to diagnose and treat conditions involving impaired movement. Not all physical therapists are sports-medicine specialists, however. The Find-A-PT link on the Web site of the physical therapy association lists 15 specialties other than sports medicine, including wound management, wheelchair mobility and hand rehabilitation.

By Kevin Helliker, The Wall Street Journal

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP