High Times in Mainstream Medicine

I have been living in Portland for almost two months now. For a very healthy/active city, they’re sure a lot of smokers. As I type this post sitting at my kitchen table looking out to a busy street, at least one in every four of the people walking by are smoking a cigarette. Many of my patients are smokers, and a few are marijuana users. Yes, recreational and medical marijuana is now legal in Oregon. In fact, medical and recreational pot is now legal in Oregon, Washington, Alaska and Colorado, as well as a handful of states in which it legalized for medical use only. I realized that I don’t know the specifics of how marijuana affects the body and it’s affects on healing. Surprisingly, there isn’t much information specifically for physical/occupational therapists on how marijuana can affect your treatment with your patient. So whether you are a user yourself or have patients who use marijuana, continue reading for a comprehensive (but not conclusive) review of how marijuana can affect different systems of the body. 

Note: This is not a pros/cons article, or a stance paper to or for marijuana, it is simply FYI based on scientific evidence.

Quick History of Marijuana

For thousands of years, marijuana was used for medicinal purposes, specifically for its analgesic properties. The ancient Romans, Greeks and Chinese used marijuana to treat various illnesses. In the 19^th century, it was introduced to the UK to be used as medical treatment. However, in the 1930s marijuana started to get a bad rep. At that time, Harry Anslinger was the head of the Federal Bureau of Narcotics and strongly opposed of marijuana use, grouping it with all narcotic medications. He was unhappy with the “over prescription” of pain relieving medication by physicians, and sought to decrease the availability of these drugs. In 1937, the federal government criminalized medical marijuana use even against the advice of the American Medical Society to do otherwise, and in 1942, it was officially removed. Within the last decade, medical marijuana has be re-legalized in some states based on its treatment for glaucoma, nausea, pain, anxiety, seizures, and spasticity. There are a zillion individuals which stories about how marijuana helped to save their lives, but little research has been performed on a large scale population. Scientists recently have focused on conducting research on the potential benefits of marijuana, which has been facing push back from the FDA with questions on how to regulate this drug. 

There are over 400 compounds found in cannabis, 60 of which are considered cannabinoids. The following cannabinoids are found with the highest concentration in marijuana:

- Tetrahydrocannabinol (THC): Psychoactive, therefore has effects on the brain since THC binds to CB1 receptors in the brain, which is responsible for altering the mind. Because of the effects on the brain, THC has been known make some users feel anxious or paranoid. Has a sedative effect that may make some feel drowsy, but may also be helpful with sleeplessness. THC also affects CB2 receptors, which are found in immune cells.

- Cannabidiol (CBD): Non-psychoactive, therefore it does not give you that “high”. With less side effects, CBD is typically well tolerated, even at high doses. CBD has been found to be an antiemetic (decrease nausea/vomiting), an anticonvulsant, antipsychotic, anti-inflammatory, anti-oxidant (combats neurodegenerative disorders), anti-tumoral/anti-cancer, and an anti-depressant. It has no sedative effect. A form of CBD, Epidiolex, got some attention in the news recently after it was found to decrease seizures for children with rare forms of epilepsy.

Note: Marijuana is a Schedule I drug, making it difficult for researchers to get grants to study the benefits. Therefore, there have been very few studies on the affects of THC and CBD on humans; most studies have been on animals.

Physical effects of marijuana on:

PULMONARY SYSTEM

Breathing: Frequent marijuana smokers can have the same breathing issues as a tobacco smoker. Any kind of smoke inhalation will irritate the lining of the lungs, which long term can lead to chronic cough, phlegm production, wheezing, and bronchitis. Some studies have found that smoke from marijuana contains many toxins, irritants, and carcinogens, similarly to tobacco smoke. Typically, marijuana users inhale more deeply and hold their breath longer than tobacco smokers, leading marijuana smokers to more tar exposure per breath. (American Lung Association).

A 20-year study from UCSF and the University of Alabama at Birmingham collected data from 5,000 U.S. tobacco and marijuana smokers. They found that tobacco smokers in general smoked more frequently than pot smokers; on average, tobacco users smoked 20 cigarettes/day vs. two to three times a month for marijuana users. Therefore, you must keep that in mind when I tell you the rest of the findings. Essentially with tobacco, the more you use, the more you lose. The more tobacco that was smoked, the worse off one’s lung function based off of measured air flow rate (speed in which a person can blow out air), and lung volume (the amount of air a person is capable of holding ie. 6 L for an adult male). This shouldn’t be too surprising. However, the same linear relationship was not true for marijuana smokers. Air flow rate increased with exposure to marijuana, up to a certain level. (Remember… marijuana smokers in this study smoked two-three times per month).

CARDIOVASCULAR SYSTEM

Heart rate: Smoking pot can increase heart rate up to two times for up to 3 hours after smoking. This has been found to increase possibility of heart attack directly after inhalation. During an exercise test, smokers reached their max heart rate quicker than non-smokers.

Blood pressure: The effects of marijuana on blood pressure are complex, depending on dose and administration. It often produces a temporary, moderate increase in blood pressure immediately after ingestion. However, heavy chronic doses may slightly depress blood pressure instead. One common reaction is to cause decreased blood pressure while standing and increased blood pressure while lying down, causing people to faint if they stand up too quickly (orthostatic hypotension). There is no evidence that marijuana use causes persistent hypertension and/or heart disease. Some users even claim that it helps them control hypertension by reducing stress. One thing THC does do is increase pulse rates for about an hour. This is not generally harmful, since exercise does the same thing, but it may cause problems to people with pre-existing heart disease. Chronic users may develop a tolerance to this and other cardiovascular reactions.

 NERVOUS SYSTEM

Brain: Cannabis with a high percentage of THC (high - 10-14%, traditional = 2-4%) has been found to affect the corpus callosum, which is white matter of the brain that connects the right and left hemispheres. Therefore, communication between the two hemispheres may become less efficient. Researchers from this study did note that it can't be for certain if cannabis changes teh white matter, or if individuals with white matter changes are more likely to smoke. On the contrary, researchers are now finding that cannabis is a neuro-protectant, protecing brain cells from trauma, injury, or disease. Current studies are begin performed on the effects of marijuana for individuals with chronic traumatic encephalopathy (think concussions), PTSD, and Alzheimers.

Nerves: Marijuana offers potential neuromodulation and neuroprotection, which protects neurons from central nervous system damage including ischemia. This may also be way marijuana can be an effective treatment for chronic pain. Studies have found CBD to be a successful treatment for diabetic neuropathy, which is the leading cause of blindness in the U.S., by protecting the nerves of the eye. A study from the University of Glasgow in the UK found that cannabis oil sprayed helped treat debilitating neuropathic pain for patients with allodynia and multiple sclerosis.

Cognition: Studies have found that infrequent users may have impaired cognition after inhalation, however complex cognitive task performance was minimally affected in experienced users.

IMMUNE SYSTEM

Immunosuppressed: A study performed at the University of South Carolina found that THC could suppress rodents’ immune systems. It has been found to decrease the immune system for individuals who are already immunosuppressed, such as those with an HIV infection. Researchers believe this may be due to a mold called Aspergillus that grows on marijuana. CBD has been found to modulate the immune system.

Autoimmune disorders: Individuals with autoimmune disorders such as arthritis, type-1 diabetes, and multiple sclerosis whose immune system is ramped up have been found to benefit from cannabis use.

“Normal” immune system: Studies on rodents have also found that injected THC may suppress the BRCA2 gene (which is a protein that normally suppresses tumor growth). The BRCA2 gene is associated with early onset breast cancer, thus suppressing this gene could increase one’s risk of breast cancer.

SKELETAL SYSTEM

Osteoporosis: A study at the University of Edinburgh in the UK assessed the effects of cannabis on mice with age-related osteoporosis. They found that marijuana helped to regulate peak bone mass through its effects on decreasing osteoclast (type of cell that breaks down bone tissue) activity, and regulated adipocyte (fat cells) and osteoblasts (bone formation).

Bone Healing: Ingesting marijuana deprives the cells of oxygen, restricting the blood flow. Therefore, it can have a negative effect on healing by slowing oxygen supply to the tissues. On the contrary, a study from Tel Aviv University studied the effects of THC and CBD on rats with mid-femoral fractures. The healing process sped up to an eight-week recovery with both the THC and CBD treatment groups. Not only did CBD sped up recovery, it also enhanced the maturation of the collagenous matrix which make the bone stronger, suggesting it would be harder to break in the future.

Joints: Osteoarthritis (OA) is the most common type of arthritis in which cartilage in joints wear away. There is currently no cure for OA, however studies have found that cannabis helps to reduce swelling in joints, and relieve pain for individuals with OA. Rheumatoid arthritis (RA) is an autoimmune disease that affects the joints. Many individuals with RA are taking multiple pain reducing and immunosuppressive medications with a long list of negative side effects throughout their entire lives. THC has been found to be a safe anti-inflammatory and pain relieving medication with minimal side effects.

MUSCULAR SYSTEM

The American Academy of Family Physicians (AAFP) found that long term marijuana use reduces testosterone levels and growth hormone in men. Lowered testosterone results in lowered muscle mass, as well as a feeling of drowsiness. Decreased growth hormone results in slowing to body’s recovery rate, causing muscle growth to delay. Decrease in these hormones may translate into a decrease in effort during exercise, as well as a decrease in overload during exercise that is necessary to improve cardiovascular performance and muscle strength. However, other top athletes have reported that small amounts of marijuana has helped them find new peaks in their training, allowing them to find a controlled and meditative state. An Olympic skier stated that cannabis causes him fearlessness, which allowed the pro to attack steeper slops with more focus.

Smoke it? Eat it? Vap it?

Edibles may be a better solution to inhalation in order to decrease some of the negative effects on the lungs that occur with smoking. However, ingesting marijuana isn’t all it’s cracked up to be. This is mostly due to the differences in how the drug is absorbed. When you consume marijuana, it is absorbed by the stomach and liver where it is converted into an active metabolite that is very effective in crossing the blood-brain barrier. This results in a more intense high, however it usually takes between about an hour to feel the effects with the effects lasting for several hours. Therefore, people tend to overdo it. Smoked cannabis goes through a different metabolic process in which THC travels directly to the brain, thus the effects can be felt within 10 minutes and last approximately 30-60 minutes. There is also a difference in the amount of cannabinoids that are delivered into the bloodstream based on method of delivery. Edibles deliver 10-20% of THC into the bloodstream versus inhaled cannabis, which is closer to 50-60%. Vaping or electronic cigarettes have been found to be beneficial for decreasing second hand smoke as well as the amount of carcinogens that are ingested.  Even though there has been little evidence of harm from their use, it is still premature to say for sure if it is safe to use since no long-term studies have been performed. In addition, one of the main components in e-cigarettes, propylene glycol (PG) is considered to be safe for oral consumption; it is not known what the health risks are for inhaling PG. Dr. Sanjay Gupta, a trained neurosurgeon and CNN’s chief medical correspondent believes that if you are going to use marijuana, it is probably best to use the vaporizing method since smoking creates a lot of unknown byproducts, and ingesting leads to uneven absorption, while vaporizing seems to activate the medicine without burning it.

Follow up questions you may want to ask your patients who use cannabis:

       How often?

       What type? 

       What method?

BOTTOM LINE: Stay true to your scope of practice. But just like all medications, it is important to know the effects in order to better understand/treat our patients.

For more information about where the medical community is today with legalizing medical marijuana, check out Dr. Sanjay Gupta's 42 minute documentary here: https://www.youtube.com/watch?v=QnVHxOPEbqc

Nap Club

"When you have insomnia, you are never really asleep, and you are never really awake". 

- Chuck Palahniuk, Fight Club

I cannot help but be extremely jealous of my four-year-old nephew. That kid has no idea how good he has it. Sure, his life in general is pretty scheduled (like us all), but within that schedule is a designated nap/rest time (it's called "rest time" because if you mention nap, he will freak out. Rest time always turns into naptime). I told you that he has no idea how good he has it. He gets a nap planned into his day, and he takes it for granted! I would do many things to get a designated nap time scheduled into my 9+ hour work day, just 20 minutes that all I ask! In fact, if I were president, I would change the typical 1 hour lunch to a 30 minute lunchtime (let's be real, half hour is enough time for lunch if you plan ahead and make one) at 11am, and a 30 minute nap time at 2:30pm. VOTE FOR ME.

In fact, there are a couple large corporations that do allow "naptime". Nike Headquarters in Beaverton, Oregon have a designated Quiet Room that is intended for expecting mothers, however it is available to anyone on campus. They just have to check out the room when they want to use it. I have no idea what this room looks like, but I'd imagine it's a lovely oasis for quick R&R. Google Headquarters in Mountain View, California have nap pods on there campus where employees can escape to relax, listen to soothing, and even get some shut eye. British Airlines and Continental pilots making international flights commonly take turns practicing “NASA naps” since they know sleep is crucial for alertness and overall wellbeing. Yes it is great that these rest options are available however unfortunately, it is not used often. After inquiring about the nap rooms from a close friend that works for Nike, the quiet room hardly gets used. This is most likely due to the stigmas associated with resting, such as laziness, lack of ambition, and having low standards. This could be one reason why naps aren't common practice. 

What are other reasons that naps aren't more of a common practice? One could argue that it takes away from productivity since employees are away from their work desks. And others may say that naps are good for children since they have growing brains (and they will be super grumpy if they don't!), not necessary for adults. I'd argue that I would probably be less grumpy if I had a naptime too. But studies are showing that just a 20 minute nap can help boost the brain... it improves memory, concentration, and overall improvements in quality of life.¹ When I say nap, I mean a cat nap at some point in the afternoon since around 2pm is when the body's circadian rhythm (natural clock) is at it's lowest point of alertness. So sure it may not be common practice in today's work place to take a quick siesta, but maybe it should be, or at least have a half hour to relax, meditate, listen to soothing music, take a T.O. for the brain. Sure as we get older we are able to concentrate for longer periods of time, but no person is able to concentrate on one task for 8 hours straight. And as we get older, we have a lot more pressures than we did as kids. We now have a family to feed, a house to pay off, we are drowning in loans, and there is your parents that you have to now look after. We are freakin' exhausted, all the time.

So is this better than have half awake zombies sleep walking around the office trying to make decisions and deadlines? The good news is that people still show up to work when they are tired, but the truth is that they are much less efficient. A 2011 study on insomnia surveyed 7,428 full-time employed people asking questions dealing with sleep habits and work performance.² Of those individuals, nearly 25% were estimated to suffer from insomnia (younger/middle aged women were most affected by sleeplessness compared to men and employees > 65 years of age). This study also estimated that insomnia costs the average America worker 11.3 days of work, which is $2,280 in productivity losses. This totals to $63.2 billion and 252.7 workdays for the whole country. Not to even mention the effects on sleeplessness to our appetite. We crave sugar and carbs when we are tired, just to gain a rush then falling right back down again shortly after drinking a soda, eating candy, or a bag of chips. I recently had an extreme case of this... I woke up with a headache, popped a could of Advil, shortly after was extremely tired, the only way I could keep my eyes open was to eat and eat and eat. Later I realized that I popped two Advil PM, oops. 

It doesn't take much common sense to understand the repercussions that lack of sleep has on the human body. We have all felt the affects at one time or another. You've had a huge project in the making, a deadline is fast approaching, you have about zillion things on your to-do list, your mind won't stop going once you lay down to rest. And after a few nights of restlessness, you get a cold, your back pain starts to creep back again, you can't remember the details of your presentation even though you know that you know it. Why is lack of sleep important to know as a physical therapist? Because lack of sleep affects pain perception, healing, learning/memory, cardiovascular function, and modulating fear/anxiety. Sleep and pain may also be one those what came first, the chicken or the egg type of situations. A 2015 study that surveyed 73 physical therapists found that 93% of physical therapists agreed that poor sleep impacts pain and outcomes, however most (75%) did not receive education on sleep in during entry-level PT education and therefore do not have an adequate outcome to assess sleep.³

True, I did not receive education in school on how to assess sleep other than asking, "how are you sleeping?” followed by gaining a visual on the position of how one sleeps in order to give advice for better positioning. When I ask my patient's with pain, whether it be shoulder, hip, back, etc., how they are sleeping, it's generally poor. My follow up question before asking about their position is to ask how their sleep was prior to the pain/injury, in which often times it was still poor. Alright, so two quick questions that now give me some insight that this person has something else going on rather than just purely positioning. Perhaps it was the physiological effects that occur from sleeplessness (decreased pain modulation, healing, memory/learning, cardiovascular function) that is the primary issue. It is easy to feel tongue tied after that since we are indeed physical therapists, not psychologists. And physical therapists are not trained in how to ask the right questions. We are educated in how to rate pain (pain only subjective by the way), location, depth, 24-hour timeline, etc., but not necessarily the cognitive aspects of pain.

I was only able to find one study that assessed the extent of pain education that was provided to DPT students. The study surveyed healthcare educators, and 61% believed that their students received adequate education in pain management.⁴  That means 39% of students did not receive education on pain management. Obviously this is an area of improvement. I can't speak for all graduate level physical therapy programs, but the extent of pain education that I was provided was very limited. I remember watching a five-minute video in one class about the physiological/psychological effects of pain, and that's about it. After I graduated, there was a poll that was sent out to the students on whether or not they believed they gained enough knowledge on pain education, however I never heard the results of that poll. 

Sure, we can't do it all and at times it would be very appropriate to refer a patient to a psychologist. However, assessing sleep is within our scope of practice. Studies have demonstrated time and time again that daily, moderate exercise improves sleep quality.⁵  We can educate patients on how to conserve energy throughout the day in order to use that energy for exercise, family time, and social activities, thus improving one's quality of life. We can teach patients about proper sleep hygiene (please see my previous post Sleep Less = Achieve More? from August 25, 2015 for my sleep hygiene tips). We can teach pain education/modulation, giving patients ways that they can gain some degree of control over their pain.

When can we fit in all this information during our 30 minutes with a patient? At any point. Be creative. As physical therapists, we have to take responsibility to talk with our patients. I am lucky enough to be able to spend 60 minutes with my patients, others get 30 or 40 minutes. This is still such a huge chunk of time compared to many physicians who get maybe five minutes with an individual due to their huge patient load. Take the time at any point of therapy to ask. Ask open-ended questions, "so how is everything going", or more specific questions "do you feel like you are a contributing member to your work team?". Train supporting staff in how to listen/look for cues such as “I don’t feel like I have any control”, “I’m afraid this isn’t going to work, again”. Educate patients on the positive effects of taking 20 minutes during their lunch break to relax/recharge. Give them the confidence to put their wellbeing first, before their intense work pressures since we know that even with intermittent "mind breaks", they will still get the same if not more work done.

I highly encourage any therapists working with chronic pain and sleep deprived patients to purchase Adriaan Louw's book Why Do I Hurt? A Patient Book About the Neuroscience of Pain. This short self- help book is 52 pages and is written for patients. If you have trouble talking about the psychological and physiological effects of pain (like I do, hence I purchased the book), then you can lend this book to patients. It has great pictures and metaphors to help one's understanding of how pain affects the brain.

Each person is an individual; therefore we must not have one cookie cutter way to treat. If they don't like to read, don't give them the book. If they are on their computer all day, send them a couple of You Tube videos about sleep or pain education. If they are having difficulty taking short breaks throughout the day to just move, sit next to them while they put an alarm on their phone that goes off every 30 minutes to stretch. If they aren't ready to make lifestyle changes, then keep educating them. Give them the confidence that they can be active in controlling of their health.

Remember, the word doctor in Latin means 'to teach'.

References:

1. Milner CE, Cote KA. Benefits of napping in healthy adults: impact of nap length, time of day, age, and experience with napping. J Sleep Research. 2009;18(2):272-281.

2. Kessler RC, Berglund PA, Coulouvrat C, Hajak G, Roth T, Shahly V, Shillington AC, Stephenson JJ, Walsh JK. Insomnia and the performance of US workers: results from the America Insomnia Survey. SLEEP. 2011;34(9):1161-1171.

3. Siengsukon CF, Al-Dughmi M, Sharma NK. A survey of physical therapists' perception and attitude about sleep. J Allied Health. 2015;44(1):41-50.

4. Hoeger Bement MK, Sluka KA. The current state of physical therapy pain curricula in the United States: a faculty survey. J Pain. 2015;16(2):144-52.

5. Tang NKY, Sanborn AN. Better quality sleep promotes daytime physical activity in patients with chronic pain? a multilevel analysis of the within-person relationship. PLoS ONE. 2014. 9(3):e92158. 

Laughter is the best medicine

"I love people who make me laugh. I honestly think it's the thing I like the most, to laugh. It cures a multitude of ills. It's probably the most important thing in a person." - Audrey Hepburn

Do you remember the last time you laughed so hard your stomach hurt? Or so hard that you couldn’t breathe? Or so hard that you almost peed your pants?

It’s pretty rare as adults to laugh out loud anymore. The closest we get is when we text “LOL” when we really just mean-- ‘I don’t know how to finish this text, so I’m just going to put LOL’. I’m pretty lucky that my boyfriend is serious < 5% of his day (which believe me gets a little annoying from time to time), but it means we are laughing a ton. The other day he asked me what I like most about him (sorry Andre, I’m calling you out). I thought about it for probably .25 seconds and responded with “YOU ARE HILAROUS”. And it’s true, his ability to make me and everyone around him laugh is the best thing about him.  

We are attracted to people who make us smile and laugh, and this is because it is actually really good for our health. In fact, there is an actual word for the study of laughter and its psychological/physiology effects on the body – Gelotology.

For a long time researchers didn’t understand the effects of laughter and brain. Some theorist believe that laughter began in the hunter/gatherer times after a near encounter with death/danger—Laughter would decrease stress by decreasing the fight or flight reflex (Note: if you want to learn more about the fight/flight reflex, please read my previous post “Literally Losing my Mind, here: http://projectpdxhale.blogspot.com/2015/08/literally-losing-my-mind.html ) Laughter may also indicate trust in ones companions, which if you are hunting some animal that is 3 times bigger, stronger, and faster than you, you probably want to trust the guy next to you. Aristotle believed that laughter was unique trait to humans (which we now know to be incorrect-- apes, dogs and rats are able to laugh when tickled and playing).  Darwin believed we laugh in order to make/strengthen bonds with others—this reminds me of preparing for a speech, presentation, performance, etc. You always want to start with some sort of joke, get everyone to relax, and build trust. I’m sure most of you have figured that out already. It works! Try it if you haven’t yet.

Here is what researchers do know:

Laughing can increase your level of natural killer cell activity – cells that help to fight off disease. But there is a catch, you must laugh out loud, those that silently watched the comedy did not have these higher immunity cells.

Laughter releases endorphins (remember Elle Woods?), which are pleasure-inducing neurotransmitters. These endorphins do the heart good by ultimately vasodilating blood vessels à increasing blood flow à reducing inflammation and à decreasing cholesterol plaque formation.

Laugher has been found to reduce cortisol (the stress hormone).

Laughing activates at least five different parts of the brain-- It's a "mental explosion". 

For individuals with "gelastic epilepsy" characterized by laughing seizures often at inappropriate times, have damage to areas of the brain that are in charge of emotion-- the hypothalamus, frontal lobe, or temporal lobe.

What I found most interesting -- We are 30 times more likely to laugh if we are with someone else. It is behaviorally contagious. You can catch laughter when others are laughing, especially if you know and trust them. So it is laughter itself, or the social context itself that is important for our health? Researchers now believe that laughter is a social, almost animalistic vocalization that binds people together.

The medical field understands the importance of laughter, and has implemented different types of treatments related to laughter for individuals with chronic pain and stress. Some physicians are prescribing alternative and combination treatments with laughter therapy (I watched a video about it, it's a room full of people literally just laughing hysterically for 2 minutes), laughter yoga, and laughter dancing.

I'm going to leave you with this story about Veterans and the power of laughter:

Social media isn’t always all that bad. I actually came across a guy that I went to college with, Danny Maher (aka Donny O’Malley) that somehow I had forgotten about. We weren’t really friends in college, but we hung around the same crowd. He was always crazy and hilarious- life of the party kind of guy. I lost track of him after college and it wasn’t until I came across his Facebook recently that I caught up on the last 5 years of his life. After he graduated, he ended up joining the Marines and served in Afghanistan. Once he returned from overseas and medically retired from the Marines, he felt different. (Speaking as a civilian, I could definitely understand why our soldiers would feel different, and my instinctual thought is that they are overall happy to be back and safe). However, the reality is that a lot of our guys and girls come back 'safely', but with mixed emotions. Danny describes his emotions as loneliness and losing some sense of purpose after being discharged from the infantry-- he missed the camaraderie, brotherhood, and intensity.  Sadly, he was also noticing a trend. Many of his fellow military veterans were silently struggling too, killing themselves at an alarming rate.

Did you know that each day, twenty-two US veterans commit suicide? 

I don’t know about you, but that is a staggering number. The VA also estimates that 11% of veterans from the Afghanistan war are affected by Post Traumatic Stress Disorder (PTSD), but I’m guessing that number in actuality is probably a lot higher. So, Danny did what he knows how to do best, make people laugh- full on, pee your pants, inappropriate, dark humor, love your brother kind of comedy. He wrote a comical satire directed towards his veteran counterparts and started a foundation called Irreverent Warriors to not only raise awareness for PTSD and veteran suicide, but to get military guys and girls back together, like how it was when they were together in the military- count on each other, open up, and have fun. They even put on hiking events where they hike 22 km with 22 kg on their backs, only wearing their silkie shorts (it’s a sight to see!). When you get together with others, you laugh.

Please visit the Irreverent Warriors website to learn more about their great program, and share with a military friend who may or may not be struggling: http://media.thelovestory.org/irreverent-warriors/