Meet the Team: Tony Trinh!

Let's meet Tony Trinh, Medical Assistant Extraordinaire!

When did you first become interested in musculoskeletal medicine?

-Participating in sports growing up and being a huge sports fan, there is nothing more frustrating then getting injured or seeing your favorite athlete injured. This really spurned my interested in the mechanisms of injury and the process of getting back to the field, and for the non-athletes, just back to every day life.

You are certified in Functional Movement Screens (FMS).  How does that influence the way you think about patients?

-The Functional Movement Screen is a ranking and grading system that looks at movement patterns that are key to normal function. It helps identify functional limitations and asymmetries that can predispose a person to injury and reduce the effects of functional training and physical conditioning. The most important thing that I was able to take away from FMS is that the body, and all of its parts, work together as a functional unit. When thinking about patients, pain may be localized to a specific area or body part, but it is likely that other structures or movement patterns are also involved and contributing to their discomfort. For example, if a patient is having pain in their shoulder or elbow from playing tennis, although it may appear straightforward and localized, an overcompensating movement pattern due to limited hip flexibility could be the underlying issue.

What are your thoughts about role of Musculosketal Ultrasound and how it improves the patient experience in treating musculoskeletal conditions?

-I had not been exposed to the use of ultrasound in a musculoskeletal capacity before coming to Lake Washington Sports and Spine, but seeing it in action, I was immediately impressed. Not only does it allows you to see structures within the body in incredibly high detail (you can see the individual fibers of tendons!), it does this in real time, so you can observe body structures with dynamic movement. Something that is also particularly help is that the patient can give Dr. Chimes and Dr. Hyman feedback in real time, letting them know whether or not the positioning of the probe is painful, allowing them to discern which irregularities are concordant with their symptoms and which ones are simply incidental. 

What is different about the way that Dr. Chimes and Dr. Hyman treat patients compared to your prior exposures to sports medicine? (What are your favorite aspects of how Dr. Chimes and Dr. Hyman educate patients?  Can you give an example of how they go above and beyond in educating patients?)

-I think that Drs. Chimes and Hyman both do a really good job of educating patients on what is going on with their bodies. When looking at the ultrasound, they understand that most people will not understand what they are looking at, so they go through the effort of explaining what exactly is being displayed on the screen. They will often use anatomical models to describe which structures are involved and how they are contributing to the problem. I think this helps patients understand the goals of their treatment options, and empowers them to follow through appropriately.  It takes extra time and effort to educate, but the patients clearly appreciate it. 

You are planning a career as a physical therapist.  What have your learned while working at Lake Washington Sports & Spine about how Dr. Chimes and Dr. Hyman integrate their care with the physical therapists they work with?

-Physical therapy is a treatment option that has proven very effective in recovering from a variety of musculoskeletal injuries. Having the correct diagnosis and following the appropriate protocols are key components that contributes to the efficiency of physical therapy. Drs. Chimes and Hyman are both incredibly talented diagnosticians, and are well versed in the strengths of various physical therapists, allowing them to best match a physical therapist's skillset with specific patients. Another element that Drs. Chimes and Hyman bring to the table is that they perform a number of different injections that can supplement physical therapy when the patient's progress has plateaued.

why do necks crack?

Great article by my close friend and colleague Chris Visco, at Columbia in NYC

http://www.nytimes.com/2013/10/29/science/what-causes-a-neck-to-crack.html?_r=2&

Complex injuries

I broke the car cable to my IPhone 5 the other day.  As I suspect is the case for many people, even though I intend to unplag the cable by grabbing the little black nubbin (.... I'm assuming "nubbin" is the technical term), in reality I probably yank on the cable more often than not.

Not surprisingly, it is starting to break, as you can see above.  To me, what is most interesting is wear it broke- at the interface between the nubbin and the casing.  It didn't have to break there- it could have broke in the cable itself, or the end of the nubbin that attaches to the casing, or the nubbin itself, or where the nubbin interfaces with the lightning plug.  It happened to break where it did, because along the chain that was the weak point.

It struck me that this was a perfect analogy for many of the musculoskeletal injuries Garrett and I see in clinic. Someone engages in some physical activity that causes an abnormal force across their body, and the body gets injured.  The place of injury can vary, though, depending on the specifics of their injury.

For example, the patellar ligament connects the patella (knee cap) to the tibial tuberosity (the little bump on the front of the shin bone), and this ligament complex can be injured from abnormal loading.  In this context, I am using complex to mean a linkage of things to one another, rather than as a synonym for complicated.  In 11 year old boys, the patellar ligament complex usually fails where the ligament attaches to the patella, something called Sinding-Larsen-Johansson syndrome.  In 14 year old boys, it usually fails where the ligament attaches to the tibia, called Osgood Schlatter syndrome, and in adolescents and young adults, it usually fails in the proximal 1/3 of the patella, called Jumper's Knee or patellar tendinopathy.

One of my job as a physician is to be familiar common loading patterns, and also recognize how things like age, gender, and common activities affect their different complexes, because they often have different injuries.

In the meantime .... fortunately my car cable still works.

Degree of Difficulty to Live a Healthy Life

One of my friend's from Pittsburgh read my post yesterday, and asked what I meant when I said the degree of difficulty to live a healthy life in Redmond is easier than Pittsburgh.  I'll elaborate here.

I loved living in Pittsburgh.  I thought the people of Pittsburgh were the kindest of any place I ever lived, and I enjoyed the communal feel of the city.  However, I think there are several factors that aggregate make it easier to be healthy when you live in Redmond (or more generally, the Pacific Northwest):

1. Less smoking.  Smoking is obviously detrimental in of itself, but also is a marker for other healthy lifestyle factors.
2. Better access to bike trails.  Redmond has one of the most elaborate bike trail systems in the country.   Pittsburgh has some nice bike trails (the one connecting Homestead to McKeesport is particularly beautiful), but there are areas of incomplete trail that make practical commuting impossible (e.g., there was no trail system connecting Pittsburgh to Monroeville), and many of the existing trails are poorly designed (e.g., the bike trail on the Birmingham Bridge requires cyclists to cross moving traffic, without a physical barrier to prevent being hit by a car).
3. Better access to hiking.  Pittsburgh has some wonderful trails within the city itself- particularly Frick Park, which is one of the best city parks in the country.  It also has access of about 70 minutes to the Laurel Highlands, which is stunning.  Redmond is still better though.  Redmond has Marymoor Park, which is pretty awesome, especially the dog park, and Snoqualmie Pass and other hiking trails is much closer, and some of the nicest hiking in the country.
4. Healthier eating culture.  Pittsburgh has some wonderful healthy restaurants, but the food is still substantially healthier in Redmond.  There are more health minded restaurants, and the grocery stores have more healthy options.  This is especially noticeable in Costco.  For example, the Costco in Kirkland has a large supply of gluten-free options.  Not that it's necessary to be gluten free by any means, but if one chose to be, it's easier to do so in the Redmond area.
5. Healthier peers.  One of my happiest moments so far practicing medicine was performing a neck injection in a woman in her 70s, and when I saw her in the post-op recovery area, her first question was "I feel great - can I go running tomorrow?"  I think the Bellevue/Redmond area probably has one of the highest densities of 70 year old runners in the world.

I loved Pittsburgh- great city, great people.  However, I think it's pretty clearly objectively true that it's easier to be healthy living in Redmond.

The next big thing in medicine .... behavior change

Modern medicine has been spoiled by some raging successes.  The development of antibiotics and vaccinations have saved millions, perhaps billions, from death and disability from infectious disease.  Similarly, in certain types of cancer (.... although importantly, not all), the use of chemotherapeutic drugs have been life saving.  Some surgical techniques, like removing a ruptured and infected appendix, can be life saving.

Unfortunately, it has also skewed our perspective about how medicine is supposed to work: Person has disease X, we give them intervention Y, and presto, they are back to normal.

However, that model does not accurately reflect the way the human body works.  Most human disability in the United States are related to chronic conditions, and most of those chronic conditions are related to behaviors that cause those chronic conditions.  One important insight to realize is that most disease is therefore related to choices.

I'll use myself as a personal example.  When I was in my 20s, I was in very good shape- I competed in Ironman Triathlons,  and did so with a frame comparable to an NFL safety or linebacker, which was unusual for a triathlete.  In fact, they offer a seperate class for men over 200 lbs, the "Clydesdale" class, in recognition that triathlons are a small man's sport.

As I entered my 30s, I started to make a series of reasonable decisions - prioritizing my PhD, my med school training, my personal relationships, making a national name for myself - that all had as unintended consequence of de-prioritizing my own health.  I didn't get enough sleep, I wasn't working out as much, and while I was generally a healthy eater, I was eating portions more appropriate for a competing triathlete, not a physician seeing patients all day.

And I got fat.

Unfortunately, I didn't have people in my life tell me I was fat routinely, so I didn't really feel the consequences of being fat.  Yes, I had to buy a new wardrobe, but that came on slowly, so it wasn't really that expensive.  I was doing well enough socially, so that didn't have consequences.  I had a high enough baseline level of fitness that I wasn't winded in every day activities, and almost all buildings have elevators these days.

I started having some minor health issues- my cholesterol went up, but a Lipitor helped that.  My blood sugars were not diabetic levels, but they were over 100, so the process of metabolic syndrome was starting.  I had a bunch of aches and pains, but I just wrote them off as in inevitable consequence of aging.

Three big factors contributed to me starting to view the world in a different way, which I think will ultimately add 10-20 years of quality to my life.

1. Sleep.  I was working on an academic project related to testosterone, and started reading the medical literature on how profoundly sleep helps testosterone levels.  Basically, all of your anabolic (healing) hormones are at their lowest when you go to sleep, and increase as you sleep.  I decided that sleep was going to be my #1 health priority, and within weeks noticed that I was less irritable, felt stronger, and many of my aches and pains went away.

2. Friends.  I shared a hallway with some wonderful endocrinologists, and I was talking to one about my concerns about my increasing blood sugars, especially with a strong family history of diabetes.  She told me (and I am paraphrasing- this is what I heard): "You are clearly on a trajectory to become diabetic, so either you focus on diet and exercise like you are a diabetic now and prevent the disease, or wait until you've started having real consequences to make a change."

3. Guatemala.  I was visiting some friends in Antigua, and I realized that someone my size simply couldn't live in Guatemala.  The average man in Guatemala is 5' 2", and I am 6'2-1/2" and even having lost some weight before the trip, weighed about 250 at the time.  The infrastructure of the country- bus seats, beds, toilets, clothing, portion sizes- were not built for someone my size.  

     I remember walking by a heavily guarded bank, and they had the burliest, scariest looking dude they could find guarding the bank with an assault rifle ... he was probably 5'6" and 165 lbs.
     What I realized from that trip was that even allowing for variation in size by country, I was lumbering around at a body size that simply was not how we were supposed to evolve, and was not sustainable.

So, I started prioritizing my own health.  Sleeping better, eating healthier, eating smaller portions, simplifying my life, removing tangential stressors, and exercising more.  Moved to Redmond, Washington, where the degree of difficulty to live healthy is easier.  And I feel healthier than I have in at least a decade.

...... But, I often think about an alternate universe where I didn't make these behavior changes.  Where I still didn't get enough sleep, ate a bit too much, took on extra complexity.  What would the health consequences be?

This is where the unintended consequences of good health care would probably lead to me having WORSE health.   My lipid panel would probably continue to deteriorate, but hey, I can just take a bigger dose of Lipitor.  That nagging Achilles of mine would first give me another excuse not to run, and then would slowly deteriorate and become more debilitating (..... a topic for another time, but Achilles tendinopathy is often the first musculoskeletal manifestation of metabolic syndrome).  I'd probably slowly enter into the diabetic category, and start taking metformin.  And because I don't have a huge incentive to make any changes, because there is always a medication I can substitute for an appropriate behavior change, I would continue the long slow progression to declining health.  This would not be despite good health care, but in large part BECAUSE I have access to good health care.

On another tangent .... when I was in my mid-20s and working on my PhD, I hit a dating dry spell. I was lamenting this with my housemate Stew, and was concerned that perhaps my dry spell was because I was acting too desperate.  He very wisely pointed out to me "No, Gary, just the opposite.  You're not desperate enough.  You're too comfortable- you're enjoying your work, going to the gym, talking to me, and so you simply aren't treating meeting someone like enough of a priority."  It was a brilliant insight- because I had enough other positive aspects to my life, I was not desperate enough to make a real change.

I think the same phenomenon is true of health care.  Behavior change is for the vast majority of patients, including me, the intervention that will make the most significant long term impact on their health.  The challenge is feeling desperate enough to make those changes.

For example, cortisone injections for lateral epicondylopathy ("tennis elbow"), have been shown repeatedly to make patients feel better at the time of the shot, but make people feel worse when followed for the years that follow.  Part of this is likely related to degradation of tissue from the cortisone, but at least part of the effect is likely because patients don't make the needed biomechanical alterations that caused the injury in the first place, and end up reinjuring themselves.

In future posts, I hope to discuss specific tactics on inducing positive change, but I think the first step is the recognition that change the most powerful pill in our medicine cabinet.

Positive Feedback- It's all about empowering patients

Recent positive feedback I heard from a patient:

"He spent an exceptional amount of time with me, especially on my first visit to review my symptoms and discuss why I was there. He was thoughtful, considerate, caring, and listened to me. My life as I knew it had been put on hold and his plan gave my life back to me. I did the work that was necessary, but he provided the people and plan that got me better."

One of the things I really love about this feedback is that the patient recognized that THEY were the person who made the biggest change, not me.

Dr. Hyman and I can facilitate patients, but ultimately what we can do is help patients empower themselves.  It's nice to know that sometimes we get this right.

New Publication by Dr. Chimes: Endocrine Abnormalities Affecting the Musculoskeletal System

Dr. Chimes has a recent publication on Endocrine Abnormalities affect the Musculoskeletal System

http://now.aapmr.org/msk/sports-medicine/Pages/Endocrine-abnormalities-affecting-the-musculoskeletal-system.aspx

One of Dr. Chimes's niches is looking into how both age and gender affect different musculoskeletal conditions.  For example, low back pain in a 14 year old female gymnast is significantly different than low back pain in a 64 year old male Microsoft executive, and our success in treating patients is dramatically improved if we tailor our treatment plans to the specific goals, needs, and variation within each individual.

Journal Club: The accuracy and efficacy of palpation versus image-guided peripheral joint injections

Reviewing a recent paper by Mederic Hall, MD, looking at the benefit of using imaging to help make sure that injections go to the right place

http://europepmc.org/abstract/MED/24030302/reload=0;jsessionid=JsAJg5bV6NLhcIHLaP3w.38

The benefits can be seen pretty easily by the summary table below

Joint	Landmark Guidance	Ultrasound Guidance
Shoulder (Glenohumeral)	10-100%	93-100%
Shoulder (Acromio-clavicular)	39-72%	90-100%
Elbow	38-100%	91-100%
Wrist	25-97%	79-94%
Knee	51-80%	97-100%
Ankle (Subtalar)	68-100%	90-100%

In all cases, the use of ultrasound-guidance improves the accuracy of making sure the injection goes where it should

At Lake Washington Sports & Spine, we strongly believe in the benefit of using ultrasound-guidance for our injections.  In addition to being more accurate, we have found the following additional benefits:

1. Hurts less.  By using ultrasound-guidance, we can find our target and still be tangential to the painful tissue. When performing landmark-based injections (or "blind" injections), the needle is targeted directly at the sensitive tissues.  This is particularly true for small sensitive structures like hands, feet, and nerves.

2. Can use less medication.  Because we are targeting medication right "where the action is", we can use smaller doses of medication.

3. More effective.  Studies are coming out now showing that the accuracy of using image guidance leads to more effective and cost-effective injections (e.g., http://www.jrheum.org/content/38/2/252.short)

4. Helpful even when they don't work.  Back when we used to perform landmark-based injections, if the patient did not benefit, we didn't know if it was because we missed the target.  Now, we know, so if the injection doesn't work, we can move on to considering an alternative diagnosis.

Dr. Chimes and Dr. Hyman take Washington, DC by storm!

Last week was the annual AAPM&R national meeting, a gathering of PM&R thought leaders at the nation's capitol

Both Dr. Chimes and Dr. Hyman were asked to help train other physicians in different cutting edge aspects of medicine.

Dr. Chimes's Activities:
- Instructor for Intensive Musculoskeletal Ultrasound Workshop
- Serving as Chair Elect for the Musculoskeletal Council, the largest Council within the AAPM&R, helping set the agenda for national discussions on Musculoskeletal Care
- Lecturing on "Gender Consideration in Pain" as part of a series on the role of the neuroendocrine system in the management of painful conditions
- Instructor for a Musculoskeletal Ultrasound workshop for Lower Limb injuries in Athletes
- Exhibitor for ActivAided (www.activaided.com), a back brace for athletic conditions, for which he serves as Chief Medical Advisor

Dr. Hyman's Activities:
- Instructor for Intensive Musculoskeletal Ultrasound Workshop
- Instructor for Ultrasound Workshop on the Shoulder
- Instructor for  Ultrasound Workshop for Nerve Injuries
- Instructor for Ultrasound Workshop on Chemo-Deinnervation

Dr. Chimes in the news- Health Tips for Active Boys and Mens

In the latest issue of Overlake Healthy Outlook, Dr. Chimes was interviewed for tips on helping males of all ages stay healthy.

http://healthyoutlook.dcphealth.com/images/stories/over1309/healthy-outlook-fall-2013.pdf

Tips for Weekend Warriors

Are you a weekend warrior?  For many busy professionals, the weekend is the only real time we can get to workout.  Here are some tips to help maximize the weekend warrior experience and prevent injury.

1. Start light.  

Warm-ups in general are a bit overrated, but for the weekend warrior, they are important to help loosen the muscles up.  

I find some light jogging intermixed with a few deep squats helps loosen up the legs, and arm circles to warm up the shoulders can be helpful.

2. Pay special attention to the groin.

The groin is particularly susceptible to injury in weekend warriors.  The groin muscles (technically the adductor muscle group) are not commonly used in every day activity, but are used frequently in sports, and therefore are prone to overuse injuries if you only use them on the weekend.

The reason we don't use them much during the week is that when you walk at a normal pace, the way your bring your thigh forward is with a group of muscles called the hip flexors (muscles in the front of your thigh and pelvis, including the rectus femoris and iliopsoas).

When you run or move more quickly, you rotate your pelvis, which engages your groin muscles to bring the thigh forward.  One way to image this is to stride as far forward as you can with your left thigh, which will rotate your pelvis so that the left side is further forward than your right side.  From this position, if you want to bring your thigh forward, you would have to use your right groin muscles in addition to your hip flexors.

Some strategies to help protect your groin:

1. Some deep squats and light jogging, as noted above

2. The butterfly stretch (http://www.ehow.com/how_2312300_do-butterfly-stretch.html) after warming up

3. The upward facing dog stretch (http://www.ehow.com/how_2277775_do-upward-facing-dog-pose.html) to help stretch the abdominal muscles.  This is important because the groin muscles and your rectus abdominus muscle (the six-pack muscles) share a common insertion point on your pubic bone.  I sometimes remind patients of this by referring to their adductor longus (one of the groin muscles) as the "seven pack" to remind them that it is part of the same group as the abdominal muscles, and therefore need to be stretched together.

4. If you are doing a kicking sports (e.g., soccer), be careful on your first few kicks that you don't slam your instep into the ground instead of the ball.  This is a common mechanism where soccer player often give themselves a particularly hard-to-heal type of groin injury called a sports hernia.

3. Try to fit in one high intensity workout during the week

Try to spend at least 30 minutes during the week in which you are exerting yourself to more than 50% of your maximum capacity.  This will help stave off de conditioning during the week.

As a practical matter, you may need to do this in short spurts.  Things like sprinting up the stairs every day when you get to work, or racing your son across the backyard when you get home, are great ways to build in short bursts of high intensity contractions.

In another upcoming essay, I will be talking more about strategies for "How to be more Awesome," which I consider an important part of the Kinemedics Philosophy.  One part of this, for parents in particular, is the importance of being excellent in the presence of your children.  I can't stress enough how important this is.  So, even little things like having your child see you do 10 push ups or  2 pull ups in front of them has some important ancillary benefits beyond their obvious health impact.

So, think of this nugget about short bursts of high intensity exercise as a variation of finding time to put more Awesome into your day.

4. Prime yourself for the weekend

One key way to make sure your weekend workouts go well is to make sure you don't go into the workouts tired.  The most important thing you can do to optimize your Saturday workout is to be healthy Friday night, and the same applies for Sunday morning and Saturday night.  

Some strategies:

1. Don't drink too much- 2 drinks is a reasonable number for most people

2. Get enough sleep.  Don't stay out more than 2 hours past your normal bedtime, and try to stay close to your normal bedtime

I realize this is tough for some people, as they prize their social time, may be in a new relationship that requires more effort, etc.  What I say is that optimizing your health is about embracing a healthy lifestyle.  As we learned recently, not even Dennis Hopper can continue to live the Dennis Hopper lifestyle forever (it may even catch up to Jack Nicholson eventually).  So if you are a partier and carouser, you will have to change some time.  That time is now.

Have a fantastic weekend!

Happily Growing Older Together!

One of my patients from Pittsburgh recently sent me a sweet letter, and she was kind enough to let me talk about her on the blog.

Margie is a very kind woman I worked with for several years in Pittsburgh.  She had a few separate musculoskeletal conditions, but I always emphasized to her that she was a person, not a collection of body parts, and that we should focus on her bigger dreams and goals, which including writing.  I told her I wanted to "grow old together" with her.  One of the highlights of my visits with her was when she would bring me something she had written, which helped me see what wonderful person she is.

One of the hardest parts of moving on to my next stage of life here on the Eastside is feeling like you are abandoning the patients you come to love.  So it was such a joy to get a letter from Margie seeing how well she is doing.

This is Margie, looking as spry and beautiful as ever, trimming some bushes.  She's wearing the Recovery Aid brace that I developed as Chief Medical Adviser for ActivAided (www.ActivAided.com), which helps her get back to action without her back pain limiting her.

Margie- thanks for letting me grow old with you!

Love- the secret ingredient in patient care!

A few years ago, I was flying home from a conference where I was teaching musculoskeletal ultrasound, and I was fortunate enough to sit next to a very kind woman who had moved to Pittsburgh from India a few years earlier.  She had been an engineer in India, but since coming to the United States, her primary focus was raising her 12 year old son, who was a child prodigy already taking college classes.

She related to me a story of how one time her son was upset that her mom made her dinner every night rather than going to restaurants.  I thought her response was very sweet, and changed the way I think about things:

“I explained to him that when you go to a restaurant, no matter how good it is, they were making that meal for a generic person.  When I make dinner for you every night, I am making dinner for YOU.  Every decision I make, whether it’s how firm to make the rice, or much coriander to use in the seasoning, I am making that decision because I want you to be happy.  Most importantly, there is one ingredient that I can give you than no restaurant can give you, and that’s love.”

I was obviously touched.  I think back to that kind woman often when I am taking care of patients.  One of the things I most love about working in a small physician owned practice like Lake Washington Sports & Spine is the love that our team can put into the care of each patient.  Being small, this empowers us to customize the patient experience.  Whenever we make a decision, we are making it for YOU.

Welcome to our family!

Meet the Team: Jami Schmitt

To help our patients meet members of the Lake Washington Sports and Spine Family, we will roll out some short interviews with our team members.  Up first, the great Jami Schmitt, our Medical Assistant extraordinaire:

What is your role on the Team at Lake Washington Sports & Spine?
My role in our team at LWSS is to assist with patient care. From greeting and rooming the patient to assisting with referring them to facilities that are convenient for them. When they have extra questions about care, I do my best to answer them and return phone calls as soon as possible. I like to make the patients feel comfortable and welcomed to the office. They should always know we have their best care in mind while helping them.

How does working for a small, physician-owned practice contribute to the family environment at Lake Washington Sports & Spine?
Working for a small physician- owned practice contributes to the family environment in many ways. One, since we all spend so much time together and the office is like a second family we, as a team, become closer. I feel that there is open communication and we all feel "safe" to talk to one another. In regards to patients, I feel that they feel more welcomed by coming to a small practice rather than a large facility with multiple doctors and staff members. Here we are able to be more personal with our patients. They can feel safe coming to the clinic and know they are receiving our full attention with their care. Since we are not part of a large corporation, we are able to get to know the patients on a more personal level. They seem to open up more when they feel comfortable with the staff and know that their doctors care about them.

What are some of the "little things" you like to do to improve the patient experience?
Some of the "little things" I like to do to improve patient experience is to make sure they know what the plan is before they leave, to make sure the patient is clear about the next step in their care. If they need prior authorization for imaging or therapy, I like to make sure they know what to expect before leaving the office. Making sure the patient knows where to go for imaging or therapy and has all referrals they need and contact numbers is helpful. If the patient has a "special request" and wants me to look into information for them, I try and complete it before they leave and, if not, try and call them by the end of the day.

What part of patient care makes you the happiest?
The part of patient care that makes me the happiest is when you see the joy on a patients face when their pain has improved. A few of our patients have come to us after huge car accidents where they suffered from many life changing injuries. You learn a lot about patients at the first visit and to see how they improve over time and how their mood improves truly makes me happy. I enjoy seeing our patients make progress and return to activity they were able to do before they were injured.

Many patients have never heard of PM&R or Sports & Spine Rehabilitation before.   What kind of patients do you meet who wish they had come to Lake Washington Sports & Spine earlier in their care?
Our sports patients, many whom don't know what type of doctor to go see.  Typically, they have seen their primary care or physical therapy, who then refer them here. I have found that many patients are unaware of all that we do here. Many have been pleasantly surprised to learn that we are able to use diagnostic ultrasound, nerve tests like EMGs testing, or guided injections like epidurals and ultrasound-guided joint injections.  

Creep

CREEP

CREEP:

- Creep refers to a material property, specifically the tendency for something to become distorted

- If you squeeze something for a short period, it will snap back into place

- If you squeeze something for a longer period, it will deform, and take time to go back into place (see, for example, the picture below of the cleaning wipe container that I squeezed)

- If you hold something in a deformed position long enough, it may permanently deform

This can happen to different structures in your body- e.g., the lumbar disk

- It is important to move on a regular basis to prevent this deformity

- You may need to perform specific exercises in a specific direction to mold tissue back into the correct place

To give yourself an example of how this may affect you in real life, pull back on your index finger so that it is an extended position, and then hold it in that position.  At first it may be a little bit uncomfortable, but as you continue to hold it in that position, it will hurt more.

I very commonly see this occur in patients who sit at their desk all day- the hunch forward, and this shortens the tissues in the front of their body (the "anterior chain") and stretches the back of their body (the "posterior chain").  This can cause significant spine pain, and needs to be reversed with postural control exercises that stretch the anterior chain and strengthen the posterior chain.  The specifics may vary with each patient, but the concept remains the same.

Bulgarian Squat

The Bulgarian Squat is a more advanced exercise- I'd make sure you can do a regular lunge and belt squat before trying.  When the front leg is forward more, it helps activate the gluteus maximus more, which is generally good.  It also helps stretch the hip flexor of the rear leg.

BULGARIAN SQUAT:

1. Stand in front of a chair

2. Place right leg onto chair, with the top of your foot flat against the chair

3. Left foot should be 2-3 feet in front of the chair

4. Slowly lower your body so that your butt moves downward, but not forward.  You will be doing a lunge with your left leg.  You should feel a stretch in the front of your right thigh (your right hip flexor), and you should feel your left buttocks and thighs contracting.

5. TIP: pay attention to the movement of your left knee.  It should move straight up and down, and not deviate side-to-side.  If you find that you are struggling to keep your left knee stable, move slower, and don't lunge as deeply

6. TIP: Concentrate on sitting back, rather than bringing your upper body or shin forward

7. Repeat for 10 repetitions

8. Switch sides

Do 3 sets of 10 repetitions for each side

Belt squats

This is another one of my favorite exercises- the Belt Squat.  It's a particularly good exercise to help activate the gluteus maximus muscle, which many patients have trouble activating

INITIAL PROGRESSION:

- Place a fat man's belt just above the knees

- Initially, started seated in a chair, with your hands on your belly

- Rotate knees outward, so that the outside of your knees are always pushing against the belt (external rotation)

- Stand up, focusing on pushing your thighs outward against the belt.  Pay particular attention to when you are sitting back down to not rotate your thighs inward

- As you come up from the squatted position, imagine that you are squeezing a $1000 bill between your butt cheeks, and don't forget to push against the belt

- Repeat for 10 repetitions, 3 sets

SQUAT PROGRESSION:

- Squat by sitting backward.  Do not let the shins move forward, try to imagine sitting back in a chair.  It often helps to have a rope or belt wrapped around a pole in front of you to help maintain balance.

Great feature in the AARP about our approach!

This article is from about a year ago while I was still at the University of Pittsburgh, but highlights the approach that Dr. Hyman and I use at Lake Washington Sports & Spine, integrating exercise prescription with advanced technologies like musculoskeletal ultrasound to provide the best possible care for sports injuries!

http://pubs.aarp.org/aarptm/20120405_PR?pg=17#pg17

Ice Ice Baby!

I'm about to give away a trade secret that could potentially put me out of business .....

Patients need to use ice more often!  It's one of my most frequent recommendations, but I find that patients tend to blow it off, waiting for the "real stuff" that costs more.  In my experience, for musculoskeletal injuries, frequent use of ice is often the most significant interventions for improving function and outcome.

When I was in medical school, I remember one of the doctors I was following recommending "moist heat" to patients with an injury, and I still hear patients come in having had that as a recommendation.  One would think, based on this recommendation, that there is a large literature supporting the use of moist heat.  There is not.

For example, here is an article discussing the benefits of ice for the calf (http://www.ncbi.nlm.nih.gov/pubmed/12492271), and a subsequent article showing the lack of efficacy in using moist heat (http://www.ncbi.nlm.nih.gov/pubmed/19827506).

So why is moist heat recommended so often?  The same reason that baseball managers used to focus on batting average instead of on-base percentage- it just became part of the orthodoxy, and no one thought to question it.  Moist heat often feels good at time zero, so following it out over time to see if it makes a difference is not intuitive.

Before I completely poo poo moist heat, I would note there is some evidence of using moist heat immediately before activity (see, for example, http://www.ncbi.nlm.nih.gov/pubmed/11805451), so there is a rule for using moist heat before physical therapy.  I would argue, however, that in most cases that a warm up of full range of motion exercise (e.g., long slow lunges or deep squats) is a preferable warm up.

The more common question I get from patients, though, is "I'm in pain, what medication should I take?"  In another blog post, we'll talk about how pharmacologic management of musculoskeletal pain is almost always the wrong choice, but I usually recommend that the "medication" of choice is ice.  When asked "should I use ice or heat?" the answer is essentially always ice.

How should you use ice?  My normal recommendation is to make an "ice pillow" as per the directions below:

1. Take a high quality gallon size zip lock bag
2. Fill it about 1/3 of the way with ice cubes (crushed ice is even better, but I wouldn't sweat it if you don't have crushed ice)
3. Press out the remaining air, and tightly seal the bag
4. Wrap the redundant plastic around the remainder of the bag
5. If you have a skin condition or something that alters your sensation (e.g., diabetic peripheral neuropathy), then you should wrap the ice with a towel.  For the vast majority of patients, though, it is safe and preferred to apply the ice directly to the injury.
6. If you can, apply some form of wrap to hold the ice compressed against the site of injury.  For example, you can use an ACE wrap, or if it's in hard to compress area like the shoulder, putting it underneath tight fitting clothing (like a compression short or Under Armour shirt) can help hold in place.
7. Use for at least 20 minutes.  In practice, I recommend doing something that occupies your thoughts for 20-30 minutes (e.g., paying bills online, watching TV).  No major harm in doing it for a few extra minutes- most people tend to under ice anyway.

If you want to take your icing to another level, a cold compression device like the Moji is even better.
http://www.gomoji.com/?kw=moji&gclid=CILS0K7sorgCFUbhQgodCW8ARQ

If I have time, I may do a full review on the Moji at a later date.  In  short, it's a well designed device to help apply ice and compression at the same time.  I particularly love the Moji knee, and use it myself.

Thoughts about Crossfit, the Denominator Effect

Every year, as a member for the editorial board for the American College of Sports Medicine's Health & Fitness journal, we are asked to fill out a survey about trends in fitness.  One of the questions was on a scale of 1-10, how "hot" a trend is Crossfit.  I said Crossfit clearly is a 10.

Like many health care practitioners, I often get a skewed perspective of new fitness trends, since I primarily see patients when they get injured.  Inevitably, as new fitness trends emerge, I will start seeing a corresponding increase in injuries.  A decade ago, I started seeing yoga injuries, followed by Zumba injuries, followed by P90X injuries, and more recently Crossfit injuries.

I think it's essential to keep in mind what I call the "Denominator Effect."  What is relevant is not the total number of injuries, but rather how many injuries I am seeing, divided by the number of people participating in that activity.  Of course, as something gains in popularity, the number of injuries will go up, but I need to know the rate of injury increase.  The other major factor- for those who are NOT injured, how much benefit are they seeing.

Let me cut to chase before going into detail- I really like Crossfit.

For those not familiar with Crossfit, it is a form of high intensity training.  High intensity training is, for those who are physically ready to handle it, arguably the single best form of exercise one can perform.  The American College of Sports Medicine recommends aerobic conditioning, strength training, balance training, flexibility training, and a training plan as part of their exercise prescription, and Crossfit is a convenient way to hit all of those exercise goals.

The typical Crossfit workout starts with a well designed warm up for 5-10 minutes, followed by 15-20 minutes of weight training (focused on classic Olympic lifts or power-lifting techniques), followed by 15-20 minutes of the "Workout of the Day" (called the "WOD" in Crossfit parlance), followed by a cool down/ stretch.

The Workout of the Day often combines different calisthenic movements for time.  For example, it may include a 200 meter sprint, followed by kettle bell swings, followed by pull-ups, then repeated, with the goal of finishing as quickly as possible.

I can't speak definitively about all Crossfits, but I have had a very positive experience at Sasquatch Crossfit in Redmond, Washington- http://sasquatchcrossfit.com/index.html.

Things I liked about the Crossfit experience:

1. Attentive care: The trainers sincerely cared about their team, and focused on creating a positive experience.  I consider myself in reasonably good shape, but I had some major deficits that needed to be addressed, particularly horrible kinesthetic awareness and hip range of motion.  I was concerned about my poor form causing an injury, but the trainers took time to work with me to enhance my form, and encouraged me to perform more simple motions so that I could develop proper range.

2. Focus on full range of motion.  One of the things that the Crossfit experience taught me was the benefit of exercising through full range.  Prior to training with Crossfit, I would encourage patients (and myself) to limit themselves through shorter arcs of motion, like half squats instead of full squats.  I was wrong.  I found that by practicing full range of motion, I dramatically improved strength in the ranges I had not previously challenged.  Perhaps more importantly, my flexibility and functional range of motion dramatically improved.

3. Supportive environment.  The team philosophy is very strong.  At Saquatch CrossFit, the owner Tim is one of the trainers, and having worked with all 4 trainers, there was a consistent quality and philosophy across the trainers.  I remember doing one particularly grueling exercise (repeated lunges with a barbell), and having Tim cheer me on from the finish line and another trainer, Everett, walk next to me to correct form and provide motivation was inspiring.  While it's theoretically possible I would be able to maintain that level of intensity on my own, but realistically I don't think I have the level of pure intrinsic motivation, and the coaches really helped in making me feel like I was part of something bigger than myself.

So those are the pros.  What are the cons?
1. Not for everyone.  The workouts are challenging, so people with low baseline levels of fitness will struggle.  I routinely found my heart rate within 80-99% of my maximum, so if you have cardiac issues, I would discuss this with your physician before starting Crossfit.  If you have musculoskeletal conditions, seeing a Board Certified Sports Medicine specialist familiar with Crossfit (..... like, of course, Garrett Hyman and I at Lake Washington Sports & Spine) can help figure out how to participate safely.
2. Knowing your limits.  With some of the exercises, it can be tempting to lift as heavy as you can.  It is much more important to focus on proper form.  In fairness to all the trainers I worked with at Crossfit, they were very attentive to this issue, but I suspect some people may be tempted to lift heavy before they learn proper form and expose themselves to injury risk.  I am a beginner, so I know I can lift heavier with bad form, but that's not my goal.
3. Inherent risks with high intensity training.  All forms of high intensity training have increased risk, so I think when assessing the risk of training for Crossfit, it really needs to be compared to other high intensity modalities like Martial Arts training, Zumba, P90X, etc.  Reviewing the scientific literature, I have seen evidence for the benefits of Crossfit (e.g., http://www.ncbi.nlm.nih.gov/pubmed/23439334), but I have not seen data on the injury rate.  In my personal opinion, I think the risk is probably on the lower end of high intensity training modalities IF you listen to your trainers.  Compared to martial arts training, you don't have as high a risk of someone else injuring you, and compared to P90X, you have supervision to assess your form.
4.Deterioration of form with fatigue.  Crossfit is tiring, so it's especially important to be attentive to form as you tire yourself out.
5. Specific areas for potential injury- all can be prevented with focus on form.
    A. The low back.  Any type of loaded flexion with twisting movements can expose the back, particularly the disks, to injury.  The back is particularly vulnerable during kettle bell swings.
    B. Knees/Hips.  You are generating  force through the "kinetic chain," so if the forces are not transmitted smoothly with proper form, both knees and hips can be injured.
    C. Shoulders: As with the knees and hips, the shoulders are the base for the kinetic chain in the upper body, and therefore care must be made to transmit forces with proper form.

Overall Thoughts and Feedback for Patients:
1. Crossfit, when done with proper form under the guidance of good trainers, can be a complete package in terms of meeting the American College of Sports Medicine's recommendations for exercise.
2. It's high intensity, so it can create better results than lower intensity exercise, but also has risk of injury inherent to all forms of high intensity exercise.
3. You need to do a realistic assessment of your capabilities, both in starting Crossfit and in advancing your loads.
4. If you are unsure of your capabilities, working with Sports Medicine physicians like those at Lake Washington Sports & Spine can help in meeting your exercise goals.

Journal Club: Effect of running and walking on osteoarthritis and hip replacement risk

The article reviewed is WILLIAMS, P. T. Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk. Med. Sci. Sports Exerc., Vol. 45, No. 7, pp. 1292–1297, 2013

http://www.ncbi.nlm.nih.gov/pubmed/?term=WILLIAMS%2C+P.+T.+Effects+of+Running+and+Walking+on+Osteoarthritis+and+Hip+Replacement+Risk.+Med.+Sci.+Sports+Exerc.%2C+Vol.+45%2C+No.+7%2C+pp.+1292–1297%2C+2013
----------
Design:

• This well designed article evaluated 74,752 runners and 14,625 walkers from the National Runners' and Walkers' Health Studies.  This is an unusually large number of runners and walkers evaluated, which is often a limiting factor in most studies.
• The runners and walkers were queried as to whether they were ever told by a physician they hip osteoarthritis.  This is an imperfect way of assessing the development of hip osteoarthritis, but as imperfect measures go, it is reasonable.  In some ways, this is a better measure than using a more "objective" standard like criteria based on x-ray or MRI imaging, since the correlation between imaging finding and functional limitations is imperfect, and for most patients, the only reason a physician would tell them they had hip OA is because they went to the doctor regarding a functional issue.  If I had a perfect measure, I'd want some form of functional assessment, but I do think this is a reasonable proxy.
• Another outcome measure was whether they reported having a hip replacement.  This is also a reasonably good measure- I don't know for sure, but I was assume that the correlation between reporting have a hip replacement and actually having a hip replacement is very close to 1.0.  Reporting bias is always a concern, but this is a case where I suspect the effect of reporting bias is negligible.

Results:

• As people age, they are more likely to both develop hip OA and get a hip replacement.  A bit of "no duh" result, but still useful to confirm.
• This effect of age was stronger for women than it was for men.  This confirms some other research (.... I'm thinking specifically of some of the aging/mobility research by Stephanie Studenski, one of my former colleagues from Pitt- http://www.upmc.com/media/experts/pages/stephanie-a-studenski.aspx), which is that people age, men are more frequently limited by medical conditions (like heart disease), and women  are more frequently limited by musculoskeletal conditions.
• Other factors associated with increased risk of either hip OA or hip replacement included: 
• Estrogen + Progesterone usage (notably, estrogen use alone did not, nor did menstrual status)
• Years of eduction (..... I guess a downside of being an MD/PhD)
• Intake of red meat (..... just what I need to hear on the 4th of July)
• Perhaps the most important finding in this study- the risk of hip OA and hip replacement went down the more someone ran.  This is an important finding, since I know many runners are concerned that their mileage is putting them at risk for developing arthritis.  It appears the opposite is true for the hips.
• A similar effect was found for walkers.
• The risk for hip OA and replacement was increased the larger the body size, as measured by body mass index.  Most, but not all, of the benefits of running and walking appeared to be related to the associated decrease in BMI.

Bottom Line: What does this mean for our patients?

• Running is good
• One of the theoretical concerns about running too much is that it may make one more likely to develop osteoarthritis or need a hip replacement.  Per this study, at least, the opposite is true
• Amongst the many benefits of running, it helps maintain a leaner body type, and this is likely one of the mechanisms that explains the protective benefit of running
• The article goes into the biology of cartilage.  In my opinion, much of that is in the realm of speculation and not assessed in this study, so this study does not do anything to alter our knowledge in those domains.  The study is valid regardless.

Prone Press Up

This may be single favorite exercise.  It is one of the most fundamental exercises in the Mechanical Diagnosis and Therapy (McKenzie) protocol, and is very similar to the Upward Facing Dog movement in Yoga.

I always do this exercise first thing when I get to my hotel room after a long plane flight, and it's very helpful for many patients who need to centralize their radicular symptoms (please see blog post about centralization- http://lakewass.blogspot.com/2013/07/centralization.html), or to help with low back stiffness while driving or flying on airplane (http://lakewass.blogspot.com/2013/07/tips-for-flying-with-low-back-pain.html).

Technical note about the picture below: I have no idea why I am grunting so much, but that is NOT proper form.  Try to stay more relaxed and control your breathing

INSTRUCTIONS:
1. Lie on belly
2. Place hands next to shoulders like you are going to do a push-up
3. Take a deep breath in
4. As you breathe out, slowly arch your back upward
5. You may feel a point of stiffness in your low back- it is important to push through that stiffness
6. Lower yourself down so that you are completely flat again
7. Take a deep breath, and then repeat

Tips:
1. Make sure your pelvis stays on the table
2. If you have leg pain, your goal is to pull that leg pain into your back.  This may intensify your low back pain- that is ok.  This called centralizing your symptoms when you pull the pain out of your legs and into your back
3. You should feel your back start to loosen after 10-20 repetitions

When to do:
1. 20 repetitions every morning
2. 10 repetitions after any time that you have been sitting for prolonged periods (car rides, airplane flights, sitting in class)

Standing Back Extension

This is one of my favorite exercises, and I commonly recommend it to patients with low back to help centralize symptoms (please see blog post about centralization- http://lakewass.blogspot.com/2013/07/centralization.html), or to help with low back stiffness while driving or flying on airplane (http://lakewass.blogspot.com/2013/07/tips-for-flying-with-low-back-pain.html).

INSTRUCTIONS:
1. Stand with your back to a table, with the edge of the table just below your waistline
2. Make sure your feet are all the way back up against the table
3. Cross your arms in front of your chest
4. Take a deep breath in
5. As you are exhaling, arch your back backward
6. You may feel some stiffness- it is important to push through that stiffness.  Try to arch back a bit further with each repetition
7. Come back to neutral
8. Take a deep breath in
9. Repeat by arching backward as you exhale

Tips:
- Your goal is to CENTRALIZE your symptoms.  This means that you are trying to pull your symptoms away from your foot, leg, thigh, and buttock, and INTO your back.  Your back hurt more at first, but should loosen up after 10-20 repetitions

Tips for Flying with Low Back Pain

Flying is one of the toughest activities for patients with low back pain.

In some upcoming posts, I will include a few exercises you can perform on the plane, particularly standing back extensions, proximal hamstring stretches, and hip flexor stretches.

This post will focus on making sure you have sufficient lumbar support.  Most (.... and my most, I mean all) airplane seats are not designed with the low back in mind.  I suggest using a lumbar support when flying - I usually use a cylindrical roll they sell at the magazine shops, often recommended for the neck.

I often forget to bring a lumbar support with me, though, so what I then recommend is using magazines in the airplane as a makeshift lumbar support roll.  I am a big guy, so I usually need 4 magazines, which usually includes the in-flight magazine and Skymall from both myself and neighbor.

The pictures included here are intended to show you how to make the lumbar support roll.

Wall Centralization Exercise

On a previous post, we discussed centralization.  One exercise that can help with centralization is the Wall Centralization Exercise.  Often, patients benefit in performing this exercise under the guidance of a skilled Physical Therapist or Chiropractor familiar with the Mechanical Diagnosis and Therapy protocol (sometimes called McKenzie, named after the person who developed the protocol).

WALL CENTRALIZATION EXERCISE:

1. Lean against the wall with your shoulder against the wall (check with your doctor, PT, or chiropractor to make sure you are performing on the proper side)

2. Place your far foot firmly on the floor, and place your near foot (the side closer to the wall) over the planted foot, so that the near foot is not bearing any weight

3. Take a deep breath in

4. As you breathe out, slowly lean your hip into the wall

5. You may feel a point of stiffness in your low back- it is important to push through that stiffness

6. As you inhale, move back to the starting position

7. Take a deep breath, and then repeat

8. The goal for this exercise is to centralize the pain going down your leg, so that you will have less leg pain.  If this makes your back pain more intense- that is ok and expected.  After repeated repetitions, you should notice the back pain improve as well

  

Tips:

1. If you have leg pain, your goal is to pull that leg pain into your back.  This may intensify your low back pain- that is ok.  This called centralizing your symptoms when you pull the pain out of your legs and into your back

2. You should feel your back start to loosen after 10-20 repetitions

When to do:

1. 20 repetitions every morning

2. 10 repetitions after any time that you have been sitting for prolonged periods (car rides, airplane flights, sitting in class)

Centralization

CENTRALIZATION:

One approach to the management of radicular symptoms (sometimes called "sciatica") is called Mechanical Diagnosis and Therapy (MDT).  The goal of this program is to teach you how to prevent further exacerbations, and give you tools to use yourself so that if you have another exacerbation, you know how to treat it.

The key concept in an MDT program is the concept of CENTRALIZATION.

 This means that you want to pull symptoms out of your foot, leg, thigh, and buttock, and INTO your back.

- This process is called centralization because you are moving your symptoms toward the center of your body

- The goal is to move disk material away from your nerve root

- Sometimes when you perform this initially, it may actually make your back pain worse.  That is ok.  Eventually, in addition to pulling pain into your back, the goal is to make your back pain disappear.

- If the pain, instead of going into your back, goes AWAY from your back and into your buttock, thigh, leg or foot, that is called PERIPHERALIZATION.  That is not a good sign, and suggest that the disk material is pushing on your nerve root.

Sometimes, after your symptoms have improved, your therapist may work on additional strategies to help strengthen your core and prevent you from an exacerbation.

- These exercises are sometimes called LUMBAR STABILIZATION or CORE STRENGTHENING exercises.

- These are very helpful exercises. However, the concept of centralization is still the priority, because if your symptoms start to peripheralize, than means you may soon have an exacerbation of your symptoms.

- Please let your therapist or chiropractor know if you start having peripheralization, as that means you need to shift the focus back to centralization.