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