Viscosupplementation

What is Viscosupplementation?

Viscosupplementation is a procedure that is often utilized by the doctors at Lake Washington Sports & Spine, mainly for patients who suffer from osteoarthritis of the knee.  Osteoarthritis (also called degenerative joint disease) is mechanical wear of cartilage and bone within a joint and often limits patients’ abilities to remain active.  Since our goal at Lake Washington Sports & Spine is to Keep People Active, any procedure that helps our patients maintain their level of physical function is a great tool in our belt. 

Viscosupplementation (also known as hyaluronic acid injections or hyaluronan injections) involves injecting a lubricating fluid into a joint (most commonly in the knee, which is the only joint that has historically been covered by insurance, but it can be helpful in other joints as well).  Hyaluronic acid is an important component of the joint fluid in healthy joints and is found in lower concentrations in osteoarthritic joints.

What is it like to receive a viscosupplement injection at Lake Washington Sports & Spine?

Both Drs. Hyman and Chimes typically recommend that their patients receive a series of three injections over the course of three weeks (one injection per week).  The patient will come in at their regular check-in time and fill out a follow-up form.  As always, we recommend patients wear athletic clothing to the appointment (shorts are particularly ideal).  The doctor will perform the injection under ultrasound guidance to make sure that the hyaluronan is accurately placed into the joint space.  There is a chance that patients will start feeling benefit after the first injection, but typically, maximum benefit is gained after all three injections have been completed. 

Doctors’ recommendations post-injection:

1.       Ice the injection site if patient is feeling any local tenderness

2.       Continue any mild to moderate cardiovascular exercise routine

3.       Avoid any High Intensity Interval Training (HIIT), weight training or resistance training for the first 48 hours after the injection

4.       Call the office with any other questions/concerns that may arise

The benefits of viscosupplement injections can be felt for between several months and a year, but of course, these numbers vary greatly between patients.  It is possible for the series of injections to be repeated; usually our doctors and insurance companies require at least 3-6 months between the first series and the second.   Additionally, it is important to understand that viscosupplement injections are not substitute for total joint replacement surgery if a patient’s osteoarthritis is severe. 

What if I have osteoarthritis in areas OTHER than the knee?

Currently, the use of viscosupplementation is FDA approved to treat knee arthritis only but it has been shown to be beneficial when used in other arthritic joints such as hips and ankles.  As a practice that focuses on delivering “pure medicine”, our doctors do not want patient care to be restricted by insurance companies, and therefore we offer competitive direct-pay pricing for viscosupplement injections not covered by insurance. The doctors at Lake Washington Sports & Spine will make it clear if they feel viscosupplementation is the best method of treatment, whether or not it is covered by insurance. 

If you are suffering from osteoarthritis that is keeping you from participating in the activities you love, we recommend you call our office and set up a consultation to see if viscosupplementation is the right choice for you!

Graduation Ceremony

Graduation: high school, college, completion of treatment?

The Graduation Wall

Have you ever been to a clinic where they have a ceremony to commemorate your success? Better yet, a clinic that celebrates when you don't have to schedule another appointment?  

Here at Lake Washington Sports and Spine, we believe it’s crucial to recognize our patients' dedication and determination to get back to being active. Our graduation wall represents the collective achievements of every patient who has completed treatment and returned to the activities they love.

The Sights & Sounds of an LWSS Graduation

Our whole office pauses for a moment to recognize your success! At graduation, you write your name on a sticky note, then slap the note on our graduation board while performing an exercise that utilizes your rehabbed body part.  As you post to the board, the LWSS team cheers and shakes maracas in celebration. But wait, it doesn't end there!  Once you walk to the end of our hallway, you press the "Emergency Affirmation" button and are congratulated with a “swag bag”.  Celebration, gifts and a body back-in-motion, who doesn't love that!? 

Why We Believe Graduation Is So Important

LWSS is built on the foundation of "Happiness Based Musculoskeletal Medicine", so we always focus on life's positives!  What could be more positive and happy than returning patients to doing the physical activities they enjoy? We recognize that you put the work in and think you deserve the credit!

For patients who are just beginning their journey with us, we hope the Graduation Wall serves as an inspiration and we look forward to celebrating you and your future success!

5 tips to prevent holiday weight gain & stay active

1) Hydrate
H2Oooooohhh yeah! Drink a large (16 oz.) glass of water 15-30 minutes before every meal, especially before hitting a holiday buffet. Water will help you feel fuller, eat less and aid in the digestion process.

2) Indulge in moderation
Deprivation is a recipe for disaster, but so is unlimited indulgence. Find a happy balance and allow yourself 2 or 3 small portions of your favorite holiday treats. For the rest of the meal, stick to healthier options like veggies, lean meats, low fat cheese and fruit.


3) Weigh in
While it’s tempting to reach for elastic waist pants and hide your bathroom scale for the month of December, neither will help keep you accountable. If you see the number on the scale creeping up or feel your favorite pants getting tighter, you’ll likely pass on that slice of pie.

Think you can take an accountability hiatus and start again in the New Year? Neglecting healthy eating habits and exercise during the holidays will only make your resolutions more difficult.

4) Make exercise appointments
Consistent exercise and protected time to de-stress are more important than holiday shopping and gatherings. To avoid making excuses or falling into the trap of being “too busy”, schedule exercise on your calendar just like you would any other meeting. Bonus, you can even set an event reminder alarm to alert you it’s time to get moving!

5) Share fitness with loved ones
The best part of the holiday season is spending time with friends and family, so connect while staying active! Take an after dinner walk with your kids, go hiking with your cousins, attend a fitness class with your best friend, or register for a fun 5K. Make fitness a new part of of your holiday tradition!

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Healthier Options: Thanksgiving Edition!

I LOVE the fall and winter holidays!  The sights, the sounds and especially the holiday FOOD.  I remember as a kid, the scent of my Mom’s turkey and gravy wafting through the house on Thanksgiving Day.  My family and I would indulge ourselves on the bountiful feast spread before us and celebrate the holiday giving thanks to family, friends and health.

Fast-forward 20 years and I am going to be preparing a Thanksgiving meal for my OWN family now.  I will definitely have Mom’s recipes in mind and will be trying my hand at lightening some Thanksgiving side dishes so I can stay on a healthy path and not fall into the Thanksgiving “coma” from over-eating heavy foods. 

This year I plan to be a more mindful eater. I will prepare some recipes in advance to test out new, healthier side dishes so I know which ones my hubby will enjoy (and which ones he will attempt to feed the dog on the sly).  I have included some lighter side dish recipes below and encourage you to also experiment on your own!  Have fun this Thanksgiving and remember: It’s a holi-DAY not a holi-MONTH so instead of embarking on a month long food fest, take control of the day and kick-start your motivation for a healthy holiday season!

RECIPES

1.   Healthy Potato Gratin with Herbs: Skip the mashed potatoes this year and try a lighter potato dish that loses the heavy cream but keeps the flavor with fresh herbs.

http://www.foodandwine.com/recipes/healthy-potato-gratin-with-herbs 

(recipe courtesy of Food and Wine)

2.   Cider-Glazed Roasted Root Vegetables: Instead of a basic sweet potato/yam dish, try this delicious recipe that brings an added sweetness with apple cider.

http://thescrumptiouspumpkin.com/2014/11/25/cider-glazed-roasted-root-vegetables/ 

(recipe courtesy of the Scrumptious Pumpkin blog)

3.  Cranberry-Pear Wild Rice Stuffing: Take unhealthy “stuff” out of your Stuffing this year with wild rice, whole grain bread and dried cranberries.

    http://www.vegkitchen.com/recipes/cranberry-pear-wild-rice-stuffing/ 

(recipe courtesy of the VegKitchen with Nava Atlas blog)

How to Prepare for Your PRP Visit and What to Do After

Platelet-Rich Plasma (PRP) is an example of proliferative therapy that we’ve discussed on this blog before. The treatment is useful for many musculoskeletal disorders, ranging from lingering tendon, ligament, and muscle injuries (e.g. hamstring and rotator cuff tears) to joint pain (e.g. knees and hips). We at Lake Washington Sports and Spine tend to recommend PRP after other conservative measures, particularly physical therapy or chiropractic care, have not produced meaningful results.

PRP is one of many treatments that we perform in the office, but it is one of the more time-intensive ones. This is due to the nature of the therapy itself. When we perform other injections in our office, medications are drawn from vials then injected into a patient. However, with PRP, the medication comes from the patient! Our blood is not just a homogenous red substance that courses through our veins. There are many types of cells in our blood – which include, but are not limited to – cells that carry oxygen, others that fight off infection, and the ones we are most concerned about: the healing factors.

These healing-inducing cells include platelets, as you probably guessed by the name of the therapy. The portion of plasma containing platelets - as well as other healing factors - is obtained by spinning blood in a centrifuge for 15 minutes, which separates the different aspects of the blood into distinct layers. The platelet-rich concentration is extracted from the resulting vial of separated blood, and injected under ultrasound guidance into the site of injury. This not only concentrates healing factors near the injured area (exactly where it needs to be), but also causes an inflammatory cascade which brings its own set of healing responses.

What can you do to prepare for the procedure itself?

1.     Come early.  Coming in 30 minutes prior to your appointment start time allows us to perform all the steps (draw, centrifuge, and platelet extraction) before the actual injection without making your appointment run late. It also gives us a time buffer in case we run into any issues during the blood collection. Additionally, this time is beneficial to patients as it gives them a time to relax between the blood draw and the injection. If you do not arrive 30 minutes early, there is a chance your procedure will need to be rescheduled. 

2.     Hydrate! Water is an important component of blood, and makes it much easier for any healthcare professional to draw blood from your arm. Your veins are fuller (making it easier to perform the actual blood draw) and your blood moves quicker (less time with a needle in your arm!).

What do you need to do after the procedure?

1.     Rest and get more sleep. Sleep is a wonderful thing, so I feel strange having to recommend it. But many patients do not get enough sleep, and lack of sleep can have a very detrimental effect on your healing rate. Use this procedure as an excuse to get more restful sleep. I recommend using your recovery phase from this procedure as a jumping off point to establish a good sleep routine you can use when you’re back to your fully functional self.

2.     Limit forceful weight bearing and movements with excessive range-of-motion.  Imagine a glob of peanut butter sandwiched between two saltine crackers. Now imagine squeezing the crackers together and spilling the peanut butter onto the floor. You don’t want peanut butter on the floor, just like how you don’t want the Platelet-Rich Plasma anywhere other than where your injury is located. The general idea behind PRP therapy is to concentrate healing factors into a specific, targeted area. An excessive contraction of a muscle, or movement of a joint past normal range-of-motion, can “squeeze” the platelets away from the targeted area. For some cases when the PRP is meant for a lower body part, we may recommend being on crutches for two weeks to really ensure the PRP stays where it should.

3.     NO NSAIDs.

4.     I repeat, NO NSAIDs. Your body’s natural response to injury is to cause inflammation. We typically only associate inflammation with pain, which is why people often take an NSAID (non-steroidal anti-inflammatory drug) like ibuprofen or naproxen (e.g. Advil, Aleve). However, inflammation also triggers a healing response by the body. PRP therapy will cause some inflammation and therefore may increase a patient’s pain level for the first two weeks. This is a completely normal part of the healing cascade, and is temporary. Taking NSAIDs to alleviate the temporary pain will reduce the likelihood of having a more permanent recovery. Do not sabotage your ultimate goal of getting back to fully functional activity for some temporary relief. Keep your end goal in mind!

5.     Ice if necessary, Tylenol if necessary. If you’ve been to our office, you know that we extol the benefits of ice like we’re the ice farmers of Frozen. We recommend ice as our first-line pain reliever, as ice has been shown to reduce pain and inflammation without having to take medication. However, PRP might be the only instance we recommend discretion when icing. As I’ve said previously, forms of proliferative therapy cause inflammation, so icing is counter to what the therapy is trying to accomplish. Therefore, we recommend icing only when completely necessary and the pain in unbearable. You can also try acetaminophen (e.g. Tylenol), as that is a non-NSAID pain reliever.

And that’s it! This is only a general overview, and I’m sure you might have more questions. The doctors here at Lake Washington Sports and Spine always have a consultation with a patient to review the appropriateness of PRP for a given patient, the risks involved, and potential outcomes. They are more than happy to answer any and all questions you may have regarding this procedure at that time.

Stay active!

Meet the Team: Shannon Mack!

-What is your role at LWSS?  What are some responsibilities​ your ​role ​​entails?

My role at LWSS is Dr. Hyman’s Medical Assistant.  Some of my responsibilities include greeting our patients with a smile and getting to know a little bit about them before they meet with Dr. Hyman; throughout the day, I follow up with patients via phone or email (I prefer to call, its more personal), assist Dr. Hyman when necessary during appointments, turnover exam rooms by cleaning and making sure that inventory is stocked, and help my team with some of their tasks. You will also find me petting Wynnie.

-Tell us a little about you ​and your path leading to LWSS: ​​where are you from originally, where did you go to school, and what drew you to Lake Washington Sports & Spine as a place to work?

What drew me to Lake Washington Sport & Spine started with the opportunity to be a part of a team that is focused on healthy, active lifestyles and helping people achieve just that. I was drawn in from the first opportunity I had to meet the LWSS staff and watched how they interacted with one another.

-Give us 5 fun facts about S.Mack!

I think ice cream tastes better during the winter!

Red is my FAVORITE color (although, I only have one red clothing item)

If I could have just one super power, I would definitely time travel

I am beyond thankful for GPS because maps confuse me

Every day, I take a moment to think about what I am thankful for; doing that really helps me to put life in perspective

-What is your favorite form of exercise?  How do you integrate it into your day?

I love running! It frees my mind and also gives clarity. I like to visualize my run throughout the day, especially if it is stressful. During the week, I prefer to run in the evenings as the day begins to cool. On the weekends, I try to hit the road early when it is still quiet and the air is fresh – after a cup of coffee of course!

-When did you become interested in medicine?  In what ways do you think your time at LWSS will impact your future as a nurse practitioner?

I have been interested in medicine ever since I was a child. I had an inspiring Pediatrician and a mom who always encouraged me to dream (she still does). I remember the moment when I decided I wanted to dedicate my life to serving others through medicine and that has motivated me through the years.  I believe LWSS will impact my future as a Nurse Practitioner in many positive ways – I am in an environment that challenges me to think critically, listen patiently, and reply thoroughly. These are skills that I feel are important for being successful as medical professional. The doctors also encourage you to think like a provider by asking questions related to each case and challenge you to consider other reasons for why and how a diagnosis could be obtained. There are so many learning opportunities here that are invaluable!

-Since you've worked in other clinics, can you provide some examples of what sets LWSS apart from other healthcare facilities?

LWSS is truly special. Dreams, goals, visions are not idle here – we all have them, from our staff to our patients, what we do here is “Keep People Active”  and you can see that demonstrated every day. The team here allows you to be yourself and encourages you to set specific goals. Because they are dedicated to seeing patients and staff succeed, they create a supportive and informative culture. From the moment you walk in, you can feel that you are in a place that creates exceptional and is dedicated to seeing patients rehab their injuries to achieve their goals! At LWSS, you are celebrated, encouraged, and set up to succeed.

-Can you give some examples of the types of patient interactions that drive your happiness at work?

I believe that laughter is necessary for healing; whenever I have a chance to laugh with a patient that makes me feel elated!

There is not a better feeling than hearing someone say ‘thank you’ after you have helped them with a need they have, such as, carrying an item or asking how their day is going. Taking one minute to be present with the patient and listen can be transformative in their experience - and mine.

I LOVE that we celebrate our patients who have completed their treatment with a graduation! In the midst of the cheer, I always look for the smile on their faces because you can see they are proud of what they did - and they trusted our team to help them get there!  

Your tendons on cake

My friend and colleague James Crownover recently wrote a wonderful blog post about the relationship between glucose metabolism and tendon injury

http://crownmd.net/your-tendons-on-cake/

Upcoming Fall Races: 5K, 10K, marathon, fun run, and more

I remember the first 5K I ever did.  It was the charity walk/run called the Furry 5K in Seward Park that benefited the Seattle Animal Shelter.  As a non-runner, I was hesitant at first to sign up because I imagined all these seasoned athletes sprinting past me while I was left in their dust.  Boy was I ever wrong!  The amazing lessons I learned that day were: A. I could power walk at MY pace and still cross the finish line and B. EVERYONE who signs up for these walking/running events is there to support and cheer one another on. 

Whether you are a competitive runner who is pushing their physical capacity in a timed race or a beginner testing the walking/jogging waters in a fun run, there is ALWAYS a race for you!  I am going to share some upcoming races in the Seattle area that I have researched, but remember, do your own research too!  A great website I utilized is http://www.runguides.com/seattle/runs which lets you filter through the types of runs you are looking for.  So check out some of these runs below and as always, stay active and be the BEST version of yourself!

September:

·         “Walk to Defeat ALS”- September 12, 2015 (our clinic completed).  This is a little less than 5K run/walk around Seward Park.  This event is to raise money for local ALS Association chapters to sustain care services and support research.  I will be doing this walk again this year! http://web.alsa.org/site/TR?fr_id=11078&pg=entry#.VdzAwvlVhBc

·         “End Aids Walk and 5k Run Seattle”- September 26, 2015.  This is a 5K run/walk around Volunteer Park.  The monies raised will go towards support in HIV prevention and care services.  https://give.lifelong.org/seattle/events/the-seattle-aids-walk/e48168

October:

·         “Magnolia 10K & 5K”- October 4, 2015. This is a 5K and 10K run/walk in the Magnolia neighborhood of Seattle.  At the finish line, there is a festival in the Magnolia Village that includes exhibitors, food and a beer garden.  http://www.promotionevents.com/magnolia/Info.htm

·         “Biggest Loser Seattle Half Marathon/5K”- October 25, 2015.  This is a half marathon/5K run/walk at Lake Stevens in Snohomish County.  There will be appearances by former contestants from "The Biggest Loser" as well as the Biggest Loser finisher's medal and awards for the best times.  http://www.biggestloserrunwalk.com/race/2015/seattle-wa-half-marathon-5k

November:

·         “The Ugly Sweater Run Seattle”- November 28, 2015 (our clinic completed).  This is a 5K run/walk around Marymoore Park.  You can expect to see tons of ugly sweaters, holiday cheer and and other goodies at the finish line.  Also, this event raises monies for the non-profit Save the Children. http://theuglysweaterrun.com/locations/seattle-washington/#.VdzipflVhBc

·         “Seattle Marathon and Half-Marathon”- November 29, 2015 (our practice manager Laura completed; she and medical assistant James will be at this year’s race).  These marathons are primarily for runners though the race does offer a smaller walker category.  The routes begin near Seattle Center and head out towards Lake Washington.  The best times from the race can be used as a Boston Marathon qualifier; there will also be other medals and awards.  http://www.seattlemarathon.org/amica-insurance-seattle-marathon

December:

·         “Run 4 Wine”- December 12, 2015.  This is a 5K run/walk around the Warehouse Wineries in Woodinville.  Pair your love of running with your love of wine!  After the race, you can enjoy some of our state’s finest wine tasting.  http://www.active.com/woodinville-wa/running/distance-running-races/run-4k-wine-run-walk-plus-wine-tasting-2015-11462108?cmp=39-34&ltclickid=08_119491134_f37bbe56-b228-4209-8bf8-36b51be4e4de&ltcmp=254301

·    "Jingle Bell Run/Walk Seattle"- December 13, 2015.  This is a run/walk near Westlake Center in the Seattle area.  Spread your holiday cheer while raising monies to benefit research for the Arthritis Foundation.  You will see lots of holiday themed runners, booths and get a free beverage in their beer garden after!  http://www.jbr.org/faf/home/default.asp?ievent=1138396&lis=1&kntae1138396=CB96B4C15EAE467089E85385687EFD27 

Behind the scenes…What goes into my appointment?

If you’ve ever been to a doctor’s office, you may have wondered at some point...What exactly are they doing??   At Lake Washington Sports & Spine, our new patient consultations range from 45-60 minutes while follow up appointments range between 15-30 minutes.  Follow-ups can include imaging/lab reviews, checking your response to a previously done procedure and/or following up after you’ve completed recommendations set forth by the doctor.  A lot of patients do not recognize the time and effort that is put into each appointment from start to finish.  We want to share with you a “look behind the scenes” at what we are doing to ensure YOU have the best experience and care with us!

Front Office…Our front office staff includes the patient care coordinator and billing manager.  They work together to make sure the appointments are scheduled correctly, any necessary insurance authorization or other provider chart notes have been obtained and direct calls to the appropriate staff.  Overall, they make sure that scheduling, check-in and check-out run smoothly. 

The patient care coordinator is the first face you see when you walk in.  They contact patients to make sure they arrive on time for their check-in time and organize patient paperwork all the while answering phones with great customer service.  They explain referrals/orders to patients upon check-out and work with the rest of the staff to make sure the patient has everything they need before they leave.  They work to send your medical records to the appropriate clinics and facilities. The coordinator also schedules your follow-up appointment as you check out, and works with you to find the best day and time available. 

The billing manager checks insurance eligibility for patients and contacts them prior to their appointment with any concerns.  They answer insurance-related questions in real-time that either the patients or doctors may have, as well as discuss balances due with the patients.  They work with the medical assistants and doctors during appointments especially before procedures are done and/or scheduled in order to ensure all aspects of the procedure billing goes well.  They code and bill claims that require immediate payment as you check-out so you leave with a zero balance.

Clinical Staff… Our clinical staff includes the medical assistants to both our fabulous doctors!  They arrive early to prepare the day for the doctors so when patients are ready to be roomed they have the full appointment time booked with the doctor.  That is why it is so important for our patients to arrive at their check-in time versus their appointment start time.

The medical assistants typically review the chart notes for upcoming patients a day or two ahead of time.  If a patient is scheduled for an imaging and/or lab review appointment, they double check with the other facilities to make sure the images and reports are completed.  If the patient has not completed the needed orders, they work with the patient care coordinator to contact the patient in order to reschedule their appointment and/or find out when the orders will be done.  For patients following up for an in-office procedure, the medical assistants set up the equipment needed ahead of time for the doctor and also make sure necessary injectables are ready to be used (like PRP kits, Euflexxa, steroids, ect). 

Throughout the day, the medical assistants are constantly prepping for the next appointment, while also answering and returning patient calls.  They clean and prepare exams rooms before each appointment and work with each other to ensure that each doctor has access to the room/equipment he needs.  The medical assistants also input data from new patient and follow-up paperwork and generate referrals your doctor may recommend.

This is just a small glimpse into the amount of work being done to make sure you have a 5 star experience at Lake Washington Sports & Spine.  Our team is dedicated to keeping you active and we will ALWAYS go above and beyond to ensure that you receive the best musculoskeletal care around!

Happiness Based Musculoskeletal Medicine: The Power of Woo

 Drs. Hyman & Chimes are the pioneers of Happiness-based Musculoskeletal Medicine. Our practice focuses on more than just injury treatment and prevention- we help you optimize your health!
Here's a fun clip to help improve your posture & boost your mood: THE POWER OF WOO!

https://www.youtube.com/watch?v=1hgzTI-N--8

Tips for Beating the Heat!

As a relatively recent transplant to the Pacific Northwest, I have quickly realized that summer in Seattle is a magical time.  All of a sudden the clouds float away and we are left with an array of outdoor activities at our finger tips.  As our excitement grows, however, it is also important to recognize the dangers of being out in the heat for too long and without the right precautions.  Below are a few tips that will allow you and your family to have the happiest and healthiest of PNW summers!

1.  Get a Big Gulp….of WATER!

                This one may seem obvious but it is absolutely critical that we all remain hydrated during these flaming hot days.  It is important to remember that the time to start drinking is NOT once you feel thirsty; by this point, you are already behind.  Make sure to drink plenty of water before starting your activity and then continue to sip water while exercising.  If you plan to do vigorous exercise, it may be wise to bring along a diluted sports drink to replace electrolytes that our lost when you perspire.  Always remember to drink plenty once you’ve completed the activity too!

2.  Temperature isn’t the only thing that matters!

                Most of us are in the habit of checking just the temperature before we head outside.  Although the temperature is indeed telling of how bearable exercising outside might be, humidity is also a critical factor.  One of the body’s main cooling systems is perspiration (sweating) and the sweat evaporating off of our skin is what cools us down.  Humidity, however, makes it much more difficult for sweat to evaporate and in turn, makes is much more difficult for us to regulate our internal temperature.

3.  Fashion police!

                I’ll be the first to admit that I don’t spend a lot of time choosing the perfect exercise gear.  However, on hot and humid days, the clothing you wear can really play a large role in how well you handle the heat.  Fabrics like cotton, although typically comfortable, are not very breathable and can make a hot, outside workout feel unbearable.  The better choice is to wear breathable, synthetic fabrics (polyester, nylon, etc) that will wick away your sweat.  It is also important to wear a hat or visor and, of course, apply plenty of sunscreen before heading outside.  

4. Know your limits        

                If this is your first outdoor workout this summer, try to go in the morning or the evening when temperatures are cooler.  Also, change your workout for different heat levels.  If it’s a scorching hot day, taking a bike ride may be healthier and safer than a long run in the sun.  Most importantly, LISTEN TO YOUR BODY.  If you start feeling dizzy, nauseous, or otherwise not 100%, STOP.  You are not doing yourself or your body any favors by pushing through a workout when you’re feeling sick. 

The main thing to remember during these last days of a beautiful Seattle summer is that there are myriad opportunities to play outside but just be sure to take care of your body so your workouts are both fun AND safe! 

                

How to choose the right bed: what we can learn from the Pepsi Challenge

One question patient's frequently ask me is "what is the right bed for me?"

Like many things in musculoskeletal medicine, the answer is "it depends."  There is no one best bed for everyone, and the best choice will depend on a few different factors

One thing to pay attention is your preferred position for sleeping.  As a general rule of thumb, the most important thing to pay attention to is the position you wake up in, rather than the position you try to fall asleep in.  I had a patient the other day who thought she was a back sleeper, but she always wake up on her right side, which tells her that her body wants to sleep on the right side.

A second factor is paying attention to placement of your hands.  One of the hardest parts of finding a good night's sleep is figuring out where to place your hands relative to your upper body.  This is especially true for side sleepers.   The constant tossing and turning to find the right hand position reminds me of the scene from the movie Talladega Nights, where Will Ferrell's Ricky Bobby character can't figure out what do with his hands during his first interview.

The same thing happens with me when I sleep, especially if I am in a bed with pillows I am not used to, or sleeping in a bed that is too small for me.

One inexpensive item that can make a huge difference is using a full-length body pillow.  You can do what I do, and get a cheap one for $15 at Costco, or you can certainly get a much nicer one at a store like Relax the Back.

A third factor to consider with sleeping is the appropriate level of firmness when you sleep.  There is no best level of firmness for everyone, but I do find that patients often sleep with a bed that is a bit softer than would be optimal for them.  I think the reason for this is that the level of firmness that is most comfortable when you first lay down on a bed is generally a bit softer than the preferred level of firmness for a good, restful night of sleep.

By way of analogy, Malcolm Gladwell had a great anecdote about the Pepsi Challenge from the 1980s in his wonderful book Blink.   For generations, Coca-Cola was a the clear #1 brand in cola sales, with Pepsi a very strong #2.  Pepsi would set up booths in public areas and ask consumers to try a sip of the two products, and then reveal the brand of the cola they preferred.  Based on this "sip test", consumers strongly preferred Pepsi.

This challenge started in 1975, but took traction in the 1980s, enough so that Coca-Cola started to see drops in sales.  It eventually led to Coca-Cola reformulating their market-leading product, and producing a newer version of Coca-Cola called "New Coke" in 1985, designed to be sweeter like Pepsi.

New Coke is one of the all-time great marketing disasters, and soon Coca-Cola brought back their original, less-sweet Classic version.  So what happened?

It turns out that the attribute that makes a cola tasty for a small sip is not the same thing that makes a cola tasty for drinking several large glasses.  When asked to drink a thimble-sized sip of a cola, tasters generally prefer whatever is sweeter.  When drinking an entire glass, however, most people prefer something less sweet, as excessive sweetness can be cloying and unpleasant.

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Getting back to beds: The quality that makes a mattress comfortable when you first lie is generally how soft it is.  However, the quality that makes for a good nights sleep is how supportive it is, which is a different quality.   Softness and support are not oppositional- a mattress can be both.  It's just important to recognize they are different qualities.

Some things I would consider when buying a bed:
1. Give yourself ample time to mattress shop.  Plan on a few hours
2. Before you go, figure out what position you wake up in, and test beds in that position
3. Give yourself at least 15-20 minutes on each mattress to determine if it is a comfortable fit for you

Some specific stores I would consider when mattress shopping:
1. The Relax the Back store.  We've had very good experiences with specific owners of the Bellevue store.  They have excellent customer service and spend a lot of time with customers.  In the past, I've had concerns about Tempur-Pedic beds because of heat retention, but the newer generation of Tempur-Pedic beds no longer have that issue (although some competing brands of memory foam do, so I'd only recommend the Tempur-Pedic brand).
2. Bedrooms & More.  Located in Seattle near I5, they offer high quality natural latex mattresses, and also have excellent customer service.
3. Sleep Number.  The sleep systems, using individual air chambers, can be nice for couples who desire a different level of firmness.  This is what I have used for myself for about 7 years, and I'm happy with it.  I can't speak to the customer service of stores in the Bellevue/ Seattle area.

Single-Limb Exercises

What’s an extremely easy way to burn more calories, improve your stability, and increase overall strength? Start doing your exercises on a single limb!

We’ve talked about single-limb exercises frequently on this blog, and that’s because we think they’re the bee’s knees, the cat’s meow, the duck’s quack … and just to keep the dated references going – well, we think they’re just swell.

Single limb exercises obviously challenge your balance, but they do much more than that. They can help eliminate any strength imbalances since you can’t rely on your stronger side to make up for your deficiencies. Also, single-leg exercises are similar to movements you do in everyday life or while playing sports, such as walking, running, or leaping.  In addition, they can help you burn more calories since it takes twice as long to complete a single exercise.

But you might be thinking: “I’m not Gaston!” And that’s right. You’re not Gaston. No-one’s as burly or brawny, or as slick or as quick. Then again, no-one eats five dozen eggs every day (think of the cholesterol!) But that doesn’t mean you can’t perform single-arm pushups or single-leg squats like Gaston (probably does). You’re just going to have to build up to it. The act of performing a single-limb exercise is going to be very difficult for most people. Not only will balance be an issue, strength will be as well. Ease into it! You can modify exercises to fit within your strength level. Here are a few examples.

-          Upper body push: Single-arm Pushups against a Wall. Face a wall or doorway, spread your legs about shoulder-width apart, and raise your arm until it’s about chest height. Perform a one-armed pushup, making sure to keep your elbow close to your body. These might seem too easy at first, but I think you might be singing a different tune after 20 or 30. Remember to keep your core tight before you start your pushups. An easy way to make sure your core is tight is to clench every muscle in your body (your legs, butt, abs, and even your hands). To up the intensity, bring your hand to a lower plane, like a heavy table, a kitchen counter, a chair pushed against a wall, and eventually, the floor!

                      



-          Upper body pull: Single-arm Door Pulls. Open a door and stand facing the edge of the door so the doorknobs are perpendicular to you (round ones help here). Grab one doorknob with one hand, the other knob with your other hand, then bend your knees until you’re in a half-squat. Lean back until your arms are straight. Then pull your body towards the door. If you can, perform the pull with just one arm. Remember to keep your back straight and your shoulder blades in a stable position. To make things easier, use both arms, or move your feet further away from the door so you’re standing more vertical. To make things more difficult, place your feet behind the doorknobs so they’re further away from you/you have to squat more; or simply hold the contraction longer.

                    

-          Lower body push: Single-leg squats. Start by holding onto a doorframe or other sturdy object (like a couch) to make sure you don’t fall over. Don’t worry about cheating with your arms; you’ll still feel a burn after doing 10+ single-leg squats even if you help yourself up. Lift one leg off the ground and hold it either in front of or behind you. Then, squat as deeply as you can on your standing leg. Suspension straps can help TREMENDOUSLY with this exercise, as seen here:

Two things to remember:

1) Make sure you keep your bending knee from leaning inward – this is called a valgus fault, and can lead to injury. Activate your gluteal muscles to remedy this, as well as keeping your knee steady/leaning out. 

2) Don’t let your knee go over your toes. You want to be sitting back and activating those glutes. Letting your knee go over your knees can lead to injury.

-          Lower body pull: Single-leg Romanian Deadlift. Stand on one leg.  Keep your leg straight but without your knee locked out. Hinge at the hips, and bend over while keeping your back straight. Maintain a controlled pace and movement – think more Drinking Bird toy, less stapler snapping closed.

      

             

If there’s a running theme throughout these exercises, it is that FORM MATTERS. If any of these exercises are too difficult to do with proper form, then you may need to modify them further.  Also, these exercises are only a guide, not a complete work-out plan. There are many resources (books, personal trainers, online forums, etc) to find more information on complete work-out plans. 

The Parable of an Insurance Company's Perfect Physician: Dr. Donoharm

The Parable of an Insurance Company's Perfect Physician

Megalopolis Health Insurance (MHI) was searching long and wide for the physician who met their platonic ideal of what a doctor should be.  They found just such a physician, named Doctor Donoharm.  Dr. Donoharm was perfect on all measures that insurance companies crave on their quality metrics in the past year.

MHI started using Patient Satisfaction surveys as a measure of quality.   Dr. Donoharm was a model of perfection- zero patient complaints for the entire year!

MHI took to heart the Institute of Medicine's  To Err is Human report that attributed between 44- 98,000 patient deaths to physician error.  MHI recognized that the best way to save lives was minimizing physician error!  What a scourge!  And lo and behold, Dr. Donoharm had the lowest rate of physician error of any contracted physician.  In fact, Dr. Donoharm had no physician errors for an entire year!

MHI also realized that they could help stamp out the cost of physician over-utilization of resources.  At MHI Headquarters, they lived by the mantra "the most expensive tool is a physician's pen", and they were going to create a series of incentive systems to prevent physicians from over-ordering expensive tests.  They would follow the recommendations of the American Board of Internal Medicine's Choosing Wisely campaign to prevent unneeded tests like MRIs and expensive lab tests.  And when MHI executives looked to see who their #1 physician in terms of avoid over-utilization was for the past year, it was yet again Dr. Donoharm.

It was clear to MHI executives they had finally found the perfect physician.  No complaints!  No deaths attributable to physician error!   No unneeded tests!

MHI decided to pay a visit to Dr. Donoharm to see how they could teach other doctors act to model themselves.  The secret?

Dr. Donoharm died a year earlier, and stopped seeing patients.

The morals of this tale:
1. From the standpoint of an insurance company, the best physician is a physician who doesn't actually see patients.  They don't actually have to be dead (although, from the insurance companies standpoint, that's also one less patient to treat)
2. When an insurance company uses the word quality, what they really mean is cost containment
3. When an insurance company says they are saving costs, what they really mean is that they are increasing their profits
4. If you want to know if a doctor is a good, the quality metrics used by insurance companies and central health systems will confusing at best.

The US Medical Soccer Team Surprises at the World Medical Football Championships

While I've been involved with the US Medical Soccer Team since June 2013, this was my first time at the World Medical Football Championships.  The tournament was a great experience.  Over 500 physicians from 18 different countries gathered in Long Beach, CA.  Most of us stayed at one hotel, the Hyatt Long Beach, and we travelled daily together via bus to the fields at Cal State Long Beach.  We had 4 adjoining fields so that once done with a game, teams could stay and watch/scout other matches.  Staying and playing in the same locations made it easy to get to know people.  Evenings 4:30-7:30p were spent (by some of us) at our concurrent medical conference, and this was another opportunity to become acquainted with our colleagues.

The competition on the pitch was fierce.  These docs came to play.  Fortunately, 

the USMST had a decent draw, and our first round group matches were against Lithuania, South Korea, and Australia.  We fought a fit and young Lithuania team to a 0-0 tie (I believe they beat us something like 8-0 last year in Brazil) on Sunday, then beat a smaller but faster South Korea team on Monday 2-0, and on Tuesday we outworked a very tall and strong Australian squad to win 3-2 to win our Group and move on to the Winner’s Bracket.  

We presented our Healthy, Fit and Smart Program to ~200 children from the Long Beach Boys and Girls Club with the help of our international physician colleagues on the Wednesday.  

Wednesday afternoon our USMST team served as ambassadors on a Hollywood bus tour for our international guests.  Fun stops included: Santa Monica pier, Rodeo Drive, and Grauman’s Chinese Theater.  While no one signed any movie contracts, the bus returned full of happy faces and many souvenirs.

Then on Thursday the competition resumed and we were pitted first against Venezuela, a newcomer to the tournament.  By this time, injuries were stacking up for both teams and we had to dig deep into our reserves.  Our energy made the difference and we finished 2-0.

Friday we took on the tournament favorites, Czech Republic.  The Czech doctors were all young, skilled, big and strong.  They were very organized and strong in the air.  Without Alan, our best defender, downed by a torn Achilles in the Australia match, we couldn’t stop their air attack.  We lost in this Semi-Final match 4-1 (the last two of their goals came late on counter-attacks after we reduced our defense).

So that placed us in the 3rd place match on Saturday against Ukraine.  They struck first in the 1st half, and we tied it up early in the 2nd half.  Then we went up 2-1 with ~5 mins remaining, and they tied the match with ~30 seconds left pushing us into PKs.  Our squad rallied, and our fabulous keeper came up big, and we beat them 5-3 in PKs.

The USMST finished in 3rd place — a great accomplishment given our squad’s best past performance has been ~10th.  The Czech Republic won the tournament, beating Hungary in the Final.

Our Master’s team (45 and over) was quite strong, and went undefeated, but due to goal differential went into the Consolation Bracket, ending up in 5th place overall.

Dr. Bert Mandelbaum, the lead sports medicine physician for US Soccer, presented a lecture at our conference, and indicated his interest in assisting our organization in making further inroads with FIFA given our common interests of physical activity promotion and injury prevention.

All in all, I’d say this was an enormously successful week for the USMST and a fabulous experience for me.  A wonderful example of physicians from around the world 'walking the talk' of physical activity and adult play for better health.

Dr. Hyman Trains with the USMST in Seattle

I had the privilege of helping to host and train with the US Medical Soccer Team (USMST -- www.usmedicalsoccerteam.org) this weekend at Starfire in Tukwila (home of the Sounders).

We had four 2 1/2 hour very intense training sessions, and the hard work has paid off as our squad is looking nearly match ready for our up and coming international tournament at the end of the month.  Our team is the host of the World Medical Football Championships (WMFC) this year, to be held in Long Beach, CA, in conjunction with the Global Congress on Medicine and Health in Sport (GCMHS).

On Friday, we partnered with the Seattle Sounders organization (www.soundersfc.com) for an outreach event.  Former first team Sounder, Roger Levesque, now the Director of Community Outreach, joined us at the Rainier Vista Boys and Girls Club in Seattle where we put on our Healthy, Fit and Smart program for approximately 70 youngsters.  The kids were creative as usual as they were asked questions about physical activity, nutrition and the human body in an interactive format.  Amazing to observe a 9 year old recount their understanding of their uncle's heart attack as one of our cardiologists and physician-athlete discusses exercise effects on the heart muscle.  We are grateful for the opportunity to partner with another wonderful Major League Soccer organization.

On Saturday evening, we were grateful that Michael Morris, team physician for the Seattle Sounders, joined us at our team dinner at the Icon Grill in Seattle.  Our physician athletes appreciated the opportunity to get to know him and learn what it's like to help manage the physical injuries of elite soccer athletes.

Sonosite (locally based, international company) was kind enough to lend me a portable ultrasound unit (the Edge), affording me the opportunity to utilize my sports medicine skills to evaluate and treat several of my physician teammates.  A hearty thank you to Sonosite (http://www.sonosite.com/), who has also kindly agreed to help sponsor the GCMHS and provide equipment that will allow me to provide onsite diagnostic services to the physician-athletes participating in the WMFCs.

So now we're only 3 weeks away from our tournament.  We expect approximately 500 physicians from 18 different nations to participate in the conference and tournament.

The competition will be fierce, and the USMST up until now has not made it out of the group stages of the tournament.  We are confident, however, that as hosts, we can best our prior performances.

This will be my first year to participate in the tournament though I have had the opportunity to train with the USMST for the past 1 1/2 yrs on several occasions.  Fabulous group of physician athletes.  Though most of us are beginning to show our age on the pitch, every so often each of us enjoys a bright moment of greatness on the field.  

Please enjoy the following silly video clip, and please come support our squad in the WMFCs in Long Beach June 27-July 4!

Sleep: quality and quantity matter

You know that sleep is essential for health and well-being, but do you recognize the importance of consistent, sufficient, quality sleep?  We're sure you have experienced a poor night of sleep- whether it was due to internal factors (stress, pain, illness) or external ones (noise, temperature, an uncomfortable mattress), you suffered the consequences the next day.  

Sleep is the brain's time for physiological maintenance: the chance to clear out waste that has built up after a day of thinking,  consolidate memories and form neuronal connections.  5 benefits of getting a consistent 7-9 hours of sleep per night include: 

• Increased cognitive function: learning, memory, attention
• Better mood and emotional regulation
• Stronger immune system
• Decreased inflammation
• Better metabolic function and weight management

So, what can you do to increase your quality of sleep?  The short answer- have good sleep hygiene.  Here are 5 tips:

• Avoid caffeine in the afternoon
• The effects of caffeine typically last 5-6 hours. The National Sleep Foundation states that caffeine can take twice as long to process in women taking birth control pills or women between ovulation and the beginning of menstruation.  Take the safe route and limit your caffeine consumption to the morning hours.

• Eat dinner more than 3 hours prior to bedtime
• Give your body a chance to adequately digest food before hitting the sack.  Also, avoid any foods that could cause indegestion or acid reflux, exacerbated by laying flat. 
• Adhere to a regular sleep schedule 7 days a week
• While it's tempting to "burn the midnight oil" Friday night and sleep-in on Saturday morning, your body's internal clock prefers routine.  Having a schedule will help you fall asleep and stay asleep easier.
• Avoid alcohol at night
• That glass of wine might make you feel like it's easier to fall asleep, but your body will have a more difficult time falling-into and maintaining deep sleep.  Result?  You wake up feeling less rested and foggy.
• Exercise regularly
• Yet another benefit of staying active!  Regular exercise promotes restful sleep but, like dinner, make sure it's done more than 3 hours prior to bedtime.

As you continue on the path to becoming the best version of yourself, don't forget that (quality) sleep is an integral piece of the wellness puzzle!