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!