"Thank you for talking to me about my weight"

I had a wonderful moment with a patient today.  She is a delightfully young middle-aged professional, who I've been treating for neck pain with a combination of physical therapy and injections.

She's by any normal sense of the world a wonderful person.  She's also a bit overweight.  Aesthetically, she's great, and she's certainly not the most overweight patient I work with, but she meets the medical criteria (BMI > 25), and more importantly I think that her weight is adversely affecting her healing, and will make it more likely she'll have recurrences in the future.

Today we were talking about the great progress she is making, and she made the very nice comment "thanks for talking to me about my weight.  My family has mentioned it to me before, but I really needed to hear it from you in order to make the final step to working on it.  Thank you."

This totally made my day.  As I've discussed in other blog posts before, I've personally struggled with obesity myself, and it's an every day challenge for me to keep my habits in check to make sure that I am the best possible version of myself every day.

It's also hard to counsel patients about weight.  I mean to really counsel them- have the hard conversations that lead to real change, not a token conversation so that you can check off a box on your electronic medical record.

Moments like today, though, are a useful reminder that it's worth it.  I love my patients and I am rooting for them to succeed, so it would be a disservice not to offer the feedback they need to meet their goals.

So Ms. Wonderful (you know who you are)- thank you for being you!

Useful link on the importance of the diaphragm

Another great post from my friend and colleague Ethan Collover

Useful link on muscle and aging

A great post from my friend and colleague Ethan Colliver

Shoulder Inflammation

With the baseball season coming upon the homestretch, the push for the playoffs is really starting to heat up. It has been quite some time since our local Seattle Mariners have been in serious contention. The Detroit Tigers are currently neck and neck with the Mariners fighting for the second American League Wild Card spot. The Tigers were dealt a pretty significant blow on August 12th when one of their starting pitchers, Justin Verlander, a recent league MVP and Cy Young Award winner, was told that he would have to sit out some games due to shoulder inflammation.

Joint inflammation may stem from inflammation of bursa(e), fluid filled sacs that provide cushion between bones, tendons, and/or muscles around a joint. They reduce friction and allow for free movement of surfaces moving in different directions. When inflamed, a normally slippery bursa becomes thickened and swollen, causing it to lose its ability to glide, which can become more irritated with movement. If you follow the Mariners, you may recall that this is a similar issue that afflicted top pitching prospect Taijuan Walker early on in spring training this year, preventing him from being able to compete for a spot in the starting rotation. While inflammation can be caused by an acute trauma such as a contusion, it is typically the result of a repetitive overuse injury caused by prolonged and excessive pressure. With a professional baseball pitcher, you can see how this could become an issue as their job description requires them to repetitively use their shoulder for prolonged periods of time. However, this is a very common injury that brings patients into our office all the time and can affect people of all ages and skill levels.

The general treatment plan for shoulder inflammation calls for ice and rest. While this can reliably help reduce the inflammation and thus pain level and discomfort, it doesn't change the underlying cause of the injury. Poor biomechanics often contribute. During Taijuan Walker's rehab, he worked on the mechanics of his pitch delivery. The can be deduced that the Mariners coaching staff and sports medicine team believed that there was a part of his delivery that was placing undue pressure on his shoulder which caused this inflammation in the first place. In fact it had been reported that he was complaining of shoulder soreness even before spring training started. But since finally coming back, armed with a refined delivery, he hasn't had any issues with his shoulder, recently striking out 13 batters in a start for AAA Tacoma.

The situation with Justin Verlander is slightly different. While the injuries are similar, from reports that I have seen the inflammation in Taijuan Walker's shoulder appears to be isolated to one particular area whereas the source of inflammation in Justin Verlander's shoulder was more complex. In addition, Taijuan Walker just recently turned 22, while Justin Verlander is 31 and pitching in his 10th major league season. Until this most recent incident, he hadn't missed a single game due to injury in his entire career. It would seem that if there were a biomechanical issue involving his delivery, this problem would have surfaced at some point in the past 10 years. A topic that will be covered in another blog post but that is relevant to this situation is injury recovery as we age. Being a pitcher in professional baseball takes an enormous physical toll; being asked to step on the mound every 5 days and torque various joints and limbs repeatedly (~100 times) in order to hurl a baseball at extreme velocities is no small task. Of all the pitchers in baseball, Justin Verlander has had one of the largest workloads, pitching over 200 innings in each of the past 7 years. As Justin Verlander ages, as with the recreational athlete, he is not going to be able to recover as quickly or efficiently as he once could. This case of shoulder inflammation could just be a case of father time finally catching up to him.

While Taijuan Walker seemed so have recovered fine, and Justin Verlander's recovery going well enough that he is tentatively scheduled to return to action this weekend, there are still instances where despite sufficient rest and biomechanical changes, the inflammation doesn't completely resolve and residual pain and discomfort remain. This is where a target intervention such as a corticosteroid injection can come into play and be quite helpful. It is widely believed that cortisone works in large part by  by reducing inflammation. Injecting cortisone into the inflamed area, reduces inflammation and pain. One of the potential downsides is that corticosteroids, if accidentally injected into the body of a tendon can weaken that tendon, increasing the likelihood of rupture or tearing. Most of this risk is associated with the most common way of doing these injections, using palpation or landmark guidance. As discuss in our previous post on musculoskeletal ultrasound, when doing a landmark based injection, there is no way to know for sure where the medication actually ended up. As you can see in the picture below taken from that blog post, the size of the bursa (indicated by the black arrow) is tiny, especially compared to the needle being used to inject the medication. As you can imagine, the chances of being able to get the medication into that small space based on palpation alone is quite slim. Thus the risk of weakening the tendon by exposing them to corticosteroids is likely the result of missing the bursa and injecting the medication directly into the tendon. When patients come into our office we can visualize the inflamed bursa and get feedback from the patient about where their symptoms are coming from in real time. Then if the doctor determines that the patient would be a good candidate for an injection, the needle can be directed towards the target with certainty, and the medication can be seen while administered in real time.

Ice water challenge to stamp out ALS

My good friend Justin Berthold threw the gauntlet down to participate in the Ice Bucket Challenge to stamp out ALS

I am happy to sacrifice my body to an ice water bath to help the good cause of helping patients like our buddy Daniel raise awareness and donate money to help ALS research and advocacy

Worthy organizations include:
https://www.facebook.com/Every90Minutes
http://www.alsa.org
http://www.alsfoundation.org

Enjoy the video!

Cutting through the noise

We have covered what a differential diagnosis is in a previous blogpost. The process of going through this differential diagnosis allows the doctor to uncover the potential causes of a patient’s symptoms, allowing them to devise the appropriate treatment plan for optimum recovery. 

This can be thought as the doctor attempting to uncover the primary signal (whatever the problem is, represented by the red line in the diagrams below). This process involves the physician going through a structured "interview", where they will ask the patient questions regarding their symptoms. Physicians have, through many years of education and experience, learned what questions to ask to get the needed information. 

Often patients will respond to these questions by giving very detailed responses in the hopes that the doctor will be able to pick out the hidden piece of information that will “break the case”. While in theory this may seem reasonable, in reality this information can be actually lead to confusion. Instead of providing additional clarity, it clouds the picture even more (like in the bottom diagram), making it more difficult for the doctor to locate the underlying signal. 

This is a concept covered by Nate Silver in great detail in his book Signal and the Noise. Each question is thoughtfully and deliberately chosen as a means of ruling in or out various diagnoses. The more succinct a patients answer, the easier it is for the doctor to cut through the noise and hone in on the correct diagnosis, and ultimately help the patient meet their goals!

Proliferative Therapy (PRP & Prolo): How it works and Why it’s worth it!

Many people with musculoskeletal pain are familiar with corticosteroid (i.e. “cortisone”) injections, which are meant to reduce inflammation.  However, inflammation is not necessarily a bad thing, as it recruits the body’s own natural healing factors. 

Another approach is to deliberately induce inflammation, stimulating the body’s own healing mechanisms to repair damaged tissue.  This is called proliferative therapy.  This method may be a longer-term method of musculoskeletal treatment, and may be a great alternative to the more well-known cortisteroid injections.  The subtypes of proliferative therapy that Drs. Hyman and Chimes perform are prolotherapy and platelet-rich plasma injections (PRP).

Prolotherapy was originally “discovered” in the 1930s by osteopathic surgeon Dr. Earl Gedney, who injected his own injured thumb with an irritating solution, and in doing so promoted the healing and regeneration of the tissue. This is based on the concept that lingering, chronic issues are often because the collagen in the damaged tissue is poorly organized.  However, because of the chronicity of the injury, the person’s body has stopped attempting to heal the chronic injury.  Proliferative therapy aims to re-stimulate the body’s natural healing response, either by inducing inflammation (prolotherapy) or placing healing factors there directly (PRP).   

During prolotherapy, a sugar solution, usually dextrose, along with an anesthetic (such as lidocaine) is injected into the affected area, resulting in low-grade inflammation to the injured area, “tricking” the body into initiating a new healing cycle cascade.   

The other method of proliferative therapy that our physicians utilize is platelet-rich plasma injections.  This technique is based on the same principle as dextrose prolotherapy explained above, but instead the solution used is a high concentration of a person’s own platelets, which contain healing factors that stimulate the body’s healing mechanisms.  Platelets, when activated, secrete a number of different growth factors that stimulate and regulate inflammation in the damaged tissue, resulting in a natural healing response. The blood is drawn from the patient at the time of the visit, placed in a centrifuge where it is spun in order to separate and concentrate the platelets from the rest of the blood, and this “platelet-rich plasma” is then injected into the injury site.  The aim is to inject healing growth factors directly into the damaged area, providing the patient’s body with the tools needed to naturally heal itself. 

The two methods listed above are a means of strengthening ligaments and tendons, providing longer-term relief for a multitude of chronic musculoskeletal problems including, but not limited to, lower back pain, knee pain, hip pain, shoulder pain, osteoarthritis, and different varieties of joint pain.  We have had great success using proliferative therapy in many of our patients, but because it is a newer class of injectable, the scientific literature has not reached a consensus on which injuries do best with proliferative therapy.  Therefore, insurance companies have deemed proliferative therapy to be “experimental” and they do not cover either of the procedures listed above.  Patients  who have invested money in their own care, however, find that proliferative therapy may provide them long-lasting relief and help them to avoid future visits, ultimately lowering their medical bills.  

Because we respect the time and money of our patients at Lake Washington Sports & Spine, we take several measures to optimize the patient’s experience when having proliferative therapy performed. These include:

1.       An initial consultation, to make sure that proliferative therapy is the right choice for the patient

2.       A discussion about which form of proliferative therapy (prolotherapy or PRP) is the best choice for the patient

3.       Always using ultrasound-guidance to make sure we are placing the proliferative therapy in the correct location

4.       Coordinating the patient’s care team, including physical therapists, chiropractors, personal trainers, physicians and other clinicians

Drs. Hyman and Chimes hope that by utilizing these cutting-edge, non-surgical techniques they can help their patients overcome chronic issues that impede their ability to live an active and healthy lifestyle!