The Key to Age Defiance? Exercise!

Remember in your younger years when a cold might wipe you out for a few days, but then you were quickly back to running and jumping on the playground?  Well, as people age, their ability to bounce back from disease and injury takes longer and a bigger toll on the body.  These changes are MOST noticeable during the transition out of middle age and into the senior years, when even the flu can be detrimental to your health. In order to delay aging, there is in fact a “Fountain of Youth”:EXERCISE!

The American College of Sports Medicine (ACSM) has designed exercise guidelines both for adults under and over the age of 65.  The guidelines include a mixture of aerobic and strength training recommendations that, when combined, can help a person reach and maintain optimum fitness and delay aging.

EXERCISE GUIDELINES FOR ADULTS UNDER AGE 65:

The following exercise guidelines are recommended by the American College of Sports Medicine:

•  Do moderately intense cardio 30 minutes a day, five days per week (intense enough that you cannot sing, but can hold a conversation)

OR

• Do vigorously intense cardio 20 minutes a day, 3 days per week (intense enough that you cannot sing)

•  Do eight to 10 strength-training exercises, eight to 12 repetitions of each exercise twice a week.

Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

 It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of daily physical activity may be necessary.  For most adults over 25, this is NOT a sustainable level of exercise, both because most professional adults frankly do not have that time of time available every day, and because most adults who exercise for that duration usually break down from injury.  This has several consequences:

1 

      We emphasize the importance of FREQUENCY rather than DURATION.  Some people are inclined to circumvent the 30 minutes per day, 5 days per week by trying to catch up and do one super-long workout over the weekend.  That is NOT equivalent.  Just as it is important to divide your food intake into 3-4 meals per day rather than one big meal, it is important to divide exercise so that is a DAILY activity.

2       For overall health, exercise is the most important intervention.  However, for the specific goal of losing weight, diet matters significantly more than exercise.  We will discuss this more in a future blog post, but no one is capable of sustainably overcoming poor dietary habits with exercise.

TIPS FOR MEETING THE GUIDELINES:

**With busy work schedules, family obligations, and packed weekends, it can often be difficult to get the recommended amount of physical activity. Try these tips for incorporating exercise into your life:

- Do it in short bouts. Research shows that moderate-intensity physical activity can be accumulated throughout the day in 10-minute bouts, which can be just as effective as exercising for 30 minutes straight. This can be useful when trying to fit physical activity into a busy schedule.

- Mix it up. Combinations of moderate- and vigorous-intensity physical activity can be used to meet the guidelines. For example, you can walk briskly for 30 minutes twice per week and jog at a higher intensity on two other days.

- Set your schedule. Maybe it's easier for you to walk during your lunch hour, or perhaps hitting the pavement right after dinner is best for you. The key is to set aside specific days and times for exercise, making it just as much a regular part of your schedule as everything else.

- The gym isn't a necessity. It doesn't take an expensive gym membership to get the daily recommended amount of physical activity. A pair of athletic shoes and a little motivation are all you need to live a more active, healthier life.

- Make it a family affair. Take your spouse, your children, or a friend with you during exercise to add some fun to your routine. This is also a good way to encourage your kids to be physically active and get them committed early to a lifetime of health.

 EXERCISE GUIDELINES FOR ADULTS OVER AGE 65, or ADULTS OVER AGE 50 WITH CHRONIC CONDITIONS:

The following exercise guidelines are recommended by the American College of Sports Medicine:

• Do moderately intense aerobic exercise 30 minutes a day, five days a week (intense enough that you cannot sing, but can hold a conversation)

OR

• Do vigorously intense aerobic exercise 20 minutes a day, 3 days a week (intense enough that you cannot hold a conversation)

ALSO

• Do eight to 10 strength-training exercises, 10-15 repetitions of each exercise twice to three times per week

·        ** If you are at risk of falling, perform balance exercises **

Both aerobic and muscle-strengthening activity is critical for healthy aging. Moderate-intensity aerobic exercise means working hard at about a level-six intensity on a scale of 10. You should still be able to carry on a conversation during exercise.

Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account. This will maximize the benefits of physical activity and ensure your safety.

Starting an exercise program can sound like a daunting task, but just remember that your main goal is to meet the basic physical activity recommendations: 30 minutes of moderate-intensity physical activity at least five days per week, or vigorous-intensity activity at least three days per week, and strength training two to three times per week.

Choose activities that appeal to you and will make exercise fun. Walking is a great, easy way to do moderate-intensity physical activity.

ADDITIONAL TIPS:

• Start, and get help if you need it.  The general recommendation is that older adults should meet or exceed 30 minutes of moderate physical activity on most days of the week; however, it is also recognized that goals below this threshold may be necessary for older adults who have physical impairments or functional limitations.
• Functional health is an important benefit of physical activity for older adults. Physical activity contributes to the ease of doing everyday activities, such as gardening, walking or cleaning the house.
• Strength training is extremely important. Strength training is important for all adults, but especially so for older adults, as it prevents loss of muscle mass and bone, and is beneficial for functional health.
• If you can exceed the minimum recommendations, do it! The minimum recommendations are just that: the minimum needed to maintain health and see fitness benefits. If you can exceed the minimum, you can improve your personal fitness, improve management of an existing disease or condition, and reduce your risk for health conditions and mortality.
• Flexibility is also important. Each day you perform aerobic or strength-training activities, take an extra 10 minutes to stretch the major muscle and tendon groups, with 10-30 seconds for each stretch. Repeat each stretch three to four times. Flexibility training will promote the ease of performing everyday activities.

Meet the Team: Elianna Fred

Q: What is your role at Lake Washington Sports & Spine?

Elianna: I am the Patient Care Coordinator at Lake Washington Sports & Spine.  I am the first face you’ll see when you walk through our door (unless one of the poochies comes to greet you first!)

Q: Give us some sense of your background.  Where are you from originally, where did you go do school, and what drew you to Lake Washington Sports & Spine as a place to work?

Elianna:  I am originally from the Bay Area of California (specifically Novato if any of you are familiar) but don’t worry, Seahawks fans, I am NOT a 49ers fan (though I definitely root for the San Francisco Giants!!) I obtained my undergraduate degree in Political Science along with completing pre-medical coursework at University of Wisconsin-Madison.  Go Badgers!  I was drawn to Lake Washington Sports & Spine for a couple reasons.  First, I was thrilled that I had found a Sports Medicine office with a job opening, because it really combines two of my main interests.  Almost more importantly, however, I was drawn to the infectious enthusiasm and positive energy I felt in the office.  I knew that I had found a place that was unique and I feel privileged to have been chosen to become part of the team!

Q: In what ways do you find Lake Washington Sports & Spine similar to other physician practices, and what are the aspects that make it a different place to work?

Elianna:  Frankly, I don’t find Lake Washington Sports & Spine to have many similarities with other physician practices.  Our doctors are highly trained, highly specialized and although there are absolutely other providers in our area who are very qualified, I feel Drs. Hyman and Chimes KNOW what they excel in and are happy to admit when something isn’t their strongest suit.  I think that’s quite special.  Other than that, I think our office is quite unique!  What other practice holds a graduation ceremony for its patients when they get better?  Or has wonderful, loving doggies to greet you?  I think that Lake Washington Sports & Spine sets itself apart by concentrating on the positive, realizing that being active and happy are keys to overall health!

Q: Can you explain what KPA means, and how that affects your job in scheduling patients?

Elianna:  KPA means KEEP PEOPLE ACTIVE and it’s our motto here at Lake Washington Sports & Spine.  Both of our doctors are highly specialized physiatrists, board certified in Sports Medicine meaning that they are the BEST at helping patients rebound from sports injuries.  When I am scheduling a patient, I make sure to figure out their activity level and what their goals are from their treatment.  If the goals are to solely get rid of pain, we are not the best choice.  If, however, a patient is trying to relieve him/herself from pain in order to play soccer, run a marathon or just get back into the gym, we are a GREAT fit! 

Q: What type of feedback have you received in terms of what factors are important from the management team in scheduling patients?  For example, do they prioritize finding the right fit, or do they prioritize your time on the phone?

Elianna:  The management team at Lake Washington Sports & Spine is always very consistent in their message that we have a very specific product to offer the greater Seattle area and finding the patients who are the right fit is far more important than making phone calls short and sweet.  If I spend a little more time hearing about a patient’s goals and making sure that they are a good fit for what we offer, it helps everybody in the long run!  We understand that there are many choices out there for sport and spine care; we want to make sure the people who end up walking through our door are the ones who will benefit MOST from our doctors’ specialized skills.

Q: What types of patients do you consider "home run" fits for Lake Washington Sports & Spine?

Elianna:  I know a patient will be a great fit if their injury occurred doing a sport/activity.  Right away I know that they fit into our KPA brand!  It is also better if a patient hasn’t had tons of treatment before finding us.  We are best able to serve our patients when we can be one of the first to take a look at the problem so that we aren’t just being utilized as a last resort after “everything else failed”.  I also know a patient is a good fit when they take responsibility for their own care.  This includes being on-time for their check-in, bringing necessary paperwork and imaging, and overall just being mentally and physically prepared to give their full attention to their visit with us.

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

A:  My favorite patient interactions have a common component: choosing to be happy!  Whether it’s one of our graduations or a patient taking a picture with one of our lovely cardboard fitness bodies, I love when our patients (even though they are here because of an injury) can choose to be fun-loving, not allowing their physical limitations to cloud over joyful parts of the visit. 

Q: Do you find that Lake Washington Sports & Spine treats their employees in a way that is consistent with how they treat patients?   If so, how?

A:  Absolutely.  I think that Lake Washington Sports & Spine takes a vested interest in how patients are doing, even if they are no longer in active treatment with us.  Both Drs. Hyman and Chimes are strong patient advocates and this definitely transcends into how they treat their employees.  I have always felt very supported both within a work context as well as in my outside work endeavors.  Drs. Hyman and Chimes consistently treat patients (and their employees) as a whole entity, and not just a sum of body parts and they are always there, rooting for you!

Q: What are the key factors that drive your personal happiness, and is working at Lake Washington Sports & Spine consistent with that mission?

A:  It is kind of funny because from the moment I started working at Lake Washington Sports & Spine, I have felt like my priorities are in line with the company’s.  I love how much LWSS focuses on fitness.  As a prior group fitness instructor, I’m a firm believer that fitness plays an integral part in all aspects of health: physical, mental, emotional.  I know I am happiest when my body can do all the exciting activities it’s meant to do.  It excites me to see Drs. Hyman and Chimes relentlessly working on getting their patients back to living active and healthy lifestyles.  Let me tell you- It’s very easy for me to stand behind our brand!

Q: As Lake Washington Sports & Spine continues to evolve as a Sports Medicine practice, which areas of growth excite you most?

A:  What I am most excited about is watching LWSS continue to reach for its goal of becoming “the Lexus” of sports medicine.  With so many guidelines and restrictions making it nearly impossible for physicians to place full concentration on providing superb healthcare to their patients, our practice continuously strives to place patient needs before CMS (Center for Medicare and Medicaid) requirements.  It’s always exciting when our doctors come up with a new tactic in order to make patient care a priority.  

Patient Lateness and Asymmetry

Last weekend, my girlfriend and I were flying home from Houston to Seattle.  I needed to check a bag, so our goal was to arrive about 80 minutes before our flight.

On the way to the airport, there was a large accident that delayed traffic, and by the time we returned the rental car and arrived at United's check-in, there were 48 minutes until the flight left.  We were told by the United agent that the airline recently changed their policy to requiring check in 1 hour before the flight if we were checking a bag, and therefore we were bumped to standby on the next flight, which was leaving 3 hours later.

Obviously, this was not an ideal situation for us, and we have some questions about whether United was being honest with us (e.g., United's own website says you need to check in 45 minutes before your flight in Houston, not an hour).  But on some level, that is besides the point.  No matter how good our intentions (we did have a time cushion when we left), no matter how valid our excuse (there was in fact an accident that caused a delay), United is absolutely correct in that we are not entitled to having the plane wait for us.

When we got to the gate, the plane that we were originally booked to fly to Seattle on was delayed 35 minutes.  On some level, I did have a feeling of bitterness "Why does United get to leave late, but if we arrive late, there is no consequence?"  The reason, of course, is that the relationship between passenger and airline is NOT a symmetric relationship.

When passengers are late, it is generally for things that are under their control.  We gave ourselves a 20 minute buffer, but if we really, REALLY wanted to make the flight, we could have given ourselves a longer buffer.  When the airlines are late, however, it's usually for things that are out of their control (weather, the incoming plane is late) or safety.

Moreoever, imagine a world where the airlines DID wait for every passenger.  What would happen?  How likely is it that any plane would leave on time?  Obviously, the plane would be late all the time.  If the plane waited for EVERY passenger, then the on-time rate for departures would be only as good as the on-time rate for the most delayed passenger. 

So, as much as I was disappointed to hang out in the Houston airport for an additional 3 hours (.... which turned into 3-1/2 hours, since our later flight was delayed by 30 minutes), I understood and ultimately agreed with the airline's policy.

----------------------------

On a related note, one of the most frequent complaints by patients is that they hate when their physicians are late to start their appointments.  I get it.  I am a patient too, and it's frustrating when I am waiting for MY doctor for over 30 minutes, and I am especially appreciative when a doctor's office runs on time.

So, an important question is "why do doctor's run late?"  I suspect, based on the anger I read from patients on the internet, that at least some patients think there is an evil cabal of doctors hanging out in some super-secret country club, drinking spritzers and conspiring with new and creative ways to waste patient's time.  

This is, of course, not true.  I don't like being late anymore than the patients do.  There are several reasons, and at least some component can be attributed to behavior of the doctor.  I have colleagues who don't show up at the office until hours after their day started, and that's obviously not considerate to the patient.  

However, in my experience, and certainly in my practice, that is a very small portion of why I run late.  First of all, it's rare that I run more than 20 minutes behind- it typically happens 3-4 times per week.  It's important to me to run on time, so I track my behavior to make sure it doesn't become a pattern.

One reason we can run behind is emergencies.  In my particular practice, I don't have that many emergencies, but when they happen, I do have to stop anything else I am doing.  If I have a 60-year old runner who develops chest pain, shortness of breath, and an irregular heartbeat, I need to get him to the emergency room.  That will delay every other patient for the remainder of the half day, but emergencies have to take precedence.

Another reason I may run behind is calls from other physicians, physical therapists, or clinical partners.  I encourage my clinical partners to use email (which I can check between patients if I get the rare free moment), and if someone calls, I'll ask if it's something they need me to address promptly.  But if someone calls, it's usually for something urgent.  I've had clinic interrupted because what I thought was a routine spine MRI turned out to be a rare tumor, or because the vascular surgeon wanted to make sure I had already ruled-out certain pathologies before he started expensive and intrusive testing.

Emergencies and phone calls may account for perhaps 5% of delays, and my behavior certainly accounts for some- probably about 10%.

Another big factor is that some patient's just need a little more time.  
- Sometimes it's because I pick up something unexpected on history or exam.  Beyond the fact the history and exam will take extra time, I now want to spend a few extra minutes contextualizing the information I learned for the patient.  
- Sometimes patients have an excellent question that warrants a longer explanation.  There are times where it's more than we can address on one visit, but if I can explain something in 10 minutes and save a patient an extra trip, I try to do so.
- Sometimes patients need some emotional support.  I had a patient yesterday morning who just had a close relative die.  Beyond expressing empathy for empathy's sake, I need to also make sure they have a sufficient support structure to help them with their stressor.

Patients who need more time than we anticipated is a big factor- probably accounts for 40% of my delays.  I do not double book, and I book longer appointments than the norm (which, by the way, is a lot less profitable than working a high volume practice, and it is devastating to our bottom line when patients no show), but even with accounting for this, I cannot always predict which patients need more time.
-----------------------------------
So I've accounted for about 55% of why I run late, which is not that often.  What accounts for the other 45%?  By far, the biggest factor is late patients.  Unfortunately, one late patient can throw the entire day off.  

I book longer appointments than is typical of most doctors (which, by the way, costs me a lot of money, but unlike some stereotypes, we don't do everything for money)- 45 minutes for a new patient.  We ask patients to arrive 30 minutes before their appointment to fill out paperwork, although we do give patients the option to fill out their paperwork ahead of time if they prefer.  We've worked very hard to refine our paperwork to get rid of unnecessary fluff, but it still takes time to fill out.  My goal is to be a good steward of the patient's time and money, so I want to start my visit at the designated time and give them my undivided attention.

Let's run through an example of a patient who shows up at 8:05 am for an 8 am new patient appointment with a check-in time of 7:30 am.  My appointment runs from 8am-845am, but by the time they finish filling out paperwork, measure their vitals signs, check of Meaningful Use criteria in the electronic medical record (as required by insurers), I will be lucky to be in the room with the patient by 8:25 am.  That leaves me 20 minutes to do something that I scheduled for 45 minutes.

Beyond condensing the entire visit, there are a few other downsides to patient lateness:
1. The patient is usually not in the right mental frame of mind for the visit.  If they are late, it's usually for some reason (running behind with their kids, traffic, a meeting ran over), and their mind is otherwise occupied.  One of the most important reasons to arrive early is to help the patient clear their mind and get in the right mental state for the visit.  Indeed, we design our intake forms as a journey to help the patient learn what information we will try to gather, so they can think of their answers in advance.  The harried, hurried patient is not in the right frame of mind to do this.
     I had two late patients yesterday, for example.  My second late patient is a very sweet woman who apologized for being late, and then tried to cram all of her history into 2 minutes.  I then spent several more minutes slowing her down so I could take an appropriate history.  This made me late for my next patient, who fortunately was very understanding.  (I also gave him a Starbucks gift card as an apology for being late).

2. The patient needs the time more than I do.  If I give a patient a diagnose of a "grade 2 tibial-sided medial collateral ligament sprain" - I immediately understand what that means, but the patient needs time to contextualize that information.  More than anything, they often need a pregnant pause so they can reflect on what they just heard.  That is extremely hard to do when you are trying to do 45 minutes worth of work in 20 minutes.


So, the patient who arrived 5 minutes late to their appointment (but really 35 minutes late for their check in) may push the entire morning 1/2 day back by 15-20 minutes.  If you throw in any other factors (phone calls, patients who need more time, emergencies), and the whole day gets backed up even more.  This is what happened to me yesterday- the second late patient pushed me back for the rest of afternoon.  I could "make up time" by truncating everyone else's visit because someone before them was late, but I made the deliberate choice to prioritize giving everyone else their full allotted time.

And this brings up an important point- mathematically, the expectation SHOULD be that physician's run on time less frequently than patients.  Much as with the airlines, once one patient is late, the options are:
1. Don't see that patient
2. Truncate that patient's time (which is very hard to do, for reasons noted above.  In particular, they are so harried by their lateness, they don't engage in the visit as well.  As a rule of thumb, late patients take longer than patients who show up on time.  In part, a high proportion of late patients are not great with time management)
3. Truncate the time of the other patients who did show up on time
4. Run late for the remainder of the patients in that half day

Sometimes a late patient in the morning half-day can cause a backlog into the afternoon.  I don't take a long lunch, and sometimes I have lunch meetings, or calls with insurance companies that can take 30-40 minutes.  So it is not uncommon that the 1 late patient in the morning can cause my entire day to back up.  

Yesterday for example, I had a patient who showed up 45 minutes late for his 30 minute appointment, so I saw him at lunch and didn't take any lunch time for myself.  I am not a martyr, by the way, and this does stink.  I would like a lunch break- after having a morning of high density cognitive work, it helps to have a break to allow my mind to reset.
      During that lunch that that I was seeing the late patient, I received a phone call from the athletic trainer for one of my college athletes in another state.  I called the athletic trainer back after I saw the late patient, but that pushed me 8 minutes into my first patient of the afternoon.

---------------------

Beyond the logistical nightmares of late patients, it's stressful.  One of the underrated challenges of being a physician is the health cost of going from one intense conversation to another.  Even the very pleasant conversations are a stressor, albeit a delightful one.   I just received a very nice email from a patient about how he made 4 positive changes in his life and how it's helping his low back pain.  I'm delighted and this will be one of the highlights of my day.  

But it also takes emotional energy.  It's challenging to go from one conversation where I've been expending a high amount of cognitive energy, stop on a dime, and then walk in another room and be ready to give a patient my full attention.   

One common outlet I use for this is talking to my partner Garrett.  During the course of a typical day, we'll stop and have 2-3 five minute conversations, mostly about a patient care decision we wanted to run by the other person.  I think this is an important part of care, both in terms of sharpening my clinical acumen, but also giving my brain a brief respite before seeing the next patient.  Because I feel that even more than my time, my patients deserve to have my mind fully engaged when I see them.

---------------------------

The bottom line is that I really don't like being late for patients.  I think it's rude, and to the extent that I can control the issue, I want to.  There are some factors I can't control (emergencies), and there are some factors I can control but something else takes a higher priority (spending extra time counseling patients who need it, taking calls from other clinicians who call me).  I've adjusted my schedule as much as I can by not double booking and making longer appointments, but there is an upper limit before I would go bankrupt and have to close the practice.

The one factor I just can't seem to control, though, is late patients.  The one place I know that doesn't routinely have late patients is on site military hospitals.  As one career officer told me last weekend - "if I'm 1 second late for my check in time 15 minutes before the appointment, my appointment is cancelled."

I've asked my physician friends what their rate for late patients has been.  In our office, it's probably 1-in 5 or 6.  Many of my colleagues estimated their rate was well over 50%.  The lowest I heard anyone say was 1 in 10.

I tried researching this on resources like PubMed, but there was not a lot of information. My motivation is trying to improve my "on time" performance by addressing the largest contributing factor, which is late patients.

So I reached out to the "Dear Mona" column on the 538 blog.  Mona's niche is researching statistics on hard-to-answer questions like what % of people pee in the shower, or how long should you wear your socks before they start smelling.  I've historically been a big fan of Mona's column, as she will typically cite multiple sources for her claims, and usually expressed a healthy skepticism if the initial answer doesn't match her expectations.  I figured that Mona would research multiple studies on "What do dogs and cats swallow?" she would put due diligence in trying to find an accurate answer to my question.

This is the letter I wrote to Mona:

"Dear Mona,

I am a physician, and like many, the bane of our existence is patients arriving late for our appointments.  I would estimate this happens for about 1/3 of patients, but I would love some hard data.  I've had a hard time finding definitive numbers.  I'd love if you would do a column on this topic.

Thanks,

Gary"

---------------------------------------------

Mona published an answer to my question on her blog published on her blog on September 25.

How did Mona do?  Well, she cited one article.  Obviously, this is not as pressing an issue as peeing in the shower or figuring out what dogs swallow, but I was disappointed that she based on her conclusion on one article.  In particular, this article cited a late rate of 1-in-13.  Outside of military clinics, this sounds like a massive outlier, since it is a rate substantially lower than any clinician I know.  I had hoped she should would have approached that result with the same healthy skepticism she has given to other topics.  She seemed quite willing, however, to take this one articles result at face value.

Mona's column was 656 words.  Here is the breakdown on those words:
- Words used answering my question: 184 words
- Words used to comment on doctor's being late: 200 words
- Words commenting on lateness in general: 272 words

So, it doesn't appear that it Mona's priority was to answer my question, but rather to change the discussion into a commentary about doctor's being late.  It's her column, and she can do what she wants with it, but I would consider this a form of low level doctor criticism.  It's by no means the most inflammatory I've seen this week, but is part of a larger and unfortunate trend in the media to bash doctors.

I'll take some responsibility.  My phrasing "bane of my existence" is harsh, and implies that my issue is disliking the patients.  I can see how that might get Mona's feathers ruffled and how she might have felt a need to put me in my place.

A better wording of my actual sentiment would be "I don't like being late for patients.  I know it bothers them.  Moreover, if hurts every patient downstream for the rest of the day.  It also hinders every communication the remainder of the day, and makes me incrementally a worse doctor.  Since, by far, the largest factor contributing to my lateness is patient lateness, I'd like to do something about it, partially for me, but mostly for the other patients who are affected.  To help me address this issue, I need some data to help assess the scope of the problem.  Do you have any actual data to help solve this issue?"

That's a more honest expression of my feelings.  It also makes for a less entertaining column.

----------------------------------

Mona's column has a comments section.  As of 10/1/2014, this is the breakdown of the comments:

Clearly positive toward physicians: 7 comments
Clearly negative toward physicians: 10 comments
Neither pro/con physicians: 9 comments

-----------------------------------

So, what do I conclude from all of this?

I'm not sure.  The problem I am trying to solve is this- I want to have a high "on time" percentage with my patients.  To the extent that I have data, I am significantly above average in this regard, but I'd like to be better.

I've been working with our team to get better on the 55% that is within our control.  I would like to tackle the 45% that I've attributed to patient lateness.

I also, sadly, recognize that public sentiment is not on our side.  Based on the amount of words in Mona's column and the comments in her column, there is a slight predisposition to view physicians more negatively than positively.

One solution is to ignore the issue.  I don't think that is the right approach.  Hopefully, this blog post at least enlightens patients on some of the issues we are trying to think about, and I am certainly open to suggestions on how we can get better.

Torn Ligaments and Platelet Rich Plasma- Examples from the Sports Headlines

Ever since Ichiro Suzuki entered MLB and lit the league on fire with the Mariners in 2001, enroute to Rookie of The Year and MVP honors, top Japanese baseball players have been highly sought after commodities across the league. The latest, and some say best yet, right-handed pitcher Masahiro Tanaka, became available at the end of last year. Carrying his team on the strength of his sparkling 24-0 record and 1.27 ERA to a league title and earning himself his second Sawamura Award (the Japanese equivalent of the Cy Young) in 2013 was enough to convince the New York Yankees to shell out a record breaking seven year contract worth $155 million. The contract is the largest ever given to a player coming from Japan, and the fifth largest contract for a pitcher in Major League history.

Much like Ichiro in 2001, Tanaka stormed out of the gates, posting a 12-3 record with a 2.10 ERA with 127 strikeouts in 16 starts through the end of June. However after his second start in July, Tanaka was placed on the disabled list with what was termed elbow inflammation. A MRI later revealed that Tanaka had suffered a partially torn ulnar collateral ligament (UCL). The UCL was made infamous in the baseball world by legendary pitcher Tommy John, for whom the surgical procedure was first performed on (by Frank Jobe) and named after. Tommy John surgery involves reconstruction of the UCL and while the recovery from this surgery improved over the years, on average it still takes at least an entire year before being able to pitch again, and it is often said that it takes two years to get back to pre-injury performance. It's easy to see why avoiding this option would be preferred by both the Tanaka and the Yankees, who are still dreaming of making the playoffs.

Ligaments are bands of tough, flexible, fibrous tissues that hold together a joint. When it comes to ligament tears, there are 3 different subtypes: partial-thickness tears, full-thickness tears, and complete tears. A partial-thickness tear is when in one plane of the ligament, some of the ligaments are torn. In this case, the structural integrity of the tendon remains mostly intact because there are still many intact fibers in the same plane as the tear along with the fibers in all of the other planes to hold the joint together. A full-thickness tear is when in one plane of the ligament, all of the fibers are torn. With these types of tears, the structural integrity of the can still remain intact, because fibers in all of the other planes can still hold the joint together. A complete tear is when in every plane of the ligament, all of the fibers are torn. With these types of tears, the structural integrity is completely lost.  This same classification scheme can be used for tendon tears as well.

Unfortunately with complete tears, surgery is essentially the only treatment option. In the case of a partial thickness tear, this is something that should heal naturally. Formal physical therapy is also recommended to help stabilize the joint and ensure proper healing of the tendon. For full-thickness tears, this is something that can heal naturally when supplemented by physical therapy.

However, depending on the extent of the damage, it may be the case that there are not enough fibers left intact for the tendon to heal properly, and surgery is required. It appears that based on reports of him considering Tommy John surgery, the injury that Tanaka sustained was of the full thickness variety . Rather than going this route and having to endure the over year long recovery process, he and the Yankees decided to avoid surgery and attempt to rehab his elbow in the hopes that he would be able to return to pitch at some point this year. Tanaka underwent an extensive exercise and controlled throwing program to strengthen his elbow and to help the tendon heal properly.

Another aspect that was added to Tanaka's rehabilitation that is less commonly used is the use of platelet rich plasma (PRP). We have discuss this type of treatment in a previous blog post, and it falls under the category of proliferative therapy. The idea behind this kind of treatment is that it will improve the healing and strengthen the ligament faster and better than the body would on its own. Thus allowing Tanaka to come back faster than he would have otherwise. After undergoing this procedure in mid July, Tanaka was able to play catch in the outfield by the beginning of August before progressing to throw 49 pitches in a simulated game on August 28th. Despite having to be temporarily shutdown due to soreness after that throwing session, he was able to return to the mound on September 6th throwing a 34 pitch bullpen without any complications, giving both him and the Yankees more confidence that he might be able to pitch in a game this year. That would put his theoretical recovery time at around 3 months as opposed to the 12-18 month that would have been required had he opted for surgery.

Many of the reports that I have seen reference this procedure done on Tanaka refer to it as just a PRP injection/shot, which is a bit of a misnomer. By referring to it as simply an injection or shot, it sounds like they collected his blood, separated the platelets, and simply injected them back into his elbow. While this could be an accurate description of what Tanaka underwent, I believe that what he went through quite a bit more sophisticated. While PRP is sometimes done this way, it is pretty obvious that Tanaka would want to make sure that the PRP was injected into the most beneficial location(s) to maximize the treatment's potential in supplementing his recovery. The best way currently available to ensure this is with ultrasound guidance, so Tanaka like had done a procedure that was similar to what would be carried out in our office.

When Drs. Hyman and Chimes perform proliferative therapy on a patient (either PRP or sugar-water prolotherapy), the injectate is carefully administered to specific parts of the affected tendon, often the area of most discomfort or damage, under ultrasound guidance. The advantages of ultrasound guidance has been discussed previously in this blog, but in short it allows for the procedure to be carried out with a higher degree of precision, improving the efficacy, and thus outcomes. When patients come to Lake Washington Sports and Spine and undergo proliferative therapy, there are getting world class care from nationally recognized physicians.

How to "Return to Play" after injury

Returning to play after injury

Returning to normal activity after pain or injury can be difficult. Many patients have questions about how much activity is appropriate and how soon until they can return to normal activity.

Here is a list of steps to follow and an example to give you a better understanding of how to safely return to your normal physical activity. 

Returning to play:

1. Start with regular light activity

2. Progress into body-weight supported drills

3. Progress into resistance training

4. Progress into sports specific drills, may include plyometric exercises

5. Progress into non-contact practice

6. Progress into contact practice

7. Return to play

Example: (for a runner, returning to running following an injury)

•   Ok to start run-walking
•  Would start with time based running (30 seconds running and 2 minutes walking)
•  Start slowly by running 1 mile or for 12 minutes
•  Slowly at first increase distance before shortening duration between bouts  (running 1 mile on day 1, increasing to 1-1/4 mile next session
•  When up to 2 miles in distance, can start experimenting with shortening gaps between walking sessions  (instead of walking 2 minutes between runs, lower to 90 seconds)
•  Key is to not run when fatigued or in pain
•  If pain develops, then go back 2 steps

What to expect from physical therapy

One of the common treatment options that Drs. Chimes and Hyman recommend to patients is formal Physical Therapy (PT). When writing these referrals, they will often prescribe 12 sessions. 

Where does the number 12 come from?  It's an arbitrary number.  Different patients need different numbers of session, so 12 is a baseline number that helps for insurance approval.  The actual number of visits a patient needs is more complex, and will vary from person to person.  Many patients get better with a much smaller number (e.g., 4-6 sessions), while some more complicated injuries may take longer.

The purpose of this blog post is to give patients an idea of what to expect out of PT and how long they should continue with it in order to obtain optimum benefit.

• The blue portion of the graph represents the period of "high benefit" where the gains are greatest, when a patient initially starts physical therapy.
• It is important to understand that the first visit is likely to be more of an assessment and that true gains will begin accumulating in the visits that follow.
• After about 2-5 sessions you should be able to get a sense as to whether or not you are on the right track.  This is the accelerated portion of PT, where the largest gains are often seen.  This is represented by the blue portion of the graph above, and may represent as few as 2 sessions, but sometimes may require as many as 10-20 sessions, depending on the patient.
• Over time, as you attend more sessions, you may experience less benefit from each session. It is still very important that you continue with the therapy as these smaller gains help with "preventing injury recurrences", represented by the red portion of the graph.
• At this point, it may be appropriate for you to increase the amount of time between appointments.  This will allow you to develop a "home maintenance program" while still periodically checking in with your PT to make sure home program is properly optimized.
• However, eventually you will reach a point when you will begin to get "limiting returns" from your physical therapy sessions. This is a time when you have developed a sufficient base to return to activity while minimizing the risk of re-injury. This is represented by the green portion of the graph.
• In regards to the question of how long you should attend physical therapy, ideally the sweet spot would be between red and green portions of graph, where you have learned how to prevent recurrences but have not reached a point of diminishing returns.
• There isn't a magic number of visit that corresponds to this sweet spot. When you feel as though you may be approaching this point, discuss this with your physical therapist and/or physician and talk about transitioning to a home exercise program.
• A physical therapy program is only as good as the effort a patient puts into it.  The bread and butter of any PT program is the home exercise program.  Patients who are fully participatory in their home program get better more quickly.  Listen to your PT!