Physical therapy…What’s the Point? Q & A on PT with Dr. Hyman

1.  What’s the goal of physical therapy (PT)?

The primary goal of physical therapy is to optimize your body mechanics, so that you may return to sport or chosen physical activity.

While pain relief is not the primary purpose of physical therapy, most often the pain goes away and stays away when body mechanics issues are corrected.

Ideally, all persons with a sports or back injury should see a physical therapist first, before seeing a medical doctor.  The majority of the time, physical therapists will lead you successfully back to full function without a hitch.  In some cases, problems persist despite physical therapy, and then ideally your physical therapist will refer you to a musculoskeletal specialist medical doctor.  I like to use a 4 visit threshold — you should see improvement in PT within 4 visits, and if not, then seeing a specialist doctor is appropriate.  Why not first see your primary care physician?  Well, in most cases your primary care physician will rely on a physical therapist to evaluate and treat an injury.  So if you’ve already been responsible enough to participate in PT, then you’re ready for specialty care with a sports medicine physician.

2.  What should you expect from a PT visit?  

Expect to arrive 10-15 mins early, dressed for exercise.  The sessions usually last 45-60 minutes.  During the initial assessment the physical therapist will get to know you and your problem by taking a history and performing an extensive physical examination. Each follow up session typically involves some period of reassessment (i.e. talking about how you’ve been doing since last session), a physical examination to check biomechanics, sometimes an intervention (i.e. hands on treatment that might feel like massage, stretching, or joint manipulation), and then additional exercise instruction.

We expect you to attend physical therapy sessions once or twice per week for several weeks before we follow up together.  Typically within 4 visits a person will notice some improvement.  The overall duration of physical therapy depends on several factors including the complexity of a condition and its chronicity.

3.  Why spend the time and resources to participate in PT?  Why don’t you just hand me a printed exercise handout?

A physical therapist is a medical exercise specialist, and they are able to design a customized exercise program to help you achieve your particular exercise goals. Each person’s body mechanics are different.  It is the physical therapist’s expertise to understand what normal flexibility and strength looks like.  Every person has areas of inflexibility and areas that are weaker than what is optimal.  Often making tailored corrections to your flexibility or weak areas will make all the difference and allow you to return to full function.

Exercise handouts are designed to treat the “average” person in a general sort of way.  Perhaps up to 50% of the time this approach works.  However, we take your recovery seriously, and we prefer better odds.   With physical therapy intervention for most conditions, the likelihood of improvement goes up to 75-85% in our experience.

Sometimes I’m asked why I can’t just teach the exercises at our office visit.  The simple answer is that I’m not a specialist in teaching people how to properly exercise.  Additionally, most physical therapists understand how to assess biomechanics on a more sophisticated level than most specialist physicians.  So they can both assess complex biomechanical issues, and they are experts in creating an exercise plan to correct those issues.  Just to overemphasize, when I have an injury or issue, I personally go to see a physical therapist because I won’t appreciate my weak spots nearly as well as a physical therapist.

Dr. Hyman, what are steroids and why do we use them?

Debunking Steroid Myths
Most people associate steroids with bodybuilding or injections, but steroids are also naturally occurring meaning that the body can make its own steroids. Steroids that are administered from outside the body, often in the clinical setting, are called “exogenous” steroids. 

The most commonly thought of steroid is “cortisone.” People will use the term “cortisone” interchangeably with steroid. 

So, what are steroids, really?
Steroids are hormones. Hormones are chemicals that signal cells to perform an action at the tissue level. In this case, steroids might signal nerve cells to calm pain signals and are also the most potent anti-inflammatory drug, meaning it will stop a cell from releasing other chemicals that promote inflammation. In our clinic, we use steroids to independently relieve pain by calming the nerve signals that carry pain signals and to suppress inflammation. 

We traditionally use steroids almost anywhere and everywhere—it has been a ubiquitous drug, either given by mouth or injected. Typically, we are using injectable steroids in our practice. Why? Because we have the ability to figure out the specific tissue that is the source of pain and thereby can target that tissue with the injected steroid. If you take steroids by mouth, it goes through the entire system and has a larger chance of affecting cells in your whole body, potentially causing a variety of side effects.

What are the potential side effects of injected and systemic steroids?
Some of the most common and usually temporary steroid side effects are insomnia, mood swings, flu-like symptoms, weight gain, increase in blood sugar, abnormal menses, and palpitations. A reduction in bone density is one longer-term adverse effect of exogenous steroids. Again, steroids are hormones and hormones can have both tissue level and systemic effects. For example, melatonin is a hormone that helps our body sleep and melatonin can be influenced by steroids, thereby creating the side effect of insomnia. Steroids can disrupt all other hormone pathways. While not always true, injected steroid may minimize those systemic side effects. 

And the truthfully, there are probably still some systemic effects of steroids because we have these little blood vessels nearby injured tissues that take up the injectable steroid. So there may be some systemic effects even when injected, potentially. 

Additionally, there is some evidence to suggest that injectable steroids can be damaging to tissue; steroid injections into the knee can degrade the cartilage more quickly and steroid injections may also increase the chance of rupture in some tendons. 

What can steroids help with?
It is important to note the risks of steroids and ensure appropriate use. When steroids are used in a targeted and appropriate manner, they can be a wonder drug; decreasing swelling, reducing pain, and restoring mobility. Typical uses for steroid include: swelling in a soft tissue, bursitis, adhesive capsulitis (frozen shoulder), and epidural injections into the spine. Steroid injections into these areas carry relatively low risk with great potential improvement for carefully selected patients. 

FAQ

I’ve been prescribed Prednisone (oral steroids) in the past and it helped. Why not try that?
Again, there is a greater side effect profile with oral steroids because they are distributed throughout the body. The benefits of an oral steroid may also be more transient and may not be prescribed at a high enough dose to be effective. 

How often can I have a steroid injected?
Short answer: it depends on the body part. In weight-bearing joints—like the ankle, knee, and hip—we try to be stingy with steroid and maybe not use it at all. Steroid injections in these joints may last only a few weeks and there is evidence that steroid can increase the rate of cartilage loss in the knee. In contrast, epidural steroid injections into the spine may be given liberally as a tool to prevent surgery and promote an active recovery. Insurance only pays for surgery and steroids for most musculoskeletal and spine pain whereas other treatments may be a better option. Other therapies like prolotherapy, PRP (platelet rich plasma), stem cells, and viscosupplementation are not covered by insurance but may be the better option.  

Snow is in the forecast!

For some of us winter sports enthusiasts, it is about time to hit the slopes with Mt. Baker, Stevens, Crystal, and the Summit at Snoqualmie all being open to some degree! Ski/board wax: check, tickets: check, hot cocoa mix: check!  With all the excitement and snow in the forecast, it is easy to forget the inherent risks of winter sports. A few quick reminders prior to strapping in:

• Safety equipment:
• Have a whistle zipped into your jacket. A whistle is a simple emergency communication device that is sufficient for most in-bounds enthusiasts. Out-of-bounds (backcountry) participation does require more advance communication equipment, skill level, and training.
• Wear a helmet. It might be dorky, but everyone else is doing it!
• Get your gear tuned up.  It is worth paying a professional who knows how to sharpen ski and snowboard edges and adjust your bindings properly. These small adjustments could be the difference between you being able to hold an edge versus skidding and falling, and then coming to see us in the office for a ski/snowboard injury!
• Know your equipment. If you have advanced gear like walkie-talkies, beacons, probes, etc. go out and practice with your equipment prior to getting on the slopes. This safety equipment is worthless if you do not know how to use it! Here is a link to get you started and REI sponsors classes:

https://www.outsideonline.com/1868866/how-use-avalanche-beacon

https://www.rei.com/learn.html

• Safety behaviors:
• Trail map. Take a look at the trail map prior to heading downhill. Everyone has a story that begins with “I confused a green for a black” but the endings aren’t always happy.
• Ride with a buddy. Besides the safety aspect, it is more fun anyways!
• Tell a third party when you’ll be home. You might have a ski buddy but what if both you and that ski buddy take the wrong route or the roads get super snowy? Just tell someone back down at sea level when you expect to be home!

Natalie's Journey & LWSS Lessons

Nearly two years ago, I took a chance, packed my car with all my belongings, and moved to Seattle, where I had a job interview lined up for a medical assisting position. The interview seemingly went well, and I was confident I would hear a ‘Welcome to the team!’ by Monday. Unfortunately, Monday came and went, then Tuesday, then Wednesday… Somehow, my master plan was not working out as I intended, and I decided I needed to get back to the hunt (job hunt, that is). I sent cover letters and resumes flying out to the ether, and before I could bat an eye, I received a cheery reply inviting me to an interview at Lake Washington Sports & Spine for the next day. That was quick!

The following morning, I fought the unfamiliar Seattle traffic to arrive bright and early, dressed to impress. This interview lasted nearly until lunchtime, and I don’t remember many specifics aside from the fact that I left desperately wanting the job, but woefully aware that I had flubbed it at every turn. I sat in my car worrying over everything I had said and everything I should have said instead… I contemplated calling to explain that ‘I can do better! I can show you! I’m not that anxious of a person!’ (false- I am). While I ruminated over and over on my performance during the interview (how come I hadn’t felt this way after my interview from the week before?) I was saved from going down the rabbit-hole of worry and self-doubt by the ringing of my cell phone. It was Laura on the other end, asking me “Won’t you join our team?!” I was flabbergasted. I was convinced I would not be hearing from them, let alone so soon after the interview. “Holy buckets! Of course!” I squealed, and I was quickly out-squealed by the ensuing clamor of cheering and dog barking in the background.  

The process of becoming a part of the Lake Washington Sports & Spine family is only the tip of the iceberg when it comes to story-telling.  I could write about the time I was convinced I had poisoned Dr. Hyman’s pup Nala with sugary sweets (nope, turns out Dr. Hyman swiped the treats himself), the time Laura scared the britches off me when she popped her head through the ‘pee collection’ window into my office, or the time Dr. Chimes ran around the office all day testing everyone’s grip strength and championing our very own ‘Office Olympics.‘ But these memories are only one piece of the pie. The whipped-cream on top (or ice cream a-la mode) is the accumulation of invaluable lessons I have learned along the way, which I will carry with me for the rest of my life. In no particular order, these are the pearls of wisdom I’ve gained from my time at LWSS:

Lesson #1 (Ok, I lied, lesson #1 is first for a reason): Prioritize. There are only so many hours in a day, in a week, and in a lifetime, so it is crucial to make clear to yourself, and others, what your priorities and values are. Say no if something doesn’t fit under one of your priorities. This time-management tool also helps me weigh what I’d like to get done with what I am actually capable of getting done, and helps me to feel more satisfied with my accomplishments at the end of each day.

Lesson #2: Keep a growth mindset. Through consistent and constructive feedback, I learned to be comfortable with making and learning from my mistakes. I learned that it is important to seek feedback and to continually strive to improve, otherwise one stagnates. I also learned first-hand how valuable it is to work with a mentor who is willing to teach, challenge, and share.  

Lesson #3: Sing and be goofy. “All work and no play makes…” life a lot less enjoyable! Working alongside Dr. Hyman really impressed upon me the value of being goofy, doing the things that bring you joy, and occasionally throwing a nerf ball at your office manager while wearing a superhero cape.

Lesson #4: Bandwidth. This is a phrase we used at the office all day long, and is something that I have now adopted into my personal life. My friends and family will often hear me saying “You know, I’d love to hear your story but I just don’t have the bandwidth for it right now,” or my partner will ask me what my bandwidth level is before launching into a story about the fulcrum load effort of his PR squat press that day. Talking about attention span in terms of bandwidth has proven to be revolutionary in allowing me to be more intentional when talking with friends and family.

Lesson #5: Sweat not sweets. The LWSS Sweat Club (our motley crew of whichever ladies decided to stay late after work to work out in the waiting room) inspired me to actually make the lifestyle changes that I want to see become a reality. Laura and Elianna in particular inspired me with their dedication to their fitness goals, which has encouraged me to pursue my own. Also, the office policy of (generally) not keeping sweet treats around is one that proves quite valuable in my own food endeavors at home; out of sight, out of mind!

Lesson #6: A/B testing. There is value in comparison, and not everything works well. I observed the doctors frequently ‘A/B testing’ their approach to various situations, and I appreciated that they encouraged everyone in the office to practice it as well. A/B testing is the idea of trying out strategy A for one situation, and then trying strategy B in the same situation next time, to help determine which is the best approach. This is a tool that will help me figure out my optimal time management plan, study strategies, or more importantly, my favorite chocolate bar.

All said and done, I cannot thank my Lake Washington Sports & Spine family enough for all that they have taught me over the past two years. These lessons will carry me forward as I pursue my next endeavor of becoming a PA. In the next phase of my career, I can only hope to find mentors as invested in my growth as both Dr. Hyman and Dr. Chimes have been, and a workplace as joyous as LWSS. So long! Merci Buckets! 

The Barre3 Experience

In an effort to better understand the factors that underlie exercise-specific injuries, the LWSS team has embarked on a mission to try a myriad of local fitness classes! Last week, our squad attended a class at barre3 in Bellevue.  For most of us, it was the first time performing any type of barre exercise.  

Notable post-class quotes:

"I was slipping in my sweat!"
"That was wayyy harder than I expected."
"During the first 7 minutes, I was looking around hoping I wasn't the only one sweating so much."
"I ran a marathon 2 weeks ago and that class made me feel out of shape!"

Interested in trying barre for the first time? Here are some tips for success:

1. Know your level of fitness.  If you haven't worked out in quite some time, barre (or any group class for that matter) might not be the best reintroduction to exercise.  We recommend a personal trainer or private lesson to ensure proper form and to prevent injury. 
2. Do your research.  Every studio and class are different!  As a beginner, you'll want to make sure you're signing up for a beginner or fundamentals class and not level 5 advanced.
3. Dress appropriately. Make sure to wear fitting athletic clothing since you will SWEAT. You won’t be wearing sneakers in the studio, so make sure to check the studios policies prior to arrival to see what they require for footwear.  We were required to go barefoot and WISH we all had some special grip socks for balance!
4. Arrive early.  This will give you time to complete the studio's forms, ask any questions, and introduce yourself to the instructor.  Make sure to let them know you're a beginner and make them aware of any injuries you have.
5. Listen to your body: go at your own pace, don't be afraid to take breaks when you need to them, and modify poses that are too challenging.

Final thoughts:

Barre3 was a great high intensity interval training (HIIT) workout.  Even the men felt it would be a great way to build diversity into an existing exercise routine! With winter and skiing/snowboarding on the horizon, barre3 would also be an excellent workout get those quads in slope-shape!  

The Hidden Cost of Immediate Medical Care

My daughter injured her wrist playing soccer a week ago.  Another player launched the ball upward into her extended wrist.  She had immediate pain.  Tears flowed.  I shifted from Dad to doctor mode and assessed her wrist on the sideline.  I had low suspicion for a fracture or severe injury.  She was able to continue playing.   

The wrist hurt more later that day.  She iced, and we applied a wrist brace we had at home.  I counseled her that it was likely a bad sprain and should get better over the next few days.  I asked her to let me know each day how she was recovering.

She improved wearing the brace.  Then the pain came back as she used the wrist more writing at school.  After a week of persistent symptoms, I decided an X-ray made sense to rule out a fracture.

Our busy family schedule didn’t easily allow for a trip to a radiology center during regular Monday through Friday business hours (of course I have the latitude to order the test myself) so I decided that I would take her in for the X-ray on Saturday morning.

I phoned the free-standing radiology group I normally patronize and learned that while they’re open for MRIs on the weekend (both Saturday and Sunday) they do not offer the more simple X-ray service on the weekend — the lion-share of their income is from MRI reimbursements so it likely does not make financial sense to pay an X-ray technician on the weekend.  So I had to find another option.

I thought next about taking my daughter to an urgent care clinic for an X-ray.  I have Kaiser Permanente (formerly Group Health) insurance that promises more cost effective care when using Kaiser providers, and so looked up the Kaiser Urgent Care in Bellevue, open 24 hours.  And off we went.

I’d never been to Kaiser’s Bellevue facilities though I work across the street.  Looks beautiful from the outside.  It’s even nicer on the inside. As a small business owner who has hired contractors to remodel my office space, I stood in awe of the elegant atrium with warm accents like a gas fireplace with couch-like seats that had nearly the feel of a ski chalet.  My daughter said, “Dad, this looks like an airport.”  And I thought, she’s right, this is kind of like the beautiful new atrium at Sea-Tac Airport…but the airport is used 24/7 — I wondered what the foot traffic looks like here on any given week.

And sure enough it was a ghost town.  We walked right up to the Urgent Care reception desk and checked in.  Two kind women were there to serve.  One seemed to be mentoring the other.

We were taken back within minutes — no sooner had I taken my daughter’s homework out of my backpack when we were brought back by a nurse for vital signs.  The nurse then had us go back to the waiting area.  One minute later we were greeted by an upbeat male technician who identified himself as an ER Tech, and taken back into what I expected would be a typical Urgent Care medical office facility.

To my surprise, the facility was a high tech and fully equipped emergency room.  The young man, the tech, told me that this was a fully functioning ER but due to contractual issues with Overlake Hospital (that has another fully functioning and state-of-the-art ER literally across the street), they must call it an Urgent Care.  

My daughter and I sat idle in a room that could accommodate a full Code Blue with oxygen lines and monitors adorning the wall.  We were right across the way from the nurses station (actually all rooms look out towards the nurses station as a deliberate and modern wheel-and-spoke ER design element).  We observed at one point approximately 10 people casually standing around chatting at the nurses station.  There were perhaps two other persons being attended to for what appeared to be reasonable urgent care type issues like cough/flu or nausea/vomiting.  

The ER tech was kind, and after I told him our story, and that I’m a sports medicine physician, he said he’d facilitate the X-ray even before we were to be seen by the physician assistant.  After about 15 minutes an X-ray technician brought us back for my daughter’s wrist X-ray.  Then we met the physician assistant, who performed a very brief history and a nominal examination.  The radiologist had concern for a buckle type fracture of the distal radius (forearm bone), and so the physician assistant got on the phone with a Kaiser orthopedic surgeon on-call.  The orthopedic surgeon kindly spoke with me over the phone and after reviewing the images and the clinical history, he did not think there was a fracture.   Ultimately we decided that bracing her for several weeks makes sense and we were discharged.  

Our experience at the Kaiser "Urgent Care” (in quotes because this is really a fully functional and state-of-the-art ER) was very positive in that we received prompt attention from a number of very friendly staff members and we met my goal of obtaining an X-ray to assess for fracture.  In fact, we surpassed my expectations as I was able to speak with an orthopedic surgeon about my daughter’s case.

My level of worry going in was very low.  My daughter was quite functional, and I deemed her at low risk for a significant injury.  I got more excited about adjacent observations during the visit that might impact cost — both my direct and indirect costs of an “urgent care” visit to an actual emergency room, and the cost to my larger community.

An article (http://www.crainscleveland.com/article/20150708/NEWS/150709836/akron-general-to-build-new-emergency-department-cost-expected-at-35) from 2015 describes a cost of ~$35 million to build a new emergency room in Akron, Ohio.  So I wouldn’t be surprised if that approximates the cost of the Kaiser “Urgent Care” here in Bellevue…again, this facility is literally the neighbor to the adjacent building of Overlake Hospital with a level 3 trauma center ER.

Aside from this being an example of overbuilding and an outrageous, and costly, redundancy in community resources, I find it remarkable that I didn’t even know that such a facility exists given that I work across the street AND I myself have Kaiser Permanente insurance.  As one of Kaiser’s insured, clearly it may benefit me and my family to know about the resources at our disposal.  As one of Kaiser’s neighbors and a community physician who treats others having Kaiser insurance, clearly it may benefit my patients to know about this extraordinarily equipped “urgent care” facility.

So what are the take home messages?  The high and growing cost of your healthcare insurance premiums relates to many things, and one of my concerns is that inter-system competition (i.e. locally, Swedish vs UW vs Overlake vs Virginia Mason) is a consequence of the consolidation of healthcare providers/systems and competing systems often compete on resources.  These resources are costly.  And that cost is passed on to you.  

We all want answers now.  Not only for emergent care, which is a bit easier to define (perhaps by my definition, care that might help you prevent loss of life or limb), but for issues that we know are not emergent but trigger enough concern or anxiety to warrant a visit right now (i.e. is it broken or just a sprain, or will my infection need an antibiotic?).  Let’s face it.  We’re all looking to escape from our anxious thoughts.  One way to do so for a health related concern is to seek attention immediately.  Escalate our urgency to a "fever pitch” (pun intended) and drive to some 24 hour clinic.  Why lie awake all night with anxiety when you can go see someone tonight?  At least this is some of the psychology that underlies patient behavior, and perhaps the more irrational behavior of health systems that more and more are squandering our money!

Did you know? Bellevue has a Farmer's Market!

The bounty of Summer is almost past, but alas Bellevue’s Farmer’s Market goes until October!

Not until recently, did I know that Bellevue has its own farmer’s market! The farmer’s market is located in the parking lot of Bellevue Presbyterian Church, half a mile north of Downtown Bellevue and is every Thursday 3:00pm-7:00pm. Open late enough to go after work for some fresh produce or a light dinner!

The market is slow enough that you aren’t going single file through a gridlock of people, like at Pike Place or Ballard’s Sunday market, which makes it a pleasant way to enjoy a Thursday evening. Being that the vendors aren’t mobbed with people, they are friendly and conversations flow easily.

The goods are mostly seasonal vegetables and fruits: peppers, beans, eggplant, and berries this time of year. My favorite booths are the tomato man and honey bee man. Full disclosure, growing up my father and his friend kept honey bees “for fun” and we actually processed the honey. We eventually moved and weren’t able to take the bees with us, but my dad’s college friend turned the hobby into a business--Cascade Natural Honey. The honey is unreal. This is the honey I grew up on: in tea, on toast, on yogurt, and over cheese. Cascade Natural Honey is unique for harvest varietal honeys; bee hives are placed in areas when pollination of a plant occurs. So “raspberry” honey is made when the bees pollinate the raspberry bushes. Same for blueberry, blackberry, thistle and Baby’s Breath, and sweet clover honey. The Thistle honey is my favorite for its dark flavor profile and being so thick one has to scoop it out of the jar with a spoon!

Bee man, or Cary, introduced me to tomato man who grows a wide variety of heirloom tomatoes, and hence the picture above. The tomatoes range in color from light yellow to striped by red and green! These tomatoes are so flavorful and meant to be consumed shortly after purchase, preferably with a sprinkle of sea salt or flash of balsamic vinegar!

Hopefully, the drool that is beginning to pool at your feet begets a trip to Bellevue’s Farmer’s Market this Thursday! Food this good makes it easier to live the healthy and active lifestyle we strive for. See you there!

Link to the Farmer’s Market: https://bellevuefarmersmarket.org/