Sentinel Events for Skiers, Snowboarders, and Mountain Bikers

Ski season is starting here in the Pacific Northwest, so many of my patients are getting ready to enjoy the winter

An important concept with sports like skiing, snowboarding, and mountain biking is a sentinel event, which is a term I use for a small biomechanical mishap that may be a precursor to a more significant injury

The model I base this on is from strokes. If we look at patients who have a devastating stroke, a significant percentage of them have a smaller "mini-stroke" in the month preceding the major stroke. Some patients ignore these mini-strokes because they are either unaware of what happened, don't recognize their significance, or feel a sense of relief that they don't have any long-term disability. This is a shame, because in the period following a mini-stroke, there is a window of opportunity where they can intervene and prevent a more devastating stroke from occurring.

The same concept applies to devastating injuries during skiing, snowboarding, and mountain biking. There are a few common elements of these sports that make them prone to devastating injuries, namely:

A. The body can gather significant momentum

B. Falls are common. High speed falls are common

C. The terrain is inconsistent

D. They require a persistent vigilance to notice changes in terrain so that you don't fall

Prior to having a devastating fall in any of these sports, it's common for the athlete to have a "sentinel event", where they have a smaller stumble that is often ignored. This is a mistake, and athletes should pay attention to these smaller mistakes, even if there is no lasting consequence

For example, a skier may notice that as they become tired, they may not notice a small change in terrain and end up taking a turn more aggressively than they should. They may have a mild fall, or merely require an atypically higher level of exertion

I encourage athletes to pay attention to these sentinel events, they are often a sign of fatigue. Specifically, they can be from two forms of fatigue:

A. Cognitive fatigue. Their brain may not be acclimated to the duration of exercise, so they are paying less attention to the small details

B. Muscular fatigue. They may be using muscles they haven't used in a while, so while their muscles were fine for the first hour of exercise, they are not as efficient after an hour or so

What is the treatment for these sentinel events? Give yourself permission to take a break

This may seem like common sense, but there are a few reasons, particularly for skiers and snow boarders, that may make them less willing to take breaks. The biggest of these is time investment. Especially for people driving to their ski facility, there is a substantial time commitment to even start skiing, so the idea of not "maxing out" their time on the mountain seems wasteful. I encourage these patients to think long term, and taking a short break to prevent a devastating injury is a good use of time and resources.

Big picture - taking a short break following a sentinel event is one of the best investments an athlete can make to prevent permanent disability.

While we can't fix your tight pants, we can fix your frozen shoulder!

This video explains how we can use an ultrasound-guided injection to help fix adhesive capsulitis, also known as a frozen shoulder

Conquer the Halloween Sugar HANGOVER

Raise your hand if you ate too much Halloween candy last night and woke up today feeling sluggish & full of regret.  

Ok, I can't see you, but I know you're out there!  Here are easy tips to conquer the post-Halloween hangover

Drop that candy bar! (or bag, lollie, etc.)

Eating sugar will make you crave more sugar.  Halloween is a holiday, not a holi-week or a holi-month.  Don't allow your one-day indulgence to become a new habit.  You have 100% control of what you put into your body! Make healthy choices today and in the upcoming weeks.Tip- if you are craving sugar, reach for a piece of raw fruit.

Eat whole foods

Adopt a clean eating diet for the next few days (and preferably longer!).  Ditch the processed foods and pick up some real, nutritious foods!  A mix of high-fiber vegetables and lean protein will help your body reset after the sugar storm.

Drink more water

Adequate water intake is essential for the body's function, but it's especially important after a day of indulgence.  Water will help your body process those treats and absorb the healthy nutrients you put back in!

Increase your exercise

Rev-up your metabolism and sweat out toxins with a high-intensity workout.  You'll feel better, have more energy and improve your mood, too!

Get some zzz's

Chances are Halloween festivities and trick-or-treating cut into your sleep time.  Make a point to get to bed early tonight and allow your body proper recovery time.

The MA to DPT Transformation

I’ve been at Lake Washington Sports and Spine since April 2015, and have loved every minute of working here. So it is bittersweet that I will be leaving in late July to start physical therapy school near Phoenix, Arizona. (Know of any hotspots? I have zero experience with Phoenix.)  I have learned so much working as Dr. Chimes’s medical assistant that I am at a loss to put it succinctly into words. However, I can at least try and share some tidbits I have learned through my time at LWSS. The nice thing is that most of these lessons have applications outside the healthcare field. Without further ado, here are a few things I’ve learned, in no particular order of importance.  Maybe I’ll rank them later in honor of Dr. Chimes.

-          Become an expert.

In other words, I want to learn as much as possible regarding physical therapy, the field/specialty I have chosen to pursue. I will never be satisfied, as there is always something new to learn. The biggest mistake I can make is to assume that I know all that there is to know about a given subject. Already I’ve learned about various subspecialties in physical therapy I had no idea existed prior to working at LWSS. I’ll never be an expert in all the specialties, but at least I can be aware of the strengths and weaknesses in order to become a well-rounded, well-informed physical therapist.

-          Admit my knowledge gaps.

This is related to the above point, but an entirely different idea in and of itself. For example, although Dr. Chimes has some experience in all medical fields, he understands and admits that he has definite knowledge gaps. It has been years since he learned about cardiology or hematology, and to further compound the problem, these fields have changed so much in the intervening years. This leaves him in the position that he’s not even sure what he doesn’t know. Did past treatments turn out to cause more harm than good? Are there new diseases that he doesn’t know about? So when patients ask about issues outside of his area of expertise, he gives a clear disclaimer that it is not within his expertise and then refers to another provider who would know better.

What Dr. Chimes is trying to avoid is the Dunning-Kruger effect, which is summed up fairly well by one of the authors during an interview with the New York Times: “… the skills you use to produce the right answer are exactly the same skills you use to evaluate the answer.” In other words, without knowing the skills yourself, you cannot determine whether someone is skilled or not. It then follows, how can you possibly come to an answer without knowing what question to ask? This is a phenomenon I had never heard of prior to working here, but it certainly has shaped how I will treat patients in my future career. I will hopefully get my patients to 100% by focusing on what I know, and referring to, and working with, other healthcare professionals with patients who are beyond my scope of expertise.

-          Know which patients will benefit from my expertise as a physical therapist.

And by extension, and possibly more importantly, when physical therapy is NOT appropriate for a patient. Being able to see patients from the perspective of a Physiatrist, where accurate diagnosis is the name of the game, will help me tremendously as a physical therapist. It is now clearer than ever that I will need to keep an open mind and consider alternate diagnoses if the initial treatment modalities I utilize on my patients do not bring any benefit.

-          Utilize a differential diagnosis process.

Low back pain is one of the most common reasons people go to the doctor. However, there are a multitude of causes for low back pain, and the symptoms often overlap. To compound matters, treatments for one cause are ineffectual for another, or may even make symptoms worse. What I’ve learned from my time here is to tease out the unique features of a patient’s low back pain in order to come to a correct diagnosis. Focusing on symptoms that apply to several possible diagnoses will not help me determine the root cause of a patient’s pain.

-          Be as transparent as possible with my communication.

We have several different iterations of this idea within the office, ranging from a tidy motto to a detailed flowchart/graph. It is never beneficial to be vague with my communication style or vocabulary when talking to another person. Furthermore, not only do I need to be clear with my communication, I need to confirm that the person I am talking to is ready to digest what I’m about to say. Having an disengaged audience can, at best, lead to repetition, and at worst, lead to a complete mishearing of what I have to say.

The above are just a few of the things I've learned while working at Lake Washington Sports and Spine. The effects of these lessons may not even be felt or become apparent for years down the line, but I know that they will only help me in my future as a physical therapist. I cannot begin to express how grateful I am for my time here. 

Wynnie's 4 Hikes for the 4th of July

Searching for ways to stay active this weekend?  Look no further!Wynnie (weekday office dog, weekend adventurer!) has four fantastic hike recommendations just for you.  Click on the links below for hiking guides & trip reports via Washington Trails Association (WTA).

McCLELLAN BUTTE

WALLACE FALLS LAKE LOOP

IRON BEAR TEANAWAY RIDGE

SNOW LAKE

ClassPass - a passport to a healthier you!

We live in a world filled with options and the wonderful thing about this is it gives each and every one of us a choice, some autonomy over what we eat, buy and do. If you are one of those people who makes choices easily, mazel tov. I tip my metaphorical hat off to you.  If you are like me, however, you only make choices under extreme duress.  One area of my life where this rings especially true is my exercise routine.

These days, there seems to be a new workout craze or boutique fitness studio on every block. After my initial excitement about all of the fun things I could try, I became overwhelmed by trying to figure out how I could possibly afford to go to all of the studios I was interested in.  Unless you are rolling in the Benjamins, purchasing a membership to FlyWheel, Pure Barre, Crossfit and a luxury gym will break the bank (unless you stop eating, seeing your friends and paying your bills, but that’s a topic for another blog).  So how do we mere plebeians manage to participate in these fitness trends?  Enter: ClassPass.

For those who are unfamiliar with ClassPass, it is a company that provides access to an extensive network of fitness studios for a simple monthly subscription.  For example, in Seattle, there are over 200 studios belonging to ClassPass and the subscription is currently around $100 (there is speculation and reason to believe that this cost may increase over the next few months).  What makes this intriguing is that instead of having to purchase memberships to each individual studio, you gain access to what feels like an endless list of options all while paying just a little more than a typical gym membership. 

I initially heard about ClassPass from my friend in San Francisco who was taking obscure classes like paddleboard yoga and aerial silk training (she hung from a piece of cloth on the ceiling - neat!).  I thought to myself, “that sounds amazing, but I would never buy a membership to classes like that”.  Once she explained how the ClassPass subscription works, I knew it was the right fit for me.  I wanted to try all the new fitness trends without having to choose just one single studio/type of workout.  

Since signing up with ClassPass I’ve tried FlyWheel (essentially a party on stationary bikes), Pure Barre (hard in a way I never anticipated), Tabata (HIIT training to the extreme), Bootcamp (I was sore for days) and a couple Zumba classes (the old dancer in me loves to shake and shimmy)!  Sure, some classes I enjoyed more than others but that’s exactly what ClassPass is for!  Which instructor keeps me motivated?  Which class makes me want to don my workout gear and get moving? I always look forward to scrolling through the app and choosing how I will get my butt kicked on a particular day. 

Now, you may be thinking “Elianna, this just sounds too good to be true. Unlimited classes?? Less than $100 a month?? How can this be?!”  Well, although I still believe that this set-up is pretty neat, there are a couple caveats that should be mentioned.  First, you can only go to one studio three times a month and that includes all of their locations.  So, for example, if I decide that I like FlyWheel classes, I can’t go to the Bellevue location three times and then the South Lake Union location three times.  This also holds true even if I’m not taking the same type of class (i.e. if one studio offers spin, Zumba and yoga). It’s three times per studio, across all locations. 

The second, latest caveat to keep in mind is that ClassPass recently increased their prices in New York City (where the company originated) to $190.  Suddenly, the once almost shockingly affordable membership doesn’t feel like such a steal.  ClassPass does offer a more economical price point if you only attend 10 classes per month. That said, these price hikes haven’t hit Seattle yet and until that day comes, I will happily get my sweat on for under $100 a month.

Like any product, ClassPass has its pros and cons, and like any middleman company, it has the challenge of making both studios and individual clients happy.  Initially, the low cost for unlimited classes was an exercise enthusiast's dream, yet studio owners were understandably frustrated by the lack of commitment from potential members.  I assume that the price increase will lead to studios receiving more money per class participant. But that being said, I am not a financial adviser for ClassPass and have no idea where their money is allocated.  

             I also recognize and appreciate that this model is not for everybody.  I have friends who like going to their one class, knowing it will be available to them week after week at the same time on the same day. My response is, "Hey, whatever works!" For me, however, ClassPass has filled a sizable void in my workout regime.  With my tendency towards exercise boredom, my fear of making choices by selecting one studio, and my inability to afford memberships at every studio, ClassPass is my fitness lifeline.  There certainly may be a day when all of this changes and my workout routine shifts in a completely different direction (and being somebody who suffers from chronic workout boredom, I may welcome this with open arms). Yet, until that day comes, you will find me shaking my tuchus to some Latin American jams, flying across imaginary terrains on my trusty spin bike or discovering some new workout to keep me motivated.  Now, the only thing left is for YOU to join me. Want $20 off your first month?  Click this link!http://class.ps/d11-0   Happy exercising! 

We 'Believe in Magic' at LWSS

At 46 years old, I crave Disney Magic as much as anyone.  I still vividly recall the effervescent energy of several cast members during a visit with my then fiancée, now wife Rachel, 20 yrs ago.  Their warm smiles and cheery voice coupled with an “I’d hug you if you were 10 and under” body language smoothed the path to a world of fairy tale and make believe.  One almost couldn’t help but ‘Believe in Magic’ after a close-up encounter with a cast member, whether street sweeper or manager.  I remember saying to Rachel, “How do they do it?  To a person, the energy is so positive, the commitment to the guest so genuine appearing, the willingness to serve…. they create a mood-elevating environment.” 

Soon after as I began working as a physician in a group private practice I learned about the Disney Institute.  My physician group hired a law firm to train us in principles similar to those taught at the Disney Institute or Ritz Carlton Leadership Center.  Their program taught us that 5 Star Service is never attained, but is always aspired.  The idea is that while you may deliver an experience that is “5 Star-esque,” there is always opportunity to do even better.

Our medical center, Lake Washington Sports & Spine, the professional business I started 4 years ago, operates on the principle of always striving to be 2% better.  And we operate on Positive Psychology principles, suggesting that in medicine we stand to learn much from the highest functioning among us.  Our mission is to “KPA” or keep people active.

The feedback we routinely receive reflects our intentions.  Our patients not only appreciate getting measurable results (i.e. returning to their desired physical activity) but they enjoy this improvement in a unique medical practice culture; for example, a live person, rather than automated phone tree, always answers the telephone, and we deliberately prioritize the patient over the population (as compared to large healthcare systems, the government or insurance industry), and we celebrate our patients’ recovery with a whimsical graduation ceremony.

My family and I just left Walt Disney World.  We spent one day in the Magic Kingdom, another in Epcot, and the final day at Animal Kingdom.  Unfortunately, it seems that Disney has misplaced the magic. 

How so?  Did the rides work well?  Yes.  Was the food adequate?  Yes.  Was the park clean.  Yes.  Were the attractions first rate?  Yes.  Well, what then?  Where was the Magic lost?

The cast members.

More specifically, Disney has allowed to disintegrate its culture of training excellence, and so this gives the customer the appearance that the magic was lost in the cast members.

Not present during our Disney visit were the routine and common interactions between guest and cast members that would elevate the mood, and so lighten one’s weary, having-stood-an-hour-in-a-line-to-enjoy-a-90-second-ride, feet.  During prior Disney visits, when the ‘magic’ was flowing, instead of heaviness or fatigue of one’s tootsies, one enjoyed a lightness of presence akin to being proverbially swept up by Alladin’s Magic Carpet.  Disney distinguished itself from other amusement parks based upon its service culture and ability to deliver a superior experience.  No longer.  Not for me or my family.  Walt would be disappointed. 

Specific examples of falling short you require?  As an extrovert and as someone with a keen ‘energy sensor,’ I routinely try and make eye contact and exchange greetings with those around me.  The Disney cast members would rarely make eye contact, their collective countenance was at best disinterested, and they rarely did exchange a big-hearted greeting.  Their energy was flat.  This energy was present in nearly all the staff I encountered.  In those staffing the rides, the attractions, the food courts/carts, and the custodial team.  The difference in animation of the Disney cast members was very clear.

I believe only once did a cast member approach one of my young children (ages 13, 10, and 6) and ask about their experience or try to engage them in a moment of Disney magic.  And this person was our handsomely paid private Disney tour guide. 

Did my family enjoy our days at Disney World?  Yes.  Walt Disney World states that they endeavor to help guests create memories that will last a lifetime.  I know my kids will remember their first backwards rollercoaster ride on Expedition Everest (I’m sure not a brainchild of Walt Disney).  Isn’t it backwards, however, that they may not know or remember in 20 years if that ride took place at Walt Disney World in Orlando or Six Flags Great Adventure in New Jersey?  Shouldn’t every child leave Walt Disney World with a love of Mickey Mouse and friends, asking for Mickey ears rather than a Star Wars light saber?  Perhaps the Magic has been lost to a new Walt Disney Company mission of earning dollars over earning lifelong raving fans?

My guess is that this is a top down leadership issue, and that the leaders of the company are more caught up with demonstrating profits to shareholders than they are interested in continuing Walt Disney’s passion for bringing the Magic to people’s lives.  A watered down mission dilutes the team culture very quickly.  The absence of cast member “Believe in Magic” enthusiasm is reflected in their quality of work.

Interestingly, we can draw parallels to what is happening right now in healthcare where the primary drive is to control costs, not care for people.  Government officials and insurance industry administrators and executives consistently invoke the buzzword “quality” in the same sentence when describing their aims of “expanding coverage and cost control.”  It is well understood that you can strive for two of three, but not all three, when speaking of accessible, high quality, and low cost health care.  Likewise, at least in days past, Disney rightly focused on two things:  providing excellent (high quality) staff training and customer experience, and ‘magical’ amusements and attractions.  And for this, they charged a premium.  The admission/ticket costs to spend a day in one of the Disney parks has always been expensive relative to other amusement parks, and now the price exceeds $100 per person per day.  Some have written articles about how Disney has priced out the middle class (https://www.washingtonpost.com/news/business/wp/2015/06/12/how-theme-parks-like-disney-world-left-the-middle-class-behind/). 

But just as healthcare systems have had to drop their focus on quality to focus on cost containment and access, Disney has dropped its focus on bringing out the ‘magic’ in each of its cast members through the once singular Disney training program, in order to concentrate on generating higher corporate profits. 

While I find this sad, my father-in-law shrugs it off, believing that all things are destined for change.  In our world of caring for active people, we see it as a glaring opportunity to serve a community of people who want and deserve excellent consultation with a wonderful team and top-notch physicians.  I suppose it does follow that Disney’s mediocrity merely makes room for the next magical visionary whose mission is our enchantment.  Perhaps that’s Elon Musk with SpaceX?  I’m sure the void in magical experiences will provide a ‘carpe diem’ moment for one so motivated entrepreneur.  And I, a self-described fairy tale fanatic, may be first in line.