Medicine Delivered at the Speed of Sound!

Dr Colliver & Crew after finishing up some Ultrasound training

Dr Colliver & Crew after finishing up some Ultrasound training

Last week was busy with several after-work activities.  One of these evenings was spent with Blacksburg Physical Therapy, reviewing musculoskeletal ultrasound.  But first, I should explain that I have known this amazing group longer than any other physical therapy group, and they have always impressed me.  For example, when a patient has a particularly difficult time in rehabilitation, we will do a “co-visit”- which is when the physician and the physical therapist meet the patient together and review the rehab plan. Also, we have done training together on Postural Restoration Institute courses and practiced Manual Medicine together.  So when they asked me to come review Musculoskeletal Ultrasound, of course I said YES!

At first, I went over my standard spiel on examination of the shoulder.  But that quickly devolved and soon everyone was looking at everyone else’s various musculoskeletal oddities, like the distal biceps pain of the professional powerlifter.  This group quickly figured out how Ultrasound is very efficient, diagnostic, and has lots of applications in the therapy setting.  This allows us to quickly evaluate shoulder pain; but also, foot, ankle, knee, hip, elbow, wrist and hand pain.

In this world of instant social media, selfies, Tweets, etc, musculoskeletal ultrasound allows the physician and patient to instantly see what inside the body looks like and how it reacts with motion.  MRI can’t even do the things that Ultrasound can!  But it does take a lot of training; and as the leading musculoskeletal ultrasound physician in the New River Valley, I feel excited to introduce this approach to as many providers who could benefit from this technology.

Thanks again, Blacksburg Physical Therapy, for a great evening.  Keep practicing.

 

Good Luck!

Valley Sports & Spine Clinic Giving you Back your Life

Dr Ethan Colliver


Where will the next generation of Physicians come from?

emg2The Practice of Medicine has alwaVCOM students practicing nerve conduction studies on each otherys been a blend of science and art.  Medical school lays the foundations for the science portion; however, the art comes from the guidance given by established physicians. In fact, you graduate medical school with a Medical Degree but cannot practice medicine until you do an internship where you train under the tutelage of an Attending Physician.

 
VCOM students practicing nerve conduction studies on each other

 

This week I helped the Physical Medical & Rehabilitation club at Edward Via College of Osteopathic Medicine learn about electrodiagnostic medicine.  This is a group VCOM medical students who have a particular interest in learning about physiatry. Electrodiagnostics include nerve conduction studies and electromyography and all physiatrists learn how to perform them over the course of 3-4 years of training. We discussed  how these studies can help patients with sciatica, carpal tunnel syndrome, neck pain, low back pain, peripheral neuropathy, myasthenia gravis, or myopathy.

After some didactics, I even had a brave volunteer allow us to practice on her so that everyone could see how to perform and interpret these studies!  I was so impressed with the students genuine interest and thoughtful questions.  By the end, all students were able to practice zapping their friends.  This experience will give the students empathy and insight for when they are faced with ordering this test for a patient in the future.

I am fortunate and privileged  to have interested students I can guide along the path to Physician.  Thank you VCOM PM&R club!

 

 

Good Luck!

Valley Sports & Spine Clinic Giving you Back your Life

Dr Ethan Colliver

 


Top 7 Rants on Exercise

In general, I will say that movement is good.  For example, if all you can do is walk 20 minutes a day at lunch, then that is better than not exercising at all.  However, in my experience, I have heard a lot of excuses or false reasonings on why someone having a musculoskeletal problem doesn’t need advice on exercise.

  1. “I don’t need to work out because I work hard at my job.”  Exercise is different than work.  At work, you are focused on completing a task.  You don’t have the time to focus on how you move or what muscles you are using.  Exercise is when you can focus on yourself, how you move, and what muscles you are using.
  2. “I don’t have time to workout.”  The American College of Sports Medicine recommends 1.5 hours of exercise a week.  There are 168 hours in a week.  That is less than 1% of hours available in a week.  This is the equivalent of a little over 20 minutes a day.  That could be a lunch break at work, before work (my preference), or a family walk after dinner.
  3.  “I can’t afford a gym membership.”  Did cavemen have a gym?  No.  I am a huge believer that exercise should be accessible to everyone.  That is why I design exercises that can be done without extensive exercise equipment.  Walking and running is free.  So are pushups, burpees, step-ups, etc.  In fact, if you have a chair, you can exercise most major muscle groups with this article.  
  4. “Exercise machines are better and safer.”  This myth came out of the thought that exercise machines can isolate muscle groups are strengthen them more efficiently without increasing your risk of injury.  In fact, most experts now propose functional exercise (exercise that emulates the way that we move in real life) because we do not do tasks with a single muscle group.  We need to train muscle groups to work together so that when we do a demanding activity in real life, the muscles have “seen” this similar movement during exercise and can say “oh yeah, I know how to do this”, and get the job done.  Also, exercise machines do not decrease the risk of injury.  In fact, many machine exercises put the person in a sitting position which is known to put excessive stress on the spine and increase your risk of injury.
  5. “NO PAIN, NO GAIN!”  THIS IS THE WORST! This myth comes from the idea that it must hurt to break down muscles in order to build stronger muscle.  First, although exercising muscle to fatigue can accelerate the build up of new muscle, given adequate recovery time, however, pain is not the same thing as fatigue.  I know of no research that shows pain is needed to build muscle.  Second, this gives the exerciser the false expectation that they must feel pain in order to get stronger.  In fact, pain can be a warning sign that you are injuring tissue, like a disc in your spine; and when patients are new to exercise, they are often times afraid of pain (who isn’t?) and so hearing this oft quoted phrase scares them away from the much need rehabilitative exercise program that will help them, ironically, out of their pain.
  6. “Physical therapy doesn’t work for me.”  This myth often comes from past experiences when patients have experienced physical therapy only involving electrical stimulation, TENs stimulation, therapeutic ultrasound, heat packs, ice packs, etc. This feels good temporarily but wears off after you remove the treatment. We call this “Shake & Bake” shops.  None of these treatments do anything for chronic low back pain and if a clinic is only offering this, that is a warning sign that you need to find a new clinic.  Physical therapy is great for showing a patient how to start an exercise program that works on increasing your flexibility and strength, without increasing pain.  If you have difficulty, they can show you ways to personalize exercises for you.  They may utilize some modalities (listed above), along with massage, manipulation, traction, etc, but all this is geared towards helping you tolerated rehabilitation exercise.  In short, who treats you is more important than what they treat you with.
  7. “Just give me a list of exercises to do.” For the most part, no exercise program is dramatically better than another, especially today when there are so many options: pilates, yoga, CrossFit, P90X, Zumba, etc.  Research shows that none of these programs are more risky at causing injury than another program.  However, I view exercise programs as tools. Some tools work better for some jobs than others. Furthermore, not all exercise programs are good for everyone.  For example, when you have an injury, you need to find the right exercise that works for you; this often takes some trial and error to find an exercise that targets the right muscles without causing pain (see #5).  That is why a standard exercise sheet doesn’t work, especially in people recovering from an injury.

Well, that is enough ranting for now.

Good Luck!

Valley Sports & Spine Clinic
Giving you Back your Life

Dr Ethan Colliver

 

 


Muscle & Bone Health in Aging

The muscle and bone systems are constantly changing and reacting throughout our lives; and the effects are different for men and women, but remarkably similar. Both muscle and bone will undergo a normal decline as we age; somewhere around the age of 25 in men.  Muscles lose strength and power for various reasons:

1. muscles lose mass: there is a decrease in muscle fiber size and a decrease in muscle fiber quantity, starting at the age of 25, due to decreases in estrogen, testosterone, and Insulin-like Growth Factor-1 (IGF-1).
2. loss of motor units: the number of motor nerves that innervate muscle cells decreases
3. less muscle protein synthesis
4. loss of aerobic capacity: this is multifactorial in itself
5. loss of synchronization of the firing of motor units: also, multifactorial, such as with prior sciataca or disc herniation

Bones lose mass as we age because of several reasons:
1. loss of sensitivity of bones to muscle: loss of testosterone, IGF-1, and estrogen decreases bone response to mechanical stimulation by muscles and result in loss of muscle mass.
2. loss of muscle mass, area, and strength: due to loss of IGF-1, estrogen, and testosterone and this loss of muscle can also decrease the stimulation on bones.
3. increased bone resorption: due to loss of estrogen and testosterone

You can counteract this decline in bone and muscle health with strength and endurance training. Regular strenuous exercise (20-60min, 3-5 days/week)increases muscle strength and power, aerobic capacity, and bone density. Currently, no medications are approved for the treatment of muscle loss that occurs with aging and some treatments, including testosterone, can have dangerous side effects. For bone loss, exercise can increase the stimulation on bones by muscles and improve power and balance to decrease your risk of falls. Many medications exist for treating thin bones, including testosterone in men, but it appears that exercise can be as effective and both treatments should be implemented.

If you are concerned about your bone and muscle health, you should check with your doctor to see if an underlying medical condition is present, or if this a natural process with aging. Your doctor may prescribe medications and exercise to treat your issues.

Good Luck!

Valley Sports & Spine Clinic
Giving you Back your Life

Dr Ethan Colliver

 



Ouch! My Neck Hurts!

Bicycling is a great non-impact sport that can be enjoyed by many, no matter the age.  I have been an avid bicyclist since I was a resident physician at the University of Utah.  When I started commuting to work, my low back pain improved, as did my overall health and endurance.  I loved the alone time and the beautiful scenery I would otherwise  miss if I drove to work.

After a few years I developed neck pain.  I tried switching bikes and used a bike rack instead of a backpack, but to no avail.  Neck pain is a common complaint

for bicyclists and affects up to 50% of regular cyclists.

When you ride a traditional bike, the rider leans forward to grasp the handlebars and this increases the kyphosis (or flexion) of lumbar and thoracic spine and hyperextends the neck.  This results in overloading of the small joints in the neck and the paraspinal muscles that hold the head up.  Hyperextension of the neck can also cause pinching of the nerves from the neck to the arms, thereby causing arm pain, numbness, and tingling.  If a rider has poor midback flexibility and strength, then the upper neck muscles (upper trapezius, levator scapulae, scalenes, sternocleidomastoid) can become overactive and put additional stress on the neck.  Dr. Janda, a renowned neurologist, referred to this as “upper crossed syndrome”.

Treatment must address appropriate exercise and proper bike fitting.  Cross-training is essential to work on antagonistic muscles and movements to oppose the sustained posture of bicycling. In my case, I should have strengthened my deep neck flexors and mid-back muscles and worked on flexibility of the anterior and upper neck muscles.

I recently took advantage of a professional bike fitting service at a local bike shop, East Coasters.  I saw a dramatic difference in my posture and neck pain while on my bike immediately after the fitting.  At East Coasters, the athlete is carefully measured and examined while on a bike in order to ensure proper seat height, arm elevation and reach, and other factors.

Neck pain that lasts more than a month or results from trauma should be a red flag to go see a doctor for further evaluation.  Severe cases may require a neck injection, manipulation, or even surgical consultation.

Good Luck!

Valley Sports & Spine Clinic

Giving you Back your Life

Dr. Ethan Colliver

 

 

 


Knee Pain

The knee is the largest joint in the human body.  It is often described as a hinge joint.  However, the knee not only bends back and forth like a hinge, it has a rotational component that occurs with flexion and extension.  The knee is composed of ligaments, muscle, tendons, and cartilage.  The femur (thigh bone) and the tibia (shin bone) are separated by medial and lateral meniscus.  These tough cartilaginous meniscuses act as shock absorbers and cushion the knee during every day activities.   The ligaments provide stability to the joint and help control movement of the knee.  See illustration below for further detail.


At some point in our lives, we will likely experience knee pain. Every day wear and tear on this heavy, weight-bearing joint can precipitate pain.  Also, injury to any of the structures mentioned above can also be a culprit.  Many things can predispose an individual to having knee problems, such as age, gender, excess weight, lack of muscle flexibility and strength, certain sports, previous injury, certain occupations, infections, etc.  The aforementioned risk factors can lead to osteoarthritis.  This condition is wear and tear of the cushioning cartilage (meniscus) of the knee.  When this occurs, the femur and tibia begin to rub against one another during movement, creating friction in the joint.  The friction creates pain, swelling, stiffness, and can even cause bone spurring.  According to the Arthritis Foundation, more than 27 million people in the U.S. have osteoarthritis, with the knee being one of the most affected areas.  By 2030, an estimated 67 million Americans ages 18 years or older are projected to have doctor-diagnosed arthritis.  Diagnosis of OA of the knee can be obtained by physical exam from your doctor, along with x-rays of your knees.  X-rays show bone and cartilage damage as well as presence of bone spurs.
Treatment of osteoarthritis consists of weight loss, physical therapy, pain relievers, steroid injections, visco-supplementation (Synvisc, Supartz, Euflexxa), and surgery. Valley Sports & Spine Clinic offers multiple treatment modalities.  One in particular is sterile, ultrasound guided joint injections.  Using ultrasound allows the provider to visualize the joint space and inject the steroid or visco-supplement (Synvisc, Supartz, and Euflexxa) directly into the joint.  Studies show that trained Orthopedic Doctors will miss placing an injection into the joint space 17-18% of the time; Ultrasound allows for 100% accuracy.   Below is an illustration of ultrasound, with visualization of the needle tip directly into the joint space.

knee US

A more recent option called  Radiofrequency Ablation involves blocking the nerves that transmit sensation from the pain, thereby blocking pain.

The main goal is to reduce pain and help patients return to their everyday activities.  To help them regain their quality of life, and enjoy doing the things they love most.

 

Good Luck!

Valley Sports & Spine Clinic
Giving you Back your Life
Holly Williams, PA

 

 

 

 

 

 


Your back hurts… because of your ankle!

No, I am not disregarding the earlier post about toilets. Let me explain. After my freshman year in college, I worked as a housepainter for two weeks. That career choice came to a screeching halt after I fell off a roof and shattered multiple bones including my left ankle. I now have a very stiff, arthritic ankle. It doesn’t even dorsiflex to neutral. In my twenties, I began having back pain and didn’t know why. I was sedentary but thin and very busy with my medical training.  I eventually realized that I had a lumbar disc herniation with occasional right leg pain. Why?

Disc herniations  happen when you have excessive flexion or twisting through a disc.  We bend over more than a thousand times a day which requires squatting.  Squatting requires full hip flexion, knee flexion, and ankle dorsiflexion.  The picture below shows a natural full squat with a lot of ankle dorsiflexion.

lady squattingNotice her degree of ankle dorsiflexion. Also, note how upright her lumbar spine is.  Her upper body is leaning on her thighs thus taking the stress off the lumbar spine which is in essence “hanging” from  her thoracic spine and not taking any significant torque.

Below is an example of a Western squat, in which the person comes up on their toes in order to get down.

Note her degree of ankle dorsiflexion.  Also, note how perpendicular her spine is to being upright.  This creates more torque on the lumbar discs than the upright posture and thus more stress on the discs.

I believe taking the weight off the heels leads to increased calf muscle activity, which leads to hamstring overactivity and inhibition of the hip muscles (ie- gluts), which lead to overactivity of lumbar paraspinal muscles and increased stress on lumbar spine.  This aligns with the work of the great Neurologist, Dr Janda.

 

 

In the above picture on the left, lack of ankle flexibility prevents her from squatting further.  If she squats further with same angle in her ankle, then she will have to lean back and thus lose her balance (also, her lumbar spine is now more parallel to the ground and thus more stressed).  In the picture on the right, having a lift under her heels allows her to keep her center of balance forward (and her lumbar spine more upright) and do a deeper squat.  This is a happier lumbar spine!

In short, healthy backs require full range of motion and strength of the whole chain.  From the lumbar spine, pelvis, hips, knees, ankles and feet.  When you have back pain, the whole system must be assessed.  The back pain is often a result of a problem elsewhere in the chain.

Good Luck!

Valley Sports & Spine Clinic
Giving you Back your Life
Dr. Ethan Colliver

 


Avoid this dangerous drug!

The World Health Organization has posted guidelines on sugar consumption since 2002. In their guidelines, they recommend limiting sugar to less than 10% of your calories and those who limit sugar to less than 5% get even more benefits. For most, that means we shouldn’t have more than 25 grams.

WHO guidelines

I am traveling to an Advanced Ultrasound course and picked up a processed package consisting of crackers, dried fruit, jerky, cheese, and almonds for dinner and it alone had a whopping 29 GRAMS of SUGAR!

that’s means I have already blown my sugar intake for the day. Humans have lived over hundreds of thousands of years without processed sugars, meaning our sugars mainly came from our fruits and vegetables.

How can we meet these guidelines? The easiest is to make your own food! That does not have to be fancy. Reach for carrots or apples for a snack. Don’t reach for something from a package.

Good Luck!

 


What is the True Value of a Physician?

 

Have you ever thought about how your Physician is unique?  Have you ever thought about how much training goes into making a Physician?  In my case, it is about 14 years… some physicians take even longer.  It is remarkable to think that there is a group of people in society who will wait so long on beginning their career and families so that they gain so much training.  And trust me, it is a good thing… you want the brightest, most dedicated people working on your health. However, Medicine is rapidly changing.  Physicians are losing compensation yearly and have little voice in current discussions about Healthcare policy in Washington.  Do you think, at this rate, that Medicine will continue to attract the best and brightest if they continually look at decreasing compensation and control; or will current bright physicians stay in their current positions?

If you want to read more on this discussion, please read this insightful article: Value

Sincerely,
Ethan Colliver, DO