Clinical Pearls From My 30 Years

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Dwight York
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1 Clinical Pearls From My 30 Years Michael C. Geraci, Jr., MD PT Medical Director, Owner, Geraci Spine and Sports Medicine Clinical Associate Professor Buffalo, School of Medicine and Biomedical Sciences Michigan State University, College of Osteopathic Medicine

2 I see nothing, I hear nothing, I have nothing to disclose

3 - This summarizes my view on my formal education

4 I m going to start and end with a quote from Sir William Osler Father of Modern Medicine

5 Philip E. Greenman, DO "People are down on what they are not up on"

7 Stuart M. McGill, PhD Where I learned my Spine Biomechanics Functional Anatomy

8 Biomechanics & Functional Anatomy McGill - Spine Biomechanist Disc Muscles and trabecular bone columns best shock absorbers less shock absorption than previously thought Disc anular tears result of micro-fractures of trabecular columns when axial loads are placed on the spine

9 Biomechanics & Functional Anatomy McGill - Spine Biomechanist Disc herniation > 25,000 flexions Primary Muscle Stabilizers: Quadratus lumborum Rectus abdominis, external obliques, internal obliques, and transverse abdominis Erector spinae

Scientific Evidence for Disc Reduction with an Extension Protocol 18 Porcine discs axially compressed and repeatedly flexed (flexion or 30 to SP) 11 discs: herniation occurred in opposite direction

10 Scientific Evidence for Disc Reduction with an Extension Protocol 18 Porcine discs axially compressed and repeatedly flexed (flexion or 30 to SP) 11 discs: herniation occurred in opposite direction along bending axis Reduction in 5 of 11 specimens with repeated extension Key characteristics of discs that reduced Maintenance of at least 70% of disc height Centrally located herniation Scannell JP McGill SM. Disc prolapse: evidence of reversal with repeated extension. Spine 2009;15;34(4):

11 Biomechanics & Functional Anatomy McGill SM. Low back Exercises: Evidence for Improving Exercise Regimens. Phys Ther. 1998;78: Motor control - most important factor in stabilizing the spine Sufficient stability - co-contraction of spine stabilizers Controlled by CNS when needed At a subconscious level 3-4% of MVIC for ADL s 10-20% of MVIC for sport/work/life-style activities

12 David Butler, B Phty, GDAMT, MAppSc, PT and Annie O Connor, MSPT, OCS, Cert.MDT Classify the type of pain a patient has

14 Classification of Pain 6 Basic Types Butler/O Connor 3 Peripheral Mechanisms Nociceptive Inflammatory Nociceptive Ischemic Peripheral Neurogenic 3 Central Mechanisms Central Sensitization Affective Autonomic/Motor

15 William Evans, PhD If you don t have time for exercise you better make time for pain Do you need another way to motivate patients to exercise? Physical Exercise help patients as they age maintain their cognitive function even more than mental exercises

16 Charles Aprill, MD "The only reason not to use contrast is because you don't want to know where you are"

17 Stanley Herring, MD

18 Stanley Herring, MD and William Osler, MD Very similar view on Dogma

19 Stanley Herring, MD "Don't let a poor outcome get in the way of a fun new procedure" Our last NASS mid-year meeting My fellow surgical course directors stated We no longer recommend Lumbar TDA Director or Charite Institute Berlin, Germany Stated 2/3 go on to auto-fuse

20 Gary Gray, PT Dumbbells are Smart Learn the 3-D function of muscles 3 Eccentric 3 Concentric

21 Henry vs Gary Gray Henry said G. Medius is a Hip Abductor Gary says G. Medius Eccentrically controls hip flexion, adduction and IR Concentrically controls hip extension, abduction and ER

22 Don't be confident about your ignorance General Guidelines Be careful about thinking you are an expert because you were asked to give a talk My general rule of thumb - take an equal number of courses as you are asked to give Physiatric Physical Exam We know orthopedic and neurologic exams well But what about the Physiatric PE=Functional Exam Learn how muscles function in 3-D 3 Eccentric functions 3 Concentric functions

23 Why would you sit all day at work or school then go to a gym and do seated weight machines and isolate muscles in a way you would never use them in real life? Sitting increases disc pressure over standing and are you really lifting anything seated?

25 Weight machines are better and safer than free-weights? A. True B. False Squat vs Seated Leg Press Testosterone increased 50% more in the squat Growth hormone increased 3 times as much in the squat These hormones are responsible for building muscle mass and burning body fat, showing that free weights have the advantage We can gain 140% more strength with free weights > machines Garber CE, et al: Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. American College of Sports Medicine. Medicine & Science in Sports & Exercise. 2011;43:1334.

26 Imaging is generally not very useful without an adequate H&P Incomes v Outcomes in your treatment We will be reimbursed soon based on outcomes Don't describe yourself by what you don't do Describe yourself as a medical spine specialist not a non-operative spine specialist

27 If it takes 25,000 repeated flexions to herniate a normal disc maybe it takes that many to fully reduce it? If so then it would take DP exercises q1h X 20 reps X 16 waking hours to get to 25,000 reps or about months once you are asymptomatic After that 10 reps BID and PRN shown to reduce recurrence rates to only 10% in the first year compared to 80% if these exercises are stopped

28 Regenerative Medicine Is there a role? Yes BUT

29 Exercise and Nutrition: David after a 20 city U.S. tour Which David would you rather treat?

30 Exercise vs This? 22 y/o w/normal imaging 28 y/o w/14 back surgeries

31 When in doubt I ask Joel, Ben, McGill or someone smarter than me

32 Here is what I told the 24 Fellows I had the privilege of training Be confident about what you know not cocky Realize you don t know it all and you never will Be a life-long learner until you retire and then still want more Don t be a slave to overhead Pass on what you know to your colleagues Always put the patient first Outcomes over Incomes Have fun everyday and love what you do or do something else

34 The End Thank you!

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