August 2, 2014

Slow Gait Predictor of Cognitive Decline?

Motoric cognitive risk syndrome (MCR) is a newly developed diagnosis that incorporates cognitive symptoms without dementia and slow gait or impaired mobility. Analysis of data from 26,802 older adults indicates that decreased scores on standardized cognitive tests and a walking speed 1 deviation below norm for a persons age and sex, may be predictive of cognitive decline, such as Alzheimer's Disease.

Along with simple cognitive tests, analysis of gait speed using a stopwatch to time an individual walking over a fixed distance, has the potential to predict risk for cognitive impairment more than 3 years out.

Gait speed has a common metric, high reliability between different protocols, and excellent validity in predicting health outcomes, he noted. And, unlike neuropsychological, laboratory, and imaging tests that can detect predementia syndromes, gait speed testing is readily available and practical in most settings.

This means simple screening tests could be performed in third world countries and first world country poverty settings where resources are limited. It's simple and does not have to be administered by a doctor and be done in wide variety of settings, further keeping costs down. This would allow clinicians to identify high risk individuals and flag them for further investigation.

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July 6, 2014

Fitness an Indicator of Cardiovascular Risk

Fitness can be used to indicate cardiovascular risk in the long term, according to new research. The Cooper Center Longitudinal study used treadmill testing along with cholesterol, triglycerides, glucose level, personal history and smoking habits during a physical exam to determine an individuals risk for cardiovascular disease in 30 years.

As expected, traditional risk factors including age, systolic blood pressure, body-mass index (BMI), diabetes, total cholesterol, and smoking were associated with increased risk of CVD death.

But when data took into account the level of fitness, the importance of HDL associated with long-term cardiovascular risk fell away.

Take home message: We're designed to walk, and it doesn't take much to improve fitness. Just three 10 minute walks daily at a brisk pace can add years to your life.

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June 29, 2014

A Thorough Chart Review

A thorough chart review is a must before seeing patients.

A 95-year-old woman with a diagnosis of Transient Ischemic Attack was recently admitted to our acute in-patient rehabilitation ward. She was on my list for an initial evaluation. I collected a quick history, reviewed her lab values, and checked her imaging studies, such as radiographs (x-rays), CT scan, MRI. Her imaging study revealed that, indeed, she had a recent CVA (cerebral vascular accident or stroke) in the right parietal lobe of her brain. Other information was included in the imaging report, so I scanned it quickly and came up short. Included in the report was "a C1 subluxation relative to the dens."

C1 subluxation on dens is a red flag. What is means is that the very top vertebra in the neck has slid forward on the second vertebra indicating an instability in the top part of the neck. This is very dangerous situation because the spinal canal is narrowed, the supporting structure is unstable, and a wrong move could either paralyze the patient from the neck down requiring life support or instantly kill them.

I searched in the clinical notes for the MD response to this problem. It was not addressed in the problem list, nor was the imaging study flagged by the reading radiology department as critical. I checked with the nurse to see if the patient had a neck brace; she did not. I sounded the alarm to my colleagues, my bosses, the nurse manager, the on-duty physician's assistant. The patient was immediately put on hold, then transferred to medicine.

As a clinician, I always worry that I'm going to miss something important. With this patient, I caught something important. Later consultations with the neurology department found that the subluxation was extremely small and that the patient was stable enough for treatment.

Those of us in the medical field are said to "practice" medicine. Practice, practice, practice. Eventually, with experience, we become good at what we do.

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May 13, 2014

Schroth Method For Scoliosis

I was intrigued when I saw this article concerning scoliosis and treatment that would correct spinal curvature, even in some patients whose scoliosis has matured and stabilized. Not only did I have several adult massage clients with scoliosis, but I have a (very) small scoliotic curve in my thoracic spine. Each client required a different massage protocol to address their unique curvature pattern.

In a quest to help them, I researched websites, one of which even recommended nutritional support for scoliosis. I believe I have an old blog post outlining my efforts. In PT school, most of the focus on scoliosis was in treatment of children. So when I found the Schroth Method, something looked familiar from a resource I found in PT school. I remember wondering "what existing equipment available in a pediatric rehab gym would simulate the wall bars, and immediately thought of the True Stretch cage.

In my own case, my small thoracic curvature creates a rotation through my thorax toward my left side. This causes my right scapula to "wing" slightly. Functionally, I'm not really affected by my curvature, however, I do have some chronic neck pain. My right shoulder sits higher than my left, and I usually get neck pain on my right side. I've finally figured out a series of exercises to manage my neck pain, involving scapular retraction, anterior neck strengthening, and sternal lifts for postural improvement.

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May 1, 2014

Spinal Cord Stimulator Helps 4 Paralyzed Men Move

On vacation a couple of weeks ago, a free copy of USA Today had a headline that jumped out at me (proving that just because you're on vacation doesn't mean you really stop working): Spinal Cord Stimulator Helps 4 Paralyzed Men Move Again.

Most spinal cord injuries (SCIs) these days are partial, thanks to advances in early intervention following trauma that reduces swelling around tender nerves. This allows some electrical signals to travel up and down the nerves of the spine. But many older injuries resulted in total paralysis of the lower limbs which prevents any movement much less walking.

But new research has revealed that with stimulation, nerve signals can be dialed up to "loud" enough levels that the brain can communicate with the lower limbs. Don't break out your sneakers yet. The four men who have been participants in the research have achieved miraculous things such as voluntary movement, standing, and with body weight support, walking on a treadmill.

But the most exciting finding is in one patient who had total lack of movement and sensation:

Other impairments caused by Summers’ injury also began to improve over time, in the absence of stimulation, such as blood pressure control, body temperature regulation, bladder control, and sexual function.

The reason this is so exciting is that it a side-effect of paralysis is a phenomenon called autonomic dysreflexia that can be life threatening. What happens: an noxious stimulation below the site of injury such as a full bladder, undetected injury, uncomfortable position genitalia, will send signals via the autonomic nervous system pathways up to the brain. The brain will respond with fight or flight signals in an effort to correct the situation, but the signal never gets below the site of injury and a correction of the problem is not achieved. Distress signals continue to be sent up the system and overload can result in respiratory distress, shock, and even death.

As physical therapists, we are trained to recognize these signals of distress and train the paraplegic to recognize them too. Then we systematically search for a cause and try to correct the situation. For this reason, scheduled bladder emptying is crucial for SCI patients. The results of this research are profound for SCI and paralysis recovery.

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April 30, 2014

3-D "Osteoid" Cast

The future of broken bones is looking cooler, and, well, less itchy and smelly! Industrial designer Deniz Karasahin has developed a 3-D printed cast, which has holes that allow for ventilation and includes a low-intensity ultrasound generator to help bones heal more quickly.

Still in the development stages, Michael Hausman MD at Mount Sinai Hospital, thinks the cast has promise. Pulsed ultrasound, research shows, is found to reduce healing time by 38% and is especially useful to aid healing of non-union fractures by 80%. How cool is that?

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April 26, 2014

Healthy Eating I Can Get Behind

I love chocolate. Sometimes, it's all that gets me through the day. I love to give chocolate and I love to receive chocolate. I should wear a sign: "Will massage for chocolate."

I am a bit picky about my chocolate, though. I prefer dark. M&Ms give me a sore throat - I don't know what's going on there. In my opinion, the darker the chocolate, the better, up to a point. It can get sour and bitter beyond 80% cacao. Schafenburger makes an excellent chocolate bar with cocoa nibs that add a bit of crunch. The workhorse in my chocolate repertoire is Lindt 85%. I will eat Dove bites, though they are a bit sweeter; they are not as waxy as other chocolates in their price point.

And now there's even more reasons to eat chocolate. It's good for you and now science is getting closer to understanding why. According to new findings from Virginia Tech and Louisiana State University, gut bacteria in the colon breaks down cocoa into small metabolites that, when absorbed, reduce cardiac inflammation. Undigested cocoa in the gut also ferments and releases substances that reduce cholesterol.

Another health-giving twist to this entire process: The gut microbes that digested the cocoa were desirable probiotics like lactobacillus. Their numbers appeared to increase after the introduction of the cocoa, while less-salutary microbes like staphylococcus declined in number.

The best way to get the health benefits of cocoa: forget the candy, go for a couple of tablespoons of straight unsweetened cocoa powder in oatmeal or on ice cream (in moderation).

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April 20, 2014

Rewire The Brain With Mindfulness

If you've been looking for updated material on Fingertips, I must apologize. Life circumstances have made it so that blogging regularly has been more difficult for me lately than in the past.

You may recall, my 10 year old feline was diagnosed with chronic kidneys disease this past fall. Because of that, my morning routine, in which I used to peruse and blog about health and wellness articles, has changed. My morning routine is now occupied with administering medications, encouraging eating, and, when necessary, trips to the vet for subcutaneous fluids.

Also, at my work, we transitioned to 10 hour work days. Coming home from work in the dark has shortened my evenings and put dinner later, which makes blogging less enticing.

And finally, in January, I began again, a drawing series, which has fed my spiritual side in ways that have yielded surprising benefits to my health and well-being. I recently found a related article about Mindfulness in the journal The Week. According to functional MRIs, brain rewiring takes only 27 minutes a day of mindfulness or meditation. And that restructuring serves to reduce electrical activity and blood flow to the amygdala, the brain center responsible for "fight or flight" emotions. It may not be traditional meditation, but I believe that creating art is having a similar effect on my brain.

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November 26, 2013

Prognosis Following a Fall

It is not new that falls among the elderly are dangerous and can lead to life changing disability. The statistics are frightening: 1 in 3 people over age 65 will fall each year. Fall prevention has been a huge initiative from the federal government since the 1990s. A quick rundown of their suggestions for prevention:
1) physical activity, especially exercise
2) with your doctor's assistance, reduced the number of medications your take
3) get regular vision checks and make sure stairs and hallways are well lit
4) prevent fall risks at home by removing throw rugs, installing grab bars/railings in bathrooms, hallways, and stairwells.

I participated in a fall prevention clinic when I did an internship at the VA in Birmingham, AL. It was one of the most exciting and rewarding activities during my training. Today, I work at an in-patient facility, evaluating patients every week. One of the questions we ask is, "have you fallen in the past 2 months?" and if so, "how many times." If the answer is "yes," we evaluate patients' fall risk using the Tinetti Balance Assessment tool.

Many falls among the elderly go unreported, especially if they do not result in injury. Many who fall end up in rehab with me because of a resulting hip fracture or head injury. So, what predicts a full recovery or lasting disability in the elderly following a fall incident? New York Times' Paula Span tackles this question in The New Old Age.

The answer to that question is multifactoral. From a physical therapy perspective, prior level of function plays a huge part in predicting recovery from a fall injury. The higher the function prior to an accident, the more likely we'll be able to return that patient to function. Another factor is a patient's medical conditions. If a patient is found to have a progressive or terminal illness, then their prognosis will likely decline over time. The nature of the injury plays an important role: hip fractures are more difficult to recover from than other injuries sustained from a fall.

The probability of recovering diminished with increasing disability before the fall. Among those with moderate disabilities, only a third recovered within a year. And “if you start off severely disabled, you’re not going to get that rapid or even gradual recovery.”

So, the results of this research begs a question: How will these findings impact health care policy in the context of health care reform? As health care budgets tighten, does it make sense to spend large quantities of money on the care of people whose positive outcome has diminishing returns? As health care dollars diminish, do we begin to pick and choose who is treated with aggressive rehabilitation? What would you choose if it was your mother?

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November 22, 2013

Discovery of New Knee Ligament

Anatomists in Belgium have reported the discovery of a new knee ligament. Actually, it's been there all along, even documented by a guy back in 1879 wrote about it, but it's so small that got buried under a pile of new anatomical discoveries until now.

It's called the anteriolateral ligament. It sits at the front of the knee toward the outside. It attaches to the femur superiorly at the lateral collateral ligament attachment and distally to the tibia lateral to Gerty's tubercle. It acts to stabilize the outer part of the knee, preventing it from collapsing inward.

And here's why it important. It reinforces the actions of the ACL - the anterior cruciate ligament. This ligament is probably most famous for the injurious tear that results from slowing down suddenly to change direction or pivot with the foot firmly planted, twisting or hyperextending the knee.

Positioned at the front of the knee, it (the ALL) would be vulnerable to tearing when an A.C.L. was injured; the same forces would move through both ligaments.

For those who have had an ACL repair and appear to be healthy but continue to experience knee instability or buckling, the ALL may be the culprit. Based upon the research of Drs. Claes and Bellemans, ALL repair may help ACL repairs restore full stability and function to the affected knee. Further research needs to be conducted to find out if this ligament can actually heal.

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November 18, 2013

How Posture Affects Your Brain

I don't know about you, but I grew up hearing things such as "stand up straight," meaning chest out, shoulders back. The resulting "military pose" was uncomfortable and hard to maintain. But it turns out that all those parents and teachers were on to something about the importance of posture.

I could speak volumes about the importance of balanced posture for functional mobility including the ability to lift our arms to improving standing balance, oxygenating the body and lubricating, or at least improving blood flow, to body organs. From an appearance standpoint, correcting a slouched posture can take years off of a person's appearance, magically transforming the decrepit looking elder into the vital individual they once must have been.

Now it turns out that science backs up the promotion of a balanced posture with surprising conclusions about it's impact on how we think and feel. LifeHacker discusses how posture affects opinion, mood, and even hormone production. They give tips for how to achieve better posture and emphasize that posture is a dynamic process, always changing because we are living, moving beings.

For me, I work on posture with myself and my patients every day. Too many directives for correcting posture is like exercise: too many and none of them will be followed. So I tell folks (myself included) simply lift your sternum (breast bone) toward the ceiling. This can be done when sitting or standing. It serves to activate the paraspinal muscles of the lower thoracic spine (the muscles on either side of the back bone on your lower rib cage). This serves to draw the shoulders back and aligns the head over the spine, requiring much less effort than the military pose we were taught as kids.

Give it a try. You'll see how much easier it is to breathe and you may even feel improved blood flow into your head.

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October 7, 2013

Chronic Kidney Disease (CKD)

As I settled into the seat next to my husband, he said, "the vet called back with the test results." Neko Case was playing that night at Radio City Music Hall and we named our first cat after her. We now have an answer as to why our cat lost 3 and 1/2 pounds in a couple of months. He has chronic kidney disease Stage 4.

Kidney disease in felines shares much in common with chronic kidney disease in human beings. Upon his diagnosis, I gave myself a crash course in kidney anatomy and physiology, lab values, and disease staging. We have more tests to conduct to try to figure out why he developed this terminal disease.

What we do know is that he tested negative for feline HIV/AIDs and feline Leukemia, both to which can result in kidney failure. He has also been cleared of a bacterial infection. Usually, cats with this condition have anemia, but he does not test positive for that yet, which may mean something else, such as kidney cancer. His next appointment with the vet will be for ultrasound. Hopefully, at that appointment, they will be able to check his blood pressure (which I am doubtful will be accurate unless they can calm him down). Hypertension in cats is another common side effect of CKD.

What we have done so far, is change our cats' diet to a renal veterinarian formula that is low in protein and phosphorus. He likes it so far, but he wants to eat the gravy and leave the meat. Also, Pepcid for nausea and prevention of mouth sores - we have seen no vomiting since we changed his food. And, subcutaneous fluids, which the vet has taught me to administer, with a needle. We've both managed that pretty well - thankfully, that is every other day for now. Also, I have found Helen Fitzsimons' website called Tanya's Comprehensive Guide to Feline Chronic Kidney Disease immeasurably helpful with the day in and day out support and details regarding the care and treatment of this condition in my cat.

It is possible that Neko's lab values will improve with treatment. BUN stands for blood urea nitrogen which measures nitrogen in the blood that is a natural by-product of protein breakdown. Creatinine is a by-product of muscle breakdown and these numbers usually appear elevated together in CKD cats (and people). What this means is that filtering capacity of the kidneys is diminished and unable to remove toxins from the blood so the animal is making diluted urine. Common symptoms include increased thirst with urine output, which, oddly, results in dehydration. Subcutaneous fluids absorb more efficiently through the tissue than drinking water, and result in improved hydration and detoxification of the body.

So far, treatments are going well and I can tell he is feeling better. I have a feeling it may be a matter of time before bribing him with food will no longer be adequate distraction from administration of subcutaneous fluids. Luckily, the whole thing takes only 5 minutes. My fear is that he will tire of the new food and we'll have to stand on our heads to get him to eat. For now, we won't invent any problems and will take one day at a time.

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