Parsteiner Blog

Archive for March, 2009

A startling 1 in 5 people over 65 who undergo hip fracture surgery will die within a year according to the Centers for Disease Control. Certainly, a fractured hip doesn’t kill outright – rather it’s the slow healing time that makes a person susceptible to other problems which cause death. We can trace the reason for death back to one thing: immobility. There are steps though that you can take to ensure the best outcome for your loved one.

Humans are not meant to be immobile for any prolonged period of time. When we are the following changes may occur:
Skin breakdown Pneumonia Muscle atrophy Depression

Let’s review the significance of each of the above problems.

1. The Hows and Whys of Skin Breakdown

Prolonged immobility leads to pressure ulcers. Indeed, very little pressure is needed before the blood supply to the area is compromised and tissue damage occurs. We measure pressure in millimeters of mercury (mm Hg) – the same measurement we use in blood pressure.

The pressure required for tissue damage to start is minimal (greater than 35 mm Hg for those who have blood pressure cuffs and want to try this out). This pressure decreases the blood supply to the tissue which then becomes starved for oxygen. The cell hemorrhages and then dies.

In order to know what 35 mm Hg pressure actually feels like, think of the pressure exerted on your arm when you have your blood pressure taken. Now 35 mm Hg is not the kind of pressure you feel when the cuff is fully inflated but rather the pressure that you feel when the cuff is just beginning to inflate after several pumps.

If you can’t remember what that feels like, that’s the point – it’s so minimal. So the next time you’re laying on the floor consider this: the pressure between your hip and a hard resting surface can exceed 300 mm Hg.

Post-operative patients have very limited mobility because of the effects of anesthesia, pain and weakness so they are not able to shift their weight around – things that we all do unconsciously thousands of time a day. That’s why frequent position changes, heel protectors, and skin hydration are all crucial during this period.

2. Pneumonia

When we are laid up in bed for several days, we don’t fully inflate our lungs nor are we able to easily cough and move secretions around. The tiny air sacs that are at the end of our bronchial tubes collapse when they are not properly inflated with air, a condition called “atelectasis”. After several days, bacteria can then build up and lead to pneumonia.

That’s why patients are encouraged to cough and deep breath after surgery especially because normal moving about is severely restricted. An incentive spriometer, a cylindrical device with a tube attached that the patient sucks on, is an inexpensive tool that encourages deep breathing and complete aeration of the lungs.

3. Muscle Atrophy

The process of healing after hip surgery is a long one involving physical therapy and a willingness on the individual to do the exercises. But the weeks of limited mobility lead to muscle atrophy, causing individuals to tire more quickly which then leads to greater limitations.

The hard work of physical therapy can not be underestimated even though the gains may seem so minimal at first. The goal during this intial post-op phase is to maintain muscle tone and strength in the face of limited activity. That’s why it is also important to make sure that pain medication is given before each session in order to maximize results.

4. Depression

Hip surgery is hard at any age but much more difficult on the elderly whose ability to bounce back quickly is diminished by a slower healing time. This combiined with the following, contribute to depression:
Loss of independence Fear of being placed in a nursing home Fear of further falls Discouragement because of the slow progress

In many cases, depression is accompanied by loss of appetite and poor sleep, both key components in insuring successful healing. The use of anti-depressants and nutritional supplements can help.

Because anti-depressants may take a while before their benefits are felt, be especially alert for the first signs of depression so that medication therapy can be intiated promptly. Be sure to seek out the help of the facility’s social work and pastoral care staff.

Individuals do heal from hip surgery and return to independent living but it requires interventions and cooperation from mutiple disciplines:
physical/occupational therapy nursing medicine social work dietary and finally, patients and families.

Focusing on these aspects of care will help maximize healing.

Traditionally, the method for early detection of this cancer was the digital rectal examination, in which the doctor introduced a finger into the rectum and could feel the prostate gland to see if there was suspicious nodules. In recent years, it can be a laboratory test: the detection of prostate specific antigen, called PSA. This test was initially introduced as a laboratory test for diagnosing and monitoring prostate problems and subsequently was proposed as early diagnostic test.

The PSA is a protein produced by cells of the prostate gland. Analysis of PSA measures the concentration in the blood. A sample of blood and is measured in the laboratory the amount of PSA that contains the sample. Because PSA is produced by the body and can be used to detect the disease, sometimes called a biological marker or tumor marker.

It is normal for men to have low levels of PSA in their blood, however, benign (not cancerous) may increase the concentration of PSA.

The PSA level alone does not provide enough information so that physicians can distinguish between benign prostate conditions and cancer. However, the doctor will take into account the outcome of this analysis to decide whether to investigate further for signs of prostate cancer.

The elevated PSA (above 4), may indicate a prostate cancer but may also indicate other conditions such as benign prostatic hyperplasia, or infection. Therefore, PSA can be considered a unique indicator of prostate cancer, but it is high, start a diagnostic process.

The recommendations of physicians regarding the screening vary. Some recommend annual screening tests for men over 50 years of age and some advise men who have a higher risk of prostate cancer to begin screening at 40 or 45 years old.

Several risk factors increase the chances that a man is suffering from prostate cancer. These factors may be considered when a doctor recommends screening. Age is the most common risk factor, since nearly 65 percent of prostate cancer cases occur in men 65 years of age or older. Other risk factors for prostate problems include race, family history and possibly diet.

I’m sure you have heard the term “Core Stability” banded around of late, especially with the way Pilates has become very popular over the last few years.

By the term ‘core’ we primarily, although not exclusively, refer to the lower back, pelvis & abdominal area. Any muscles which have an influence over these areas need to be assessed to ensure they are providing optimum core stability.

Muscle Imbalance.

Before I go any further however, I would like to explain my perception of core stability, as it may differ a little from others…

Rather than use the term core stability, I prefer the term “Muscle Imbalance” as I believe it is this which is the main cause of nearly all Low Back Pain & Sciatica problems.

If our lower back & pelvis are working in perfect harmony, the muscles will be playing the role of mobilizer (i.e. contracting and therefore allowing us to move our back) and stabilizer (i.e. providing the lower back with support & stability).

However, due to either the way we are born or habits we have developed over our lifetime, the muscles can become tight, weak or both.

Weakness:

Those muscles that become weak will not be able to provide the lower back and pelvis with the support it needs. This in turn will result in excess movement occurring across certain joints and soft tissues, potentially resulting in pain.

Tightness:

Those muscles that become too tight will be ‘pulling’ or ‘tugging’ on the structures they are attached to. This increased force will also be encouraging further movement across certain joints and soft tissues, once again potentially leading to pain.

Weakness & Tightness:

This is the worst case scenario. If there are weak muscles present, they will be unable to resist the natural stresses being placed across joints and soft tissue. However, if there are also tight muscles present, these will be placing abnormal increased loads across the same structures which cannot be supported properly due to the weak muscles present. This is a kind of ‘double whammy’ and is an almost certain recipe for pain.

The aim of treatment is to gently strengthen the weak muscles, while also stretching the tight muscles.

The most common muscles responsible for problems in this area are the Piriformis & Hamstring muscles (which are typically tight) and the Abdominals and Multifidus muscles (which are typically weak). However, this is not an exclusive list and there are other muscles which can become either tight or weak and therefore contribute to Low Back Pain or Sciatica.

Nearly all Low Back Pain and Sciatica suffered is a result of muscle imbalance, be it tight muscles, weak muscles or a combination of the two. However, if you know what to look out for and also what to do, there is no reason why these painful conditions cannot be resolved.

If you address any muscle imbalances present related to your lower back and pelvis, this area will regain the strength and stability it needs to function correctly with no pain at all.

It was strange in both of these instances that my Grandfather, who is about the same age as my father-in-law, and my father-in-law both outlived their wives. Statistically this isn’t usually the case. My father-in-law was doing fairly well living independently until he had a series of falls and couldn’t stay alone any longer. At fist he was hospitalized as he was recuperating from hip surgery and then came the tough part of deciding what to do for him.

We decided to have him go to an assisted living facility in Utah for rehabilitation after surgery. This worked quite well and the family was able to visit him on a regular basis. The only problem we had was that he stopped eating. We couldn’t be sure if it was depression or if the food wasn’t very good. The staff was supportive and kind and in all ways accommodating. We decided to try another senior living center in Utah by where his children all live, and found a facility more to his liking. Again, we were impressed with the compassionate care afforded him. It made it a fun outing for our children to go visit grandpa with the fish tanks, roaming dogs and cats and bird cages.

My grandfather lives in Arizona, so at the same time we were searching for an assisted living center in Arizona to fit his needs. He is less independent than my father-in-law so an assisted living center in Arizona fit the bill better than a senior living center. Often you have to shop around a little and find the one that fits your needs. There are fantastic centers to compassionately care for our parents and grandparents if they need short of long term care, sometimes I think three cooked meals a day and constant activities along with housecleaning services wouldn’t be such a bad thing after all.

Spinal stenosis is a condition where for a variety of reasons the spinal canal becomes more narrow. This narrowing can put additional pressure and compression on the spinal cord and can cause a pinching of the nerve roots. If the narrowing is in the lower part of spinal cord it is referred to as lumbar spinal stenosis and if the narrowing is in the upper part of the spinal cord then it is referred to as cervical spinal stenosis. While stenosis can also occur in the thoracic or upper back region, the lumbar and cervical areas are the most common.

Who Gets Spinal Stenosis?

While some people are born with stenosis, most of the time spinal stenosis is seen in people over the age of 50 who already have some disc degeneration just as a consequence of getting older as well as the gradual wearing down on the spine from normal activities. As we get older, our spinal ligaments can calcify, bone spurs may form, and we can get herniated or ruptured discs. All these conditions can lead to a narrowing of the spinal canal which can compress and pinch the spinal nerves.

Spinal Stenosis Symptoms

Symptoms of spinal stenosis can include back pain radiating to the legs, numbness or pain in the buttocks that worsen when walking or exercising, leg weakness, decreased physical endurance, loss of balance, and leg and neck pain.

Spinal Stenosis Treatments

In general doctors tend to take a conservative approach when initially treating spinal stenosis. Drug therapy such as pain relievers and anti-inflammatory medications to reduce swelling are usually prescribed first, along with bed rest and reduced physical activity. Steroid injections can also be use to help reduce swelling although the pain relief is normally temporary.

Traction and spinal decompression may be prescribed, along with physical therapy which can be used to help increase flexibility as well as build endurance.

If the pain is acute, then surgery may be needed in order to widen the spinal canal and to correct the conditions that are contributing to the nerve compression.

Some of the surgical procedures used to treat spinal stenosis are:

Decompressive laminectomy. This is used for treating lumbar spinal stenosis and involves removing the top of the vertebra to create more space for the nerves.

Laminotomy. This is a partial removal of the lamina which can be done to widen the spinal canal and relieve compression on the nerve roots.

Foraminotomy. Removal of bone, scar tissue, or other obstructions that are compressing the nerve root exiting the spinal canal.

Due to the risks involved, many doctors will resort to surgical treatments only after non-surgical treatments have been tried first.

This article is not meant to replace the sound advice of a personal physician. Patients should discuss with their doctor all their treatment options before taking any medical course of action.

The problem with low back pain & Sciatica, is that the lower back itself and surrounding area is so important with regards to any movement or activity you become involved in. It is not like when you have injured an arm or a leg, where you can rest the arm in a sling or use some crutches for your leg in order to allow healing to take place, with low back pain you are not afforded that luxury.

With regards to functional activities, the first thing which needs to be addressed is to divide them into two categories:

i) Those which cause or aggravate your low back pain or Sciatica.

ii) Those which cause you no pain or do not increase your pain at all.

The chances are that there is a common factor linking the components of each of these two groups.

For example, let’s say sitting down aggravates your low back pain yet keeping upright and a small amount of walking eases your pain. We are going to be thinking along the lines of flexion activities being the aggravating factor for your low back pain and extension type activities being the easing factor.

With this above example, first and foremost we need to modify or temporarily avoid the aggravating factor i.e. sitting down. Now I am not suggesting you do not sit down at all during the day, but rather you try and sit in a more upright chair, with say a rolled up towel for some support for your lower back. In addition to this, I would also recommend that you spend no longer than a maximum of 15 – 20 minutes sitting down without break i.e. getting up out of the chair.

Moving on to encouraging the easing factors, and once again using the above example, I would suggest you try to have a little walk a few times during the day. This can be anything from a few minutes to say 20 or 30 minutes. The important thing is your low back likes this activity and therefore it is important to provide it with it, as it will be providing you low back with the optimum conditions for it to heal itself.

NB You can get too much of a good thing, therefore do not just walk for the sake of it. For example, if your low back pain eases after 5 minutes walking, but becomes aggravated after 15 minutes, feel free to walk for 5 minutes, but not too much longer, otherwise you will be simply interfering with the healing process again. With regards to aggravating and easing factors, it is important to be as specific as possible. Therefore in the example I have just given, walking for 5 minutes is an easing factor, yet walking for 15 minutes is an aggravating factor.

The main principle is little and often throughout the day. Tying in the above two, the logical thing to do with regards to sitting, is every 15 minutes or so stand yourself up and have a walk up and down the living room. By taking on board the above principle, it will result in less stress being placed across the structures responsible for your low back pain and therefore give your body a chance to heal them. As they heal, they will become stronger, and if they are stronger you will find you can begin to do more and more.

A positive cycle will result, whereby encouraging the easing factors will promote more healing, which itself will result in your low back becoming stronger and therefore less easily aggravated. If it is less aggravated, it means more healing will take place and therefore you can become more active and your back will become stronger…. and so on.

Sound too simple?

Well there is no doubt I have simplified things a little just to highlight a point. However, it is not too difficult either as the underlying principle is the same. The all important aspect is firstly analysing your day to day activities and working out which are the aggravating and which are the easing ones. When you have established this, begin by temporarily avoiding / modifying the aggravating activities and encouraging the easing ones. As you do this, your low back pain or Sciatica will begin to ease and you will be able to become more active.

At this stage, it will be important to consider addressing any muscle imbalances which are present (as it will almost be certain there are some). A simple but effective exercise programme to strengthen any weak muscles and stretch any tight ones will soon have you returning to those functional activities you are finding difficult at the moment.