Haus of Physical Therapy

Constipation #2 part C

2010-04-10T18:40:00.000-07:00

ARE YOU CONSTIPATED

Functional constipation

If you meet two or more of these symptoms for more than 12 weeks you may have functional constipation.

- straining during 25% of bowel movements
- lumpy or hard stools in 25% of bowel movements
- sensation of anorectal obstruction/blockage during bowel movement
- manual maneuvers to facilitate bowel movement
- fewer than 3 bowel movements per week

25% of the time is not that much. More of you may be suffering than you think. If you have two or more of these symptoms see your family physical therapist and ask what they can do for you. Or your medical doctor, but be sure to ask if physical therapy using biofeedback is an option. Remember constipation is usually a symptom. It indicates something is not working the way it should. So work with your MD to figure out what is causing the symptoms of constipation.

Table below lists different medications that affect bowel motility.

PHYSICAL THERAPY’S ROLE IN CONSTIPATION MANAGEMENT

What’s my PT doing down there…I thought PT’s only treated joints?

True having a bowel movement doesn’t involve joints, but it does involve muscles. A PT’s area of expertise is retraining motor control and coordination. The profession is so much more than strength training muscles; it’s about making changes at a cortical level. Bet ya didn’t think your physical therapist could get inside your head now did ya…

Who should treat you?

Not every PT is an expert in pelvic floor disorders. You will have to research a bit and find a physical therapist specializing in the pelvic floor. PT’s specializing in pelvic floor and/or women’s/men’s health treat both incontinence and constipation.

WHAT IS ANISMUS / PUBORECTALIS DYSSYNERGIA AND WHAT DOES THE PELVIC FLOOR HAVE TO DO WITH IT.

Pelvic floor dysfunction related to constipation includes anismus also called puborectalis dyssynergia. This is the inability to relax the external anal sphincter and pelvic floor muscles (puborectalis) during defecation.¹

Normal:

Rectal contraction à relaxed pelvic floor à bowel movement.

Normally, when the rectal vault contracts the fecal mass moves toward the exit. The pelvic floor muscles and external anal sphincter will subsequently relax allowing for a smooth evacuation.

Puborectalis Dyssynergia:

Rectal contraction à pelvic floor contraction à lots of straining little to no bowel movement

Abnormal muscle coordination as with puborectalis dyssynergia both the rectal vault and the pelvic floor muscles tense up. The end result is a very difficult straining bowel movement, if one even occurs. This is different from slow transit constipation that was discussed in previous constipation posts.

INTERVENTIONS: HOW CAN PHYSICAL THERAPY HELP

The main physical therapy goal with puborectalis dyssynergia is teaching you how to relax the puborectalis muscle when the rectal vault is contracting.

How exactly is this done...?

Physical therapy intervention includes EMG biofeedback, balloon biofeedback, and manual biofeedback.² EMG biofeedback can be a surface electrode that measures the electrical activity within a muscle. If the muscle contracts a signal is registered by the machine. This is a very sensitive and objective measure of muscle activity. Internal balloons are exactly what you think they are, balloons expanding within the rectal vault. This mimics the fecal mass by causing a stretch response/contraction of the rectal vault. Manual biofeedback is the good ol’ hands-on…I mean ‘hands-in’ approach. Manual biofeedback is great because the PT can get a lot of information about what exactly is going on up in there. Problem, the relaxing of the patient’s puborectalis while their PT’s finger is all up in the backside…is not so easy.

More interventions

Interventions include positional training, such as different ways to sit on the toilet. Yes, there IS more than one way to sit on a toilet. These positions stretch the pelvic floor muscles, making it more difficult and less likely for an inappropriate contraction of the pelvic floor muscles to occur. After reviewing the descriptions of the positional techniques they have some mild similarities to old-school/Chinese/Indian style of squatting. While sitting on the toilet place feet on a stool, so feet are higher than pelvis then lean forward and grab ankles.

I happened upon this website which explains the benefits of squatting during evacuation. I tried it one morning balancing my feet across the toilet seat. I have to say the only straining I experienced was my poor feet clinging to the toilet seat. The website raises some interesting and logical points in support of squatting over the traditional toilet sit. I’m not going to advise you either way, but on mornings when I feel more dexterous I’ll be squatting. Check it out benefits of squatting and evactuation.

Abdominal massage can help with bowel motility. When performed everyday for 10-20 minutes abdominal massage appears to improve bowel motility. However, the studies reporting this had small sample sizes. There are no negative side effects to gentle abdominal massage, but this should not be done if you have a known bowel obstruction or had abdominal surgery within the last 6 weeks.³ Each circle should take 1 minute to complete.

DON’T STRAIN, HUFF YOUR FECAL MASS TOWARD EVACUATION

Excessive straining during a bowel movement will have deleterious effects on you, if not today at some point in your future. Straining can increase intracranial pressure. Remember the patient admitted to the hospital due to stroke like symptoms after straining on the toilet. Straining increases intra-abdominal pressure, leading to hemorrhoids. Hemorrhoids come in two varieties internal and external. And really, if you had to choose why would you pass up the option for external anal accessories. Take those external anal hemorrhoids from freaky to fabulous with a little glitter (joke don’t actually do this). The other problem caused by straining is hiatial hernias hiatial hernias. Increased intra-abdominal pressure from straining pushes the esophageal-gastric junction out of the abdomen above the diaphragm. This leads to a weakened lower esophageal sphincter, which allows stomach acid to flow up the esophagus. Hello heartburn.

You can avoid all this by replacing your strain with a huff.³ A huff is easy. Inhale as much as you can then hold it 1 second. Instead of straining perform a forced exhale contracting your abdominals and making a “huff” sound. Repeat as needed, but remember to take a few regular breaths in between your “huffing.”

EASE UP ON THE LAXATIVES

Constipation and chronic use of laxatives is highly correlated to colon cancer.

PT TREATMENT OUTCOMES.

PT intervention for puborectalis dyssynergia actually improves quality of life scores and decreases symptoms.² People treated by physical therapists continued to report improvements in symptoms a year after their last PT appointment. They report more frequent stools, decreased laxative use, and decreased assistance. I’m not sure what they meant by assistance maybe a neighbor, a friend, a stranger in the next stall over…who knows. People who are constipated are also very motivated when it comes to treatment. Motivation may be another component explaining the favorable outcomes in many of these research studies. Motivated people adhere to their prescribed therapy protocol, which usually leads to the desired outcome.^{2, 4}

Does your state have a bowel control program…Michigan does!

“Since 2004, the Michigan bowel control program, a multidisciplinary program for the treatments of pelvic floor and bowel disorders, has been enrolling patient with chronic constipation into a standardized database.”²

It’s not just Michigan, there is an international panel of experts meeting annually to discuss constipation and issue recommendations.

1. McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma MG. Pathophysiology of constipation in the older adult. World J Gastroenterol. May 7 2008;14(17):2631-2638.

2. Lewicky-Gaupp C, Morgan DM, Chey WD, Muellerleile P, Fenner DE. Successful physical therapy for constipation related to puborectalis dyssynergia improves symptom severity and quality of life. Dis Colon Rectum. Nov 2008;51(11):1686-1691.

3. Harrington KL, Haskvitz EM. Managing a patient's constipation with physical therapy. Phys Ther. Nov 2006;86(11):1511-1519.

4. Battaglia E, Serra AM, Buonafede G, et al. Long-term study on the effects of visual biofeedback and muscle training as a therapeutic modality in pelvic floor dyssynergia and slow-transit constipation. Dis Colon Rectum. Jan 2004;47(1):90-95.

COMIC SERIES - Passover and Easter weekend

2010-04-03T10:09:00.000-07:00

Constipation #2 part B

2010-04-03T08:50:00.000-07:00

TREATMENTS

Well there are many - like eating more fiber, laxatives, fiber supplements, vacuum cleaner attachments (joking do not hook a vacuum up to your rear end). Or if you’re lactose intolerant like me cow’s milk is another productive way to speed up your bowel transit time. But, there exists a far tastier option with no side effects.

RYE BREAD = REGULARITY

No joke, 7 pieces of whole grain rye bread is more effective for relieving constipation than laxatives! What is it about rye that’s so wonderful? It’s the affinity large intestine bacteria have for rye, specifically Arabinoxylan a chemical in rye, which ends up creating lots of short chain fatty acids (SCFA).

SCFA’s are the love children of unabsorbed carbohydrates (rye) and large intestine bacteria. Rye and bacteria meet just beyond the ileo-ecal valve (foyer of the large intestine) have a brief, but passionate affair then seconds later…SCFA’s.

Take home…

Not all carbs are created equally, and apparently bacteria seem to prefer whole grains, beans, and rye. Rye most of all. So eat more whole grains, beans, and RYE, and you’ll produce more SCFA’s.³ More SCFA’s = higher acidity in the colon. More acidic colon = happy colon. Besides rye bread has kept my Czech/Austrian grandma dancing and 'regular' for 80 some years.

Want to understand the Recto-anal reflex, then read this section

Fecal matter is stored in the sigmoid colon. Movement of the fecal mass toward evacuation is due to a series of reflexes. Once stretch receptors in the sigmoid colon reach the ‘critical filling level’ the smooth muscle contracts. This leads to an emptying of the sigmoid colon and a filling of the rectum.¹ The sigmoid-anal inhibitory reflex causes the rectum to dilate in order to accept the incoming fecal mass. As the fecal mass continues to distend the rectum, the rectum sends an excitatory signal to the sigmoid colon to keep contracting. This is the ano-sigmoid excitatory reflex, and it is responsible for the complete emptying of the sigmoid colon. Recto-anal reflex occurs when the rectal vault is distended to it's critical filling level causing a contraction of the rectal smooth muscle and a relaxation of the internal anal sphincter.² At this point you'll have a strong urge to find a bathroom.

Can I store things in my rectal vault?

Absolutely, you can store stool. I do not recommend using the rectal vault to store anything else beside stool. Valuables, small animals, pool balls, vegetables, etc... are best kept elsewhere like in the safety deposit box, a terrarium, pool table, fridge etc…

Still constipated after trying rye and other treatments. Try digital stirring of the rectal vault.

Sticking a finger or finger like (lubricated) object up the back end and moving around in a gentle circular direction causes the rectum to stretch (distend). The rectum reflexively responds with a contraction.¹ The concept is similar to when the doctor taps your knee (patellar tendon) and the leg kicks out. The contraction in the rectum likewise causes a contraction up the large intestine (sigmoid-anal inhibitory. anal sigmoid excitatory, and recto-anal reflex).² This essentially stimulates the last portion of the GI tract to move that stubborn fecal mass towards successful evacuation.

If you’re doing this on a patient "TALK BEFORE TOUCH!"

SEX AND THE CITY WINNER IS…

Miranda Hobbs!

Why?

Miranda: Child birth can cause the pelvic floor muscles to freak out (more on incontinence in another blog) also Miranda seems very uncomfortable by other people’s fecal evacuation in front of her - Season 4 her fling Doug…remember? Further more Miranda has a hard time relaxing…high stress…lower quality of life score…possibly due to constipation.

Why not the others…

Carrie: Back in season 2 while dating Big, she announces to the girls that the relationship is getting serious because she has started to leave things at Big’s apartment, including her morning #2. No more running back home early morning.

Charlotte: Poor charlotte has had bad luck with food poisoning twice - season 6 from bad Chinese food with Harry, and her trip to Mexico the famous Poo-kipsy. Charlotte may have an overactive GI tract.

Samantha: Not one for much anal talk; however, Samantha is adventurous and would be more than willing to perform digital stirring of her rectal vault if need be.

If you still want more...

The physiology of fecal evacuation in a healthy person.

Oralsville to Analdale Water parks and Recreation.

Let’s GPS the trip

Start: Oralsville – Masticate (chew) bolus (food) 10 seconds turn south towards upper esophageal sphincter.

Merge: Enter esophagus keep to the right of trachea. The voluntary action of swallowing switches to involuntary smooth muscle contractions (peristalsis) taking bolus down esophagus. At this point just go with the flow. Bolus approaches the lower esophageal sphincter/ cardiac sphincter about 6 seconds.

-malfunctions in the cardiac sphincter lead to gastro esophageal reflux disease GERD…Heart burn-

Merge: Pass lower esophageal/cardiac sphincter to enter the stomach, after about 2 – 4 hours of churning continue towards Pyloric sphincter.

Continue: Pass Pyloric sphincter see sign on right ‘Welcome to the Small Intestine Duodenum Glen straight ahead.' Merge with bile and pancreatic juice. Continue for 20 feet. Estimated travel time 5 hours through small intestine. Pass ‘Jejunum Grove’ and ‘Ileum Heights’ stop at Ilio-Cecal valve.

Stop: Ilio-Cecal valve break. Bolus is about to leave small Intestine and enter the large intestine. This is land strewn with bacteria drive carefully.

Continue: Pass appendix to the south, continue route along ‘Cecum.’

Continue: Take the ‘Cecum’ towards ‘Colon County’ follow scenic loop (passing ascending, transverse, and descending colon) around to ‘Sigmoid Brook.’ About 5 – 6 hours.

Rest stop: Sigmoid Brook, sit and wait for other digested food to arrive. The bolus now turned fecal mass will stretch the Sigmoid colon past the critical filling level stimulating a contraction of the sigmoid colon.

Continue: Quickly move from the contracting ‘Sigmoid Brook’ to ‘Rectum Grove.’

Continue: The rapid rectal filling and stretch of the rectal vault causes a similar muscle contraction to occur. The ultimate response is the urge to poop followed by the relaxing of the internal anal sphincter.

Continue: head south towards Internal anal sphincter may come across roadblock. External anal sphincter closed

-external anal sphincter is voluntarily controlled…good thing!-

Continue: Prairie dog through external anal sphincter.

END: End at the famous Analdale Water Park. Have fun!

What’s next…

Find out what your physical therapist can do for constipation? Why is it bad to strain/force a bowel movement, and what exactly is anismus (I did not just make that up)?

Thanks for reading Haus of Physical Therapy. Please comment and subscribe!

1. Shafik A. A study of the effect of distension of the rectosigmoid junction on the rectum and anal canal with evidence of a rectosigmoid-rectal reflex. J Surg Res. Mar 1999;82(1):73-77.

2. Shafik A, El-Sibai O, Ahmed I. Role of the sigmoid colon in the defecation mechanism with evidence of sigmoido-anal inhibitory and ano-sigmoid excitatory reflex. Front Biosci. Oct 1 2001;6:B25-29.

3. Holma R, Hongisto SM, Saxelin M, Korpela R. Constipation is relieved more by rye bread than wheat bread or laxatives without increased adverse gastrointestinal effects. J Nutr. Mar 2010;140(3):534-541.

4. McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma MG. Pathophysiology of constipation in the older adult. World J Gastroenterol. May 7 2008;14(17):2631-2638.

http://healthrevelations.com/2010/03/04/laxatives/

*The actual physiology of digestion and fecal evacuation is way more complex than this, but this is a decent abbreviated play-by-play synopsis. Plus I’m not a GI specialist, just a simple PT student curious about most things.

Constipation #2 part A

2010-03-29T21:52:00.000-07:00

The Numbers.

Constipation is estimated to affect around 25% of the western world’s population. In the hospital the numbers seem more like 90%. Everyone is constipated in the hospital, and everyone feels the need to talk about it.

Case 1: “Hi I’m Justin from Physical therapy”

“Oh I don’t want to get up, I just got back into bed from the commode”

Patient gestures to the commode behind me, which presently looks more like a work of tortured modern art than assistive medical equipment. Honestly I’m intrigued. How did she manage to get such fluid graffiti like coverage?

Patient states she hasn’t had a bowel movement in 7 days. 7 days! OMG. She’s been overdosing on stool softeners and finally on the 8^th day the rectal gates opened, Alleluia-praise-Jesus-Christ-almighty, she moved her bowels and perhaps some internal organs, 7 times in one day. As to why nobody called for a priest/chaplain is still beyond me.

Case 2: Patient is in hospital for knee replacement. He goes home only to return a week later for stroke like symptoms at the time of admission. Taking his history the following day it turns out he was straining on the toilet because he hadn’t had a bowel movement since before he was admitted the first time. That’s 9 days ago!

Anything more than 2 days for me is uncomfortable, so I seriously cannot imagine what it must feel like to have a weeks worth of fecal matter all up inside you. Not surprisingly research reports that constipated people consistently score lower on the quality of life scale than those with regular bowel movements. So no wonder they want to talk about it. If someone you know talks about their constipation be supportive, they are feeling very uncomfortable, and need to talk about it. Currently, there is no constipation hotline, but if there was it should be 1-800-CLOGGED1 or something similar.

MYTHS

“Sorry Granny you’re just going to have to deal with it. You’re old and that’s just what happens.”

You don’t have to resign yourself to a life of stalled bowels just because you’re old. Constipation is NOT a natural part of ageing.¹ The factors affecting bowel mobility are chronic diseases, increased medications, dietary changes, and possibly inactivity these are usually associated with old age, but definitely not exclusive to the elderly. Young people get constipated too. Age alone is not a reason for constipation or prune juice. In fact healthy older adults have similar bowel transit times to young people. Meaning the commute from Oral-ville to Anal-dale takes approximately the same amount of time in both grandpa and junior. Weather forecast in Oralville, a balmy 98.6 degrees this Tuesday morning.

I guess I just need to be more active

Well of course you need to be more active, EVERYONE needs to be more active. But…increased activity is NOT related to constipation. WHAT!???!!! Yes multiple studies have shown that there really isn’t a relationship between constipation and how active you are.² I know, I’m still in disbelief, but we all know science isn’t flawed (kidding). In all seriousness though, many studies have looked at the prevalence of constipation within non-active and active groups, and the conclusion is pretty consistent that activity doesn’t have a significant effect.

For those of you still shocked by this earth shattering news here are some benefits of exercise for constipation.

(1) Activity may decrease the overall transit time, but still doesn’t decrease the occurrence of constipation.

(2) Active 'constipated' people score higher on quality of life tests. So although activity won’t alleviate constipation it will at least make you a happy constipated person.²

“Yes, I’m still constipated. but thanks to exercise I’d now describe myself as Pleasantly Constipated”

Sex and the City

Knowing that roughly 1 and 4 people are constipated, and that women more than men suffer from constipation, which Sex and the City Character do you think suffers most from constipation? Please comment and give a reason.

Carrie

Samantha

Charlotte

Miranda

Quizzes by Quibblo.com

WHAT’S NEXT?

What are treatments for constipation, how exactly does this bowel transit system work, what is the rectal vault - can I keep valuables there, what exactly is digital rectal stirring, as well as my answer to the SATC quiz next posting.

Thanks for stopping by Haus of Physical Therapy for a read!

1. McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma MG. Pathophysiology of constipation in the older adult. World J Gastroenterol. May 7 2008;14(17):2631-2638.

2. Tuteja AK, Talley NJ, Joos SK, Woehl JV, Hickam DH. Is constipation associated with decreased physical activity in normally active subjects? Am J Gastroenterol. Jan 2005;100(1):124-129.

Acute care clinical pearls of wisdom.

2010-03-28T22:39:00.000-07:00

How to keep patients’ fluids off of you.

People in the hospital don’t feel well, and the risk for an unintentional encounter with a patient’s bodily fluids is high. How can you protect yourself as a health care practitioner, a visiting friend, or a family member?

Nausea.

First of all you should be aware of some common causes of nausea in the hospital

- Coming off of anesthesia and/or side effects of other meds

o So watch out especially if the patient has just had surgery

- Drop in blood pressure with sitting after laying in bed for a day or two

- Eating a big meal or drinking

o Retching on an empty stomach is like bluffing in cards

- Strenuous activity with a Physical Therapist (evil PT)

- Feeling ill

- Anxiety related to moving,

- have more…please comment and I’ll add (as long as appropriate)

Ask early and ask often…

Asking a patient whether or not they are nauseated is one of the most important questions I ask in my interview, and again multiple times during my treatment. Maybe I’m over doing it, but I haven’t been hurled on yet. If I’m within target range I start asking, “Are you feeling nauseated?” When I move a patient into a different position, get them standing, walk them, tighten the gait belt around their waist, or do any activity that contracts the abdominals I ask. I never assume a patient will tell me they are nauseated.

Are you feeling nauseated?

If the answer is NO. Continue what you’re doing, but realize the status can always change, so ask early and ask often.

If the answer is YES. This doesn’t mean you have to run out of the room in horror with your hands over your head. You just need to get in Vomit Ready Mode. (1) get the equipment you’ll need such as a clean towel and two vomit buckets (always have a back up), and make sure you keep these items within arms reach. (2) Don’t stand in front of the patient. Consider guarding safely from the side, and be ready to move out of the way with reflexive speed at the first sign of retching, and uh...don’t drop the patient.

If a patient starts to retch, heave, or say, “Oh mercy, I’m going to be sick,” do NOT take these physical and verbal warnings for granted. Immediately jump into Vomit Ready Mode! I recommend holding the bucket for them. These are sick weak people, trust me the last thing you want is a spill. This also means you’re going to have to look…gross…I know, but again you don’t want anything spilling. Plus, you have to monitor the patient, rub their back, and comfort them. In addition to being gross and uncomfortable for all parties involved never let a patient apologize for vomiting and do your best to mitigate any feelings of embarrassment. After all, besides your mom and maybe your former best friend, how many people have you hurled in front of?

Vomiting is like an earthquake after shocks are likely.

Once the heaving has commenced make sure the patient is safe, then empty and clean the vomit bucket in bathroom. If you need to, this would be an appropriate time to vomit yourself. Return with clean equipment and continue treatment. Continue to ask often and be prepared to move into Vomit Ready Mode. You seriously can’t let your guard down, or else you will be the one changing into the extra set of scrubs.

Is vomiting still productive PT treatment time?

Absolutely!

Okay so claiming you educated a patient on proper hurling techniques, and billing insurance for skilled care is a bit of a stretch. But, hurling is definitely productive. At the motor control (muscular) level the patient is actively contracting their abdominal muscles and pelvic floor muscles, supporting themselves in a seated position, holding their head upright, and helping to hold the vomit bucket. Clearly vomiting is a complex task requiring cortical (brain) level coordination and dual processing. At a sensory level vomiting sends a shock of sensation throughout the body. Nothing wakes up the peripheral sensory system like a good puke.

Vomit Ready Mode in action

This past weekend after prematurely celebrating 3 weeks in acute care without getting any patient related fluids on me I had the opportunity to help a patient hurl. And just to make sure she was clear on proper hurling mechanics we practiced it a second time near the end of my treatment. Now how is that for patient education. Considering I didn’t have to give any verbal or tactile cueing the second time I would say my intervention was successful.

Next blog, thankful for regular bowl movements. That’s right it is all about constipation, which is arguably the hottest topic in the hospital. I’m going to discuss myths, causes, and treatments.

Thank you for taking a moment to read Haus of Physical Therapy.

Mild Traumatic Brain Injury = Concussion

2010-03-21T14:11:00.000-07:00

You’ve probably noticed that concussion is a hot topic right now [SIZZLE]. It's been all over CNN, if you attended the combined sections meeting (it’s a PT thang) there was a 2 hour all section meeting devoted to it, and there is oodles of research being conducted on concussion and mild traumatic brain injury. Why and why should you care?

Well the NFL wants you to care; at least retired NFL players want you to care. Retired football players are coming out together claiming they are suffering from depression, memory loss, dementia, and other symptoms related to head trauma sustained when they played pro-football 10, 20, 30, years ago. This could be true. Certainly there is substantial research showing that head trauma leads to these disorders, but there is also a lot of research showing that head trauma affects adolescence and young kids more so than adults. Assuming that most of these retired pro-football players played football competitively long before signing their first contract with the NFL, how can they be so certain their early onset of memory loss and depression is from their time with the NFL, and not from the years of football playing prior.

What I’m getting at is they are filing workman’s compensation claims, and I believe winning them. I honestly think it’s great. I’m all for people being taken care of, but where does it stop? If you’re reading this blog maybe you’re working a desk job sitting in poor posture. In 10 years after you retire will you be allowed to file workman’s comp for neck pain or intractable low back pain? I have yet to hear of a former dancer receiving workman’s compensation years after retirement for new hips, spinal fusion, or knee replacements. What about factory workers doing heavy lifting? How long does workman’s compensation cover someone for? Please enlighten me.

With any profession I believe most people are aware of the risks involved. For example, as a former ballet dancer I was very aware of the long term risks of dancing: bad hips, bad back, bad knees, bad feet, bad neck, going crazy from the MAD artistic world, but I did it because I loved it. Does this mean I too can get workman’s compensation from the companies I danced for when I need a new hip? Who’s to say my future injuries won’t be due to bad training I had prior to dancing professionally or due to my natural genetic make-up.

Please don’t misinterpret this. I do care about anyone who is suffering from early onset of dementia, memory loss, or depression these are awful diseases. It IS tragic for anyone to have taken their own life especially due to complications with repeated head trauma, but I argue that NFL players had to be aware of the risks involved and if they are winning workman’s compensation then shouldn’t a whole bunch of us be able to get in line for our checks too?

HUFF…

The Brightside of all this publicity is money for research about concussions, lots of money. So if you care to learn more about concussions or what tools you can use to screen for them please continue on. Please comment what is your take on the whole thing? I want to discuss this.

If you do decide to read further you’ll learn there is testing that can be done on athletes or anyone really as a screening tool. Companies are most likely going to a high school near you to perform these screenings on athletes for a $fee$. What do these tests tell us…they provide a more objective measure to help decide when it’s appropriate for an athlete to return to play post concussion. However, it still doesn’t change the fact that repeated mild head trauma has long-term severe effects on the brain with or without paying to have these tests done.

The good news all this education has made PT’s better equipped to treat and help lessen the severity of concussions. Again I invite you to read on, and learn how your family PT can help.

Had a bad day?

…sometimes

Frustrated?

…occasionally

Want to bang your head against the wall?

NO!

Regardless of how bad things get always treat you brain well. You don’t want to cause a mild traumatic brain injury (MTBI).

What is a concussion/MTBI exactly and how does it happen.

All the cells in the brain are filled with ions, for the non-scientists/medical peeps this is a throw back to chemistry class ala periodic table. The movement of ions in and out of the neuron is carefully controlled by a Na+/K+ pump. This all requires energy delivered from the blood usually in the form of glucose broken down into ATP (major energy source for cells). Neurons are very organized excreting certain chemicals absorbing others by way of the Na+/K+ pump. In many ways the brain is a happy “normal” healthy society of neurons. All the neurons have a specific job to release and absorb these chemicals in response to the release of chemicals by other neighboring neurons. The whole process is very controlled and so complex it’s still not fully understood.

Move ahead to traumatic blow to the head, which doesn’t have to be just a blunt object to the head; it can be a rapidly decelerating head causing the brain to crash into the interior of the skull (whiplash perhaps). Anyways, all the happily functioning brain cells involved in the crash get the chemicals, ions, etc knocked out of them. Meaning there is a flood of free floating chemicals in the brain. The near empty neurons go to work right away cleaning up the mess, and try to get whatever was shaken out of the cell back inside by using the Na+/K+ pump. This pump requires a lot of energy to do this clean up work, and work requires food (ATP). Our cells usually use glucose, so the obvious solution is getting more glucose to the area. Somebody call FEMA: flooded neurons need supplies. Unfortunately, there is a small problem: glucose is transported through the blood and with external trauma to the head there can be up to a 50% decrease in blood flow.¹ Decreased supply, huge demand (there are a lot of hungry cells) = huge problem. How long can this imbalance last? Well, reports say up to 2-4 weeks post-head bumping/brain to skull collision.¹ Interestingly, this imbalance is seen in people who experience a loss of consciousness and those that have no symptoms.³ The imbalance can cause a loss of consciousness, dysfunctional memory, confusion, reflexive changes, disorientation, dizziness, headache, visual disturbances, and a host of other symptoms.^1-3 Congratulations, you now know and understand the neuro-cascade.

General thought for concussion recovery is that it will resolve within 7-10 days. But more often than not people return to normal activities after just a few days if they take any time off at all. So what…right? Well, there are many reasons why the actual recommendations for concussion recovery aren’t usually followed (official guidelines provided at end of blog):

(1) it doesn’t show up on an MRI/CT scan so therefore it doesn’t really exist, (2) symptoms are mild and everyone feels them differently or not at all, (3) it’s only a big deal if there is a loss of consciousness, and a concussion isn’t thought to be a big deal.

Okay let’s see the results on a CT scan or MRI…

Imaging like CT scans and MRI’s often don’t show anything abnormal^{2, 3} because concussions are metabolic in nature. Remember, it’s the intracellular chemicals that were shaken out of cells and CTs/MRIs don’t pick this up. An imaging system that can pick up metabolites is needed. Fortunately, there exists such a thing: magnetic resonance spectroscopy (MRS). According to a recent study, MRS may just be the imaging system for the job. Halleluiah! Finally the imaging evidence all the non-believers need.² Not to bore you with details about imaging, but MRS in this study detected metabolic changes not only at the impact site, but also in the primary motor cortex following a concussion. The motor cortex controls all of our movement. It’s the last stop for motor information in the brain before it heads out of the brain to the muscles. You can bet that changes in this part of the brain will affect movement. The study had a small sample size but provides objective data, and it is definitely worth further investigation. The only downside is MRS is new, and not everyone has access to these expensive machines. But before you throw your hands up there are other options to choose from.

How am I feeling? Me? Oh you know, I’m totally recovered…nope, not having any symptoms. I swear.

Subjective data collection is problematic because honesty may be an issue, and a concussion can impair the ability to report symptoms. It is important to have objective measures to assess whether or not the insult to the brain has healed. In the absence of MRS imaging, Neurocognitive testing may be the best clinical measure of a concussion. Ideally, the test is given prior to a concussion creating a baseline measure, then if a concussion occurs the test can be again administered to compare scores.

In the research, Neurocognitive testing consistently shows a significant decrease from baseline test performance in subjects post concussion. Significant decreases in scores are observed even when subjects post-concussion report no symptoms. This further supports that merely taking a subjective history is not enough to decide when it’s safe and appropriate for someone post-concussion to return to prior level of activity.

In an ideal world everyone would have an up-to-date copy of the Neurocognitive test in the database. It’s all right if you don’t because there exists a database of normative data a clinician can use to compare test results to. Another screening tool for concussion is the balance error scoring system (BESS).⁴ This test is better when combined with other screening tools.

Post-concussion overstimulation of brain is BAD!

Why? Think about it. Brain cells are already working hard trying to clean up the mess from the head trauma. They have little food/glucose because of restricted blood flow to the brain. Now add activity such as: reading this blog, watching an intense T.V. show, playing video games, or other high function tasks. The injured brain just doesn’t have the resources to deal with these demands. Overstimulation can prolong recovery and possibly cause more damage.

What you want me to relax and do nothing?! But I really don’t feel that bad besides I have a lot to do…

Second impact syndrome

Suffering another blow to the head before the brain has fully recovered is B-A-D like Supaahhh bad. The brain’s resources are already spread so thin, and now it’s supposed to deal with another disaster…imagine hurricane Katrina followed by Tiffany (Katrina’s older moodier sister), are you imagining? Well that’s what would be going on in your head.

Since decision making and general brain function are handicapped following a concussion, the likelihood of having a second concussion is very high, and we now know that that is really really bad – supaahhh bad.

Repeated mild trauma to the head even with recovery time also not such a good thing.

For sure one huge traumatic concussion is bad thing, and the risk of Second Impact Syndrome is also bad, but repeated mild head trauma is more common and also bad. Research is showing multiple smaller concussions, many that go unreported, can be just as damaging with effects that may not show up until years later. In football players (not picking on FB players, it’s just the population that was studied) multiple concussions (2 or more) may be related to decreased reaction time, decision processing speed, verbal memory, and the ability to accurately identify and report severe symptoms.³ This is a problem because these deficits put anyone at risk for future injury to the head or other parts of the body. An athlete who needs to react quickly to his/her environment these deficits put them at a much greater risk for injury.

Long-term effects of multiple concussions

Multiple concussions are associated with an increased likelihood to have memory loss, mild cognitive impairment, and Alzheimer’s disease. When compared to age matched men, retired football players reporting multiple concussions during their career had a significantly higher prevalence of cognitive decline.⁶ Again not picking on footballers it’s just the population the most recent research has been conducted on.

What is the best marker of a concussions severity post concussion amnesia screen...what?

Loss of consciousness was long thought to be the best indicator of severity. However, multiple studies are showing that loss of consciousness is neither a requirement for a concussion nor is it indicative of a concussions severity.³ Post-injury amnesia appears to be the best marker of severity.³ Yes loss of consciousness can still be a screening tool, but knowing the extent of amnesia, if any, is way more important.

Age and concussion recovery

Children and adolescence actually have a more severe response to head trauma when compared to adults.^{3, 5} Adolescence post concussion have more brain swelling, and the swelling lasts for a longer period of time than it does in the adult brain.³ When it comes to children post-concussion recovery, treatment needs to be more conservative (see recovery guidelines at end of blog).

It’s only a concussion why are you making such a big deal.

The article, “My Child Doesn’t Have a Brain Injury, He Only Has a Concussion” looks at the semantics of concussion verses MTBI. The study found that a diagnosis of a concussion was correlated with a shorter hospital stay and a quicker return to school when compared to a diagnosis of MTBI.⁵ Even though MTBI and concussion are the same, a diagnosis of a concussion seems to imply something less serious.⁵ This study did have some limitations, but I mention it because the current perception regarding a concussion is largely it isn’t a big deal.

Gender differences.

Yes we are different post concussion

Grossly men score better on visual memory tests. “HOOTERS?”

And,

Women score better on verbal memory tests. “Can we talk about this?”

Concussion myth

DON’T FALL ASLEEP

I didn’t find anything that supported waking someone up throughout the night post head trauma. The only thing I did find said this was done to help monitor symptoms. Not because there was a fear the person would slip into a coma and never come out of it.

Take home message

Be good to your head. The skull is a hard casing around a very important gelatinous mold. Concussions should always be reported, don’t down play any trauma to your head. It’s conservatively estimated that there are over 300,000 concussions in the U.S. every year so you’re not alone, don’t closet your concussion. Keep your neck muscles strong, muscles help to absorb external forces, strong neck muscles = more force absorbed at the neck less by the brain. other site

Impact for physical therapy…

What can your PT do for you.

A PT can monitor the symptoms and prescribe exercises to help with balance and dizziness complaints, provide safe and graded exercises to prepare you for a safe return to their prior level of function.

Why do PT’s care.

As U.S. PT’s continue to win direct access across the country, we will be seeing more people post concussion before they’ve seen the MD. The multi-section program this year at the American physical therapy association’s combined section meeting (CSM) was all things concussion. Considering how concussion can occur – blunt trauma to head, neck (whiplash), or body – many patients we treat with musculoskeletal problems could also have a concussion too.

Recovery recommendations:

- cognitive rest – the brain is working hard to repair the damage and with limited resources. Thinking takes a lot of energy, but so does reading, and playing video games. The recommendation seems to be doing nothing or next to nothing.

- Motor rest – Imaging showed that the primary motor cortex can be involved in a concussion. Even if it’s not, movement requires multiple parts of the brain. So patients should not be spending their days off on Dance Dance Revolution.

If you need more guidance here is the official recommendation from the International Conference on Concussion in Sport⁷ (my additions are in italics).

Acute Response and Return-to-play/life Recommendations⁷

(1) an athlete/person with any signs or symptoms of concussion should be:

a. removed from the game/work/social setting

b. not permitted to return to play/work/social setting

c. closely monitored (keep your eyes on them)

(2) Athletes/people should be medically evaluated after the injury, including:

a. Ruling out of more serious intracranial pathology

b. Neurocognitive testing for injury assessment

(3) Stepwise return to play/life. Once ASYMPTOMATIC* and medically cleared, proceed to next level:

a. No activity/reading/higher level reasoning, etc

b. Light aerobic exercise/reading, reasoning

c. Sport specific training/higher level reading reasoning

d. Non-contact training drills/try half days at school/work

e. Full contact training/near full integration back to normal activities

f. Game play/return to life as you knew it before your concussion

*if at any point there is a complaint or return of symptoms during the outlined stepwise progression back off.

How do you know when you’ve recovered?

(1) The Neurocognitive tests are back to baseline or normative values

(2) there is no complaint of symptoms

(3) there is no complaint of symptoms with mental and physical exertion.

1. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train. Sep 2001;36(3):228-235.

2. Henry LC, Tremblay S, Boulanger Y, Ellemberg D, Lassonde M. Neurometabolic changes in the acute phase after sports concussions correlate with symptom severity. J Neurotrauma. Jan 2010;27(1):65-76.

3. Reddy CC, Collins MW. Sports concussion: management and predictors of outcome. Curr Sports Med Rep. Jan-Feb 2009;8(1):10-15.

4. Davis GA, Iverson GL, Guskiewicz KM, Ptito A, Johnston KM. Contributions of neuroimaging, balance testing, electrophysiology and blood markers to the assessment of sport-related concussion. Br J Sports Med. May 2009;43 Suppl 1:i36-45.

5. Dematteo CA, Hanna SE, Mahoney WJ, et al. "My child doesn't have a brain injury, he only has a concussion". Pediatrics. Feb 2010;125(2):327-334.

6. Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. Oct 2005;57(4):719-726; discussion 719-726.

7. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. Feb 2002;36(1):6-10.

INFORMED CONSENT – conversations in the Acute Care setting

2010-03-15T22:11:00.000-07:00

CONVERSATIONS WITH PATIENTS…

Patient: “I’m concerned about the wireless capabilities in this hospital”

Me: “Oh don’t be. You’ll be directed to the hospital home page where you have to agree to the terms and conditions about hospital policy Internet usage. The wifi is great…I mean you can’t access porn sites…not that I would know anything about that…”

Patient: (silent and wide eyed)

Instructor: (jaw on floor)

Luckily these awkward moments don’t happen often. A better example of physical therapist to patient conversation is as follows.

Hello, I’m Justin from physical therapy. Your doctor wanted me to work with you. How about we do some physical therapy today?

No? Are you sure you don’t want any physical therapy?

Yes, I’m sure. I don’t feel well.

Obviously, when you’re in the hospital you don’t feel well, but sometimes, I wish I could say, “Look, nobody here feels well, but they still do their physical therapy. So 1-2-3 let’s get moving.” I know that physical therapy (PT) is beneficial for these patients and if you’ve read the past blog-2 and blog-3 you too can appreciate that PT is important for these patients. But I’m not entirely convinced some patients understand how important PT is for them. Maybe the wifi wasn’t working, or the hospital has also blocked my blog.

DISCHARGE PLANNING…

An event occurred last week with a patient who was less than interested in PT. He repeatedly refused treatment, or put forth minimal effort. My primary concern as a ~~SUPER~~ student PT (SPT) was he couldn’t go from sit to stand without two people lifting him. The criteria for discharge from a hospital usually requires that a patient can independently (1) walk 150ft (with or without an assistive device), (2) sit to stand, (3) get in and out of bed, and (4) their medical condition needs to be stable/or improving. If 1-4 is not met you can go home, but must sign a form stating you do so Against Medical Advice (AMA). Knowing this he was still insistent on going home. After all he had a lift chair, and a helper that visits one hour a day. This is a huge problem for reasons I’ll explain but first things first…

LIFT CHAIRS

I never heard of them before working in acute care, but let me tell you these chairs are all the rage Miley Cyrus:under 20 girls (and me)::Lift chairs:over 55’s. Everyone seems to have them. In fact these chairs are so popular people have extras that they loan to neighbors when in need. A patient’s wife put the phenomenon into perspective.

“Well ya’ know my neighbor lady down the street just had surgery, and I called her up askin’ if she wanted my extra lift chair, because they aren’t cheap ya’ know at $600 a pop. Well…she says it’d be too much trouble, and not to bother. When I says, TOO LATE! It’s already loaded in the pick-up, junior is drivin’ it over.”

You can imagine that PT’s* don’t share the same excitement over lift chairs. Unless you’re on hospice or have some boney hip/knee deformity the lift chair just perpetuates laziness and muscle loss. Tell your grandparents NOT to purchase a lift chair unless they’ve done a cost benefit analysis and consulted with their family PT.

BACK TO THE PATIENT…

Since his medical condition was improving the MD gave his blessing for discharge. However, in order for the hospital to stand behind a discharge the patient must meet the outlined discharge criteria 1-4.

My instructor was a bit frustrated by his constant refusal for care, and as we left the room she told me what would happen to this patient,

“You know what’s going to happen to this patient. He will return home, sit all day, develop a decubitus ulcer (pressure sore = very bad), get sepsis (even worse), and either return to the hospital or die (the worst!).”

Lemon drops and moonbeams right? It’s not information you respond to with a smile and a casual, oh that’s interesting. I wanted to run back into the patient’s room and save his life from this pending infected ulcer. But on the other hand he did refuse care.

PATIENTS RIGHTS…

My instructor was clear that if a patient refuses care you can’t force them. This got me thinking (Carrie Bradshaw style…Sex and the City writer). Are we educating our patients enough in the hospital setting about physical therapy so they can make an informed refusal? [RESEARCH TOPIC –I couldn’t find anything already published]

Come to Jesus Talk…

Luckily for this patient an intervention was staged. Known locally as the Come To Jesus Talk (CTJT). It’s supposed to bring the patient toward enlightenment, errr reality. The CTJT power team was - the social worker, two family members, the PT, and the SPT (me). Do not be fooled CTJT’s are intense there is a lot of finger pointing, tears, and some tongue biting.

Seeing the light…

The intervention worked and he is now actively participating in PT treatment. In case you need a little more Hollywood charm he even agreed to move to a skilled nursing home until criteria 1-3 were met. Yea for happy endings!

INFORMED CONSENT PRACTITIONER RESPONSIBILITY…

informed consent is a responsibility that falls on every health care practitioner. Specifically for PT’s, the APTA'S website states:

The law of informed consent—much of which has grown out of litigation involving physicians—embodies a very similar respect for patient autonomy. For example, the New Jersey Supreme Court—in Matthies v Mastromonaco [160 NJ 26, 733 A.2d 456, 1999 NJ LEXIS 833) (NJ 1999)], a case involving admissibility of testimony as to whether a physician obtained informed consent for a non-aggressive approach (i.e., Link bed rest ) to treating an 81-year-old woman with osteoporosis who had fractured her hip—ruled that:

“Physicians thus remain obligated to inform patients of medically reasonable treatment alternatives and their attendant probable risks and outcomes. Otherwise, the patient, in selecting one alternative rather than another, cannot make a decision that is informed.”

Because informed consent law focuses on the patient's right to make an intelligent choice, a practitioner can be held liable even in the absence of malpractice. That is, a patient need not prove that the treatment was provided negligently in order to recover damages for failure to inform.

What is interesting about the Matthies v Mastromonaco case is historically informed consent was only relevant for surgical interventions. This was a non-surgical intervention gone awry, and the state ruled in favor of the patient. Check out this site for more legal cases regarding informed consent.

As the Health Care Practitioner

· YOU are the expert.

· Being the “expert” comes with responsibility

· Be clear about the risk and benefits of both the treatment and refusing the treatment

· Document everything that was done and said.

As the Patient

· Make sure the health care provider has explained the choices you have and the benefits and risks of those choices. There’s always a choice.

*I’m not speaking for every PT there may be a handful that likes them.

EXERCISE vs BED REST pt 2

2010-03-11T21:22:00.000-08:00

Exercise reduces systemic inflammation...

Huh!? Liar!!!! Why am I always so sore after working out?

Following exercise there is an increase of anti-inflammatory molecules circulating in the blood. Remember systemic inflammation is thought to cause cardiovascular diseases, diabetes, certain cancers, and a variety of lung disease. This doesn’t mean go run a marathon. By all means, run a marathon if you’ve been training for one, just exercise smartly [DON’T OVER DO IT, and take a peek over at the disclaimer].

Skeletal muscle is an endocrine gland…allegedly

Physical activity causes an increase in cytokines (termed myokines)* that act as anti-inflammatories.^{1, 2} How cool an endocrine gland you can control. Just contract your muscle and presto instant anti-inflammatory production. Watch out Advil and Tylenol.** I can’t believe big pharma is allowing this research to be published!

Thoughts?

Contracting muscles ability to produce these anti-inflammatories is important to us because it protects against rogue inflammatory molecules that may eventually cause chronic non-communicable diseases. In fact the presence of systemic inflammatory agents in the body may be a stronger risk factor for heart disease than LDL’s (bad cholesterol).^{1, 2} This is bad news for Lipitor, unless Pfizer increases the weight of the pills, so we can get some resistance training (pill lifting) in before taking it. For sure increased physical activity will also decrease LDL levels, but Lipitor alone isn't going to change systemic inflammation. More research needs to be done, but it doesn't sound like cholesterol management is the single most important factor for preventing cardiovascular disease and arterial plaque build up.

Fat (adipose) tissue is not to be one upped by skeletal muscle, it too releases stuff, but bad stuff. Specifically adipose tissue releases an inflammatory cytokine called Tumor Necrosis Factor (TNF). I know this is an intense paragraph just bare with me. Interestingly research is showing that the presence of TNF (aka – “bad molecule”) actually inhibits skeletal muscles ability to use insulin.³ Remember if the muscle can’t use insulin effectively then blood glucose will increase, which leads to an over-worked and angry pancreas. Angry pancreas…quits job = Diabetes.

Diabetes…

Muscle activity helps increase the body’s ability to regulate blood glucose. Chew on this information-candy-bar. Healthy subjects put on bed rest for 5 days showed significant elevation in resting blood glucose and insulin levels.⁴ Translation…inactivity makes the body less efficient at regulating blood glucose, so more insulin has to be released in order to regulate the increased blood glucose. Long term elevated blood glucose => type 2 diabetes.

Today with the economic downturn we are all concerned about productivity. We’re stressed out, and we have different coping mechanisms. Some of us read The Art of War and prepare for battle, while others just shut down. Well, the pancreas also has productivity concerns. Eventually, an overworked stressed out pancreas is forced to choose a coping mechanism. Unfortunately, the pancreas is not a fan of Sun Tzu, and instead of battle it shuts down (factory closed). BUT, you can give your pancreas a break. Exercise your power as the CEO, and hire some skeletal muscle back by engaging in exercise.

How does that happen…

Well exercise makes your muscles more efficient at using insulin, so the pancreas can produce less. Furthermore, a working muscle is a hungry muscle. Go ahead ask your hard working bicep what’s for dinner.

*cytokine info - http://www.medterms.com/script/main/art.asp?articlekey=11937

**exercise is not meant to replace Advil and Tylenol.

1. Mathur N, Pedersen BK. Exercise as a mean to control low-grade systemic inflammation. Mediators Inflamm. 2008;2008:109502.

2. Pedersen BK, Fischer CP. Beneficial health effects of exercise--the role of IL-6 as a myokine. Trends Pharmacol Sci. Apr 2007;28(4):152-156.

3. Nieto-Vazquez I, Fernandez-Veledo S, Kramer DK, Vila-Bedmar R, Garcia-Guerra L, Lorenzo M. Insulin resistance associated to obesity: the link TNF-alpha. Arch Physiol Biochem. Jul 2008;114(3):183-194.

4. Brower RG. Consequences of bed rest. Crit Care Med. Oct 2009;37(10 Suppl):S422-428.

BED REST pt 1

2010-03-10T23:07:00.000-08:00

You’re sick you need BED REST or do you…

The idea that sickness is best dealt with by laying in bed may not be the best remedy. I’m in the middle of a clinical rotation at a hospital right now. The majority of my patients have pneumonia, heart failure, kidney failure, and cancer, as well as this belief that they need to rest. A review of current research by Dr. Bower does not find much if any benefit to a prescription of bed rest as a way to deal with chronic inflammatory diseases. Que pasa? Chronic inflammatory diseases are cardiovascular diseases, diabetes, certain cancers, and a variety of lung disease. Why do we think bed rest is good? Sick = body needs rest so all the energy can be allocated towards curing the (Insert sickness of your choice). It makes sense, but hopefully the information below will give you a different opinion.

Bed rest can decrease your muscle mass up to 2% per day.¹ Muscle mass is not exactly the same thing as muscle strength.² But broadly speaking there is a relationship between the two. luckily we don’t have to fuss over the details because, studies have also shown that bed rest decreases muscle strength. Thank you devoted researchers! It’s important to know that many of these changes occur within days of bed rest. So don’t think these studies are only looking at peeps who are bed ridden for months.

If not BED REST what then…

Physical activity of course. I’m in the business to promote this stuff, so let me get my soapbox and mega phone out. Hear ye hear ye! Smoking, hypertension, diabetes, and cardiovascular pathology aren’t as good a predictor of pending death as the American Lung association would have you think.³ Physical activity and fitness levels prove to be a better predictor of mortality beating out smoking!³

I don’t know, is this good news for Marlboro and Virginia slims or not? Will the government start banning physical inactivity in public places across the U.S.? From this day on you must remain active or receive a citation!

According to the study work related physical activity was not as important a predictor in survival as recreational physical activity was. The predictors for survival related to activity ranked from best to worst.

1. Exercise capacity = best predictor of fighting off that cloaked dude with the scythe.

2. Energy expenditure during recreational activities.

3. Occupational energy expenditure.

Unfortunately, the calories you burn at work was not found to be associated with survival.³ However, I’m not clear if this means all occupations from ballet dancer to the slightly more sedentary office worker. But, what I do know is that the most inactive adults literally have the most life to gain from increased physical activity.

Recommendations...

Find a way to incorporate some activity into your life. An easy way, is going for a walk. Make the walk more entertaining by seeing how fast you can get from point A to B then try to beat your time the following day. If you work in an office try getting off the elevator a few floors early and take the stairs. When you go from sit to stand instead of getting up once repeat sit to stand ten times or more. So what if you’re getting the crazy look from people. You can just reply with “my frontalis can make that expression too!” Most important: if you do end up in the hospital listen to your physical therapist and do what they tell you. Always check with your health care practitioner before making any changes to your normal daily activity routine.

1. Brower RG. Consequences of bed rest. Crit Care Med. Oct 2009;37(10 Suppl):S422-428.

2. Nass R, Johannsson G, Christiansen JS, Kopchick JJ, Thorner MO. The aging population - Is there a role for endocrine interventions? Growth Horm Igf Res. Apr 2009;19(2):89-100.

3. Myers J, Kaykha A, George S, et al. Fitness versus physical activity patterns in predicting mortality in men. Am J Med. Dec 15 2004;117(12):912-918.

1st blog...1st day in Quincy IL

2010-03-08T22:35:00.000-08:00

Here it is, my first entry ever...

Very excited to share a blend of relevant information regarding common physical aches and pains as well as personal stories. Hopefully neither will cause you additional headaches, but if so lay down and close your eyes. Then ask a friend to place their thumbs over your eyebrows close to midline. I personally like the first knuckle of the thumb. Your 'friend' should apply a gentle pressure and slowly, following the top outline of your eyebrow, move toward each ear. Of course you should consult with your health care practitioner before trying this activity. This is a great way to relax the frontalis. WTF??? See picture to your right and say hello to the frontalis, "Hi Frontalis!" Frontalis - Interests: loves surprised expressions, suggestive double eyebrow raising, the inquisitive single eyebrow raise, and long walks in the park. Dislikes: botox and expressionless people. The frontalis is a muscle and it can get tight – say from reading bad blogs – and cause headaches.

I’m in WESTERN IL... right now on my second clinical. First impressions…well according to my Grindr app the nearest gay men all love cars and hunting. And sadly they are all 90 miles away. Also I've never seen a pizza mexican restaurant. Just when I thought the big city (Chicago) had exposed me to everything.

This morning I started my acute care clinical. Honestly I was really excited. I feel very – perhaps for a student overly – prepared to treat an inpatient population. Unfortunately, the first five patients I visited didn’t want anything to do with PT. One was sleeping. Another patient said she was busy… doing what I have no clue. I wanted to say, you’re in the hospital what on earth could you possibly have written in your daily planner? But my favorite – "I can't right now (pause) my soap is on." I felt like a candy striper offering some cheap optional service.

Candy Striper in Intermediate Care...

“Hello my name is Celine Dion and I am the greatest Physical Terapist in de whole whurl. I have lucky strike cigarettes, maple leaf shaped cupcakes, people magazine, a cat that performs tricks and meows like Robert Plant and/or therapeutic exercises that will shorten your hospital stay. Do any of these things interest you?”

“No, my soap is on, can you come back?”

Abandoning my earlier excitement I went to lunch. Upon returning I saw a dying man. Meaning he seriously may not be there tomorrow. There is nothing like pending death to help facilitate gastrointestinal peristalsis after lunch. With lunch digesting I carried on my fruitless mission to bring PT to my patients. After multiple failed attempts I finally found a patient interested in PT. Wahoo! At about mid treatment her friend came in for a visit. Not a big deal it's good to have family and friends sit in on a PT session, as long as the patient stays focused.

The topic of my age came up, because I look like I should still be in high school. After finding out my age the patient and her elderly friend awkwardly gushed on about how great I look, and how amazing my complexion is. I thought they were done so I resumed my treatment. But apparently too soon because during active assisted straight leg raise number 4 I felt a strange-old hand caress my cheek, and then vocal confirmation, “yup Hester his skin is flawless!” My first thought, good thing I shaved this morning, and… uh… well, you know... attend grad school, because obviously smooth skin and PT skills are important for inpatient care. The day ended and I headed for two margaritas with some new friends from work. I’m looking forward to tomorrow. My last patient was motivated and grateful for PT, and sometimes that is enough to make the whole day of blah worth it.