Smoking, Health and Forest Fires.


Living in Reno, Nevada, we are frequently engulfed in smoke from forest fires around the area. Last year it was the big Yosemite fire, this year we were living under a blanket of smoke from the massive King Fire just east of Sacramento, California. Air quality was in the unhealthy range day in and day out. With clean air in the Truckee Meadows so dependent on the wind direction, we were praying for wind direction changes and the return of our Nevada blue skies.

Someone told me about a scene he saw at his work during the time we were blanketed in smoke. He left for lunch and walked past the smoking area outside the building. He saw two people smoking outside in the already smoky air and one waving her hand, cigarette in the other, “This smoke is killing me!” We humans are a funny bunch!

So I thought I would have some fun with that and take a photo. My disclaimer: I am not a smoker and never have been and boy did I learn something about smoking in the brief 10 minutes I had cigarettes going for the photograph!

  1. My tongue felt fury.
  2. My wife did not enjoy our first kiss.
  3. My clothes smelt of smoke immediately afterwards and this did not disappear until I washed them.
  4. I coughed immediately.
  5. I had to brush my teeth and take a shower right away.
  6. If I disliked it so much then it must be addicting as I struggle to believe those who have chosen to smoke don’t eventually bypass these sensations and thereby continue to smoke.
Smoking and our Reno Air Quality

Smoking and our Reno Air Quality

My Dad was a thoracic surgeon with a specialty in lung and esophageal cancer. As a consequence, I have always been very aware of the health issues related to smoking. I have never been addicted to anything (some who know me well may say I am addicted to exercise, talking to strangers and coffee!). I have seen numerous patients who smoke despite having significant reasons not to. For example, one person I recall had COPD, was on oxygen, had cardiovascular disease and had recently had a spine fusion (smoking delays healing) and was still smoking. Some of these smokers are in the healthcare profession too. Putting these factors together suggests to me that whether we like it or not, smoking must be incredibly addicting. Everyone who smokes knows it is bad for their health but they continue doing it. This begs the question: “What makes people change?”

People change because the pain of their present situation (smoking) is more than the pain of making the change (the withdrawals after stopping?). The pain of smoking depends on the individual and is different for each person. Some may see their wife pregnant and decide to stop smoking on account of the youngster about to be born. Some will have significant ongoing disease and still keep smoking (not painful enough yet). I have even spoken with someone who had simply given up as the disease process had gone too far.

I feel somewhat cheap talking about smoking cessation as I am not a cessation specialist nor am I a smoker who has kicked the habit. I have a real interest in why people change. This is the reason for my post. That being said, I recently met an incredible man. During his lifetime he stopped alcohol, methamphetamine, smoking and violence all cold turkey!

How is it he was so strong and quit all those things and many of us struggle?

Reasons to Choose Custom Physical Therapy


5 Simple Things to do Before a Knee Replacement.


Pre-operative conditioning!

Vital in determining the post-operative outcome of a total knee replacement.

Ask anyone who did the right things before surgery.

Sharine came in to see us for a single visit to learn what to do and then exercised daily until the day before her knee replacement.  “After watching my Mother and my husband go through knee replacements I took the advice from Andre’ and my surgeon to exercise and strengthen the muscles in my legs as well as other parts of my body. I am now about 3 1/2 weeks after surgery and I must say it has helped me. I am told that I have reached goals that others do not reach this soon. You MUST exercise before your surgery and I would recommend you start at least 6 weeks before.”  Her husband, Bob, had a knee replacement without pre-op instruction.  “Eight years ago I had a knee replacement. I was dismayed at how weak my “good” leg was!  I had the good fortune to be treated at Custom Therapy.  I learned that anyone having this surgery should or must exercise weeks before the event to ease the recovery period.  My wife just had her knee done.  We went to André 6 weeks prior for his counsel.  He examined her and recommended a course of pre-surgery exercise.  Having done without myself and seeing her result and progress I cannot recommend more strongly that others should absolutely follow this advice.”

  1. Ride a bike daily.

Bike riding creates controlled movement in a non-weight bearing position so will be less traumatic to the joint than walking or any other weight bearing exercise.

  1. Stretch hamstrings and calf muscles.

This helps get/keep your knee straight.  Painful knees are typically kept in a slightly flexed position for comfort which shortens these muscles. 

  1. Stretch your knee into full extension.

It can be done sitting in a chair with your heel on a coffee table or ottoman or lying face down on your bed with the edge of the bed just above your knee. 

  1. Pull your heel to your butt.

This will maximize your knee flexion.  The more range you have before your surgery, the more you will regain afterwards. 

  1. Strengthen your quads.

Your goal is to maximize your quad recruitment pre-operatively; this makes it easier to contract them after the trauma of the surgery.  A simple quad set, SAQ, or SLR (my favorite) is what is needed.

Your Call to Action:

  1. If you are planning on having a total or partial knee replacement consult a physical therapist as to what you need to do preoperatively to maximize your post-operative outcome.
  2. Forward this post to someone you know who may be having a total/partial knee replacement.
  3. Please post your comments regarding your experience with having or not having preoperative exercises and how they helped you. 

It is not osteoporosis that causes fractures.


We all know someone who has had a bone mineral density test and been diagnosed with osteopenia or osteoporosis.  This means they have lower than normal bone mineral density and hence their bones may be more fragile.  This in itself does not necessarily cause fractures but does need to be addressed.

A comprehensive, multifaceted approach to the treatment of osteopenia and osteoporosis will have a significant impact on bone density.  Clearly there are suitable medications one can take which your physician can address (beyond my scope of practice for sure).  I am sure you have all seen the numerous commercials on TV for these medications with that classic … “Ask your doctor about Boniva (or whatever medication they are advertising)” at the end.

The predictive value of bone mineral density measurements has been called into question in that it can under or overestimate density by 20% to 50%.  If it underestimates the density of the bone, you may receive unnecessary treatment.  If it overestimates bone mineral density you may not receive the most effective treatment.  So, what should you do?

Recognize that it is the fall that causes fractures and not the osteoporosis or osteopenia.  So if you address the physical limitations causing falls you will reduce the frequency of falls and thus reduce fractures.  75% of fractures occur in people without osteoporosis.  80% of low impact fractures occur in people who do not have osteoporosis.  Yes, it is the falls.

Preventing falls among older adults reduces the incidence of fractures, sometimes by over 50%.  Scientific evidence supports a reduction in fall frequency through strength and balance training, followed by reductions in the number of psychotropic drugs, dietary supplementation with Vitamin D and calcium and, in high risk populations, assessment and modification of home hazards.

This is where physical therapy is involved.  A fall prevention program should include targeted strengthening and stretching, static and dynamic balance training, posture modification, home hazard removal and of course an ongoing home exercise program which should be completed on a daily basis.

How do you know if you, a friend or a family member may need a fall prevention (and hence fracture prevention) program?  Answer “YES” to one of the questions below and you should consult with a physical therapist.

  1. Do you have difficulty going from a sitting to a standing position?
  2. Have you fallen without a known precipitating event?
  3. Have you fallen more than once in the past 6 months?
  4. Does it take you longer than 13 seconds to get up from a seated position and walk 10 feet?
  5. Do you have osteopenia or osteoporosis?
  6. Are you unsure if you would benefit from a fall prevention program?

Do your own assessment and decide if you, a family member or a friend may need to address balance issues with a physical therapist.  You will be glad you did.

Antibiotic treatment of Low Back Pain


I recently came across an interesting pair of research papers in which low back pain was treated with antibiotics successfully.  This research is published in the European Spine Journal April 2013, volume 22, Issue 4, pages 690-696 and 697-707.

This concept took me by surprise.  Dic herniations can apparently become infected with the bacteria from plaque in your teeth and from acne.  The link between dental hygene and cardiovascular disease, and I think diabetes (not sure), has previously been documented so I do not think this premise is a far stretch.  The authors investigated nuclear disc material from patients who underwent surgery for annular tears and removal of visible nuclear tissue.  43% of patients had evidence of infections.

They then treated patients with chronic low back pain and vertebral bone edema with antibiotics for 100 days (that’s a long time).  The antibiotic treatment significantly improved the chronic low back pain when compared to placebo.

Well!  I am somewhat taken aback but realize this is very interesting and may explain some cases of low back pain that do not progress as well as they should.

Your call to Action:

  1. What do you think of this?
  2. If you are a healthcare provider, post your comments please.
  3. Forward this onto someone who may have some comments and have them post their thoughts to our blog.
  4. Have an incredible week!

Swelling and Knee Function


The most read post on this blog deals with “Swelling, Effusion, Edema and Bruising – What’s the difference?”.  I will take the concept one step further and discuss how knee swelling or joint effusions impact your ability to control your knee extension when you walk.

So, you injure your knee and develop swelling inside the joint.  You may notice your knee giving way.  That means when you transfer weight onto your injured leg the knee buckles.  This is due to the quadriceps (front of your thigh) not contracting efficiently and hence not controlling the knee in extension.  Knee extension is vital in walking because it stabilizes the leg to accept the transferred weight from the opposite leg when you are in stance phase of gait.  If the knee is unable to go fully straight while stepping onto it you have difficulty swinging the other leg through to take another step.

This happens because of the swelling (and possibly pain too) within the joint.  A neural reflex is set up by distension of the joint structures.  It passes through the spinal cord and back to inhibit the quadriceps.  It is then difficult to contract them at the right time and with sufficient speed during the gait cycle.  Hence, unsafe walking and difficulty going up and down stairs, for example.  You may notice immediate deterioration of your ability to contract the quadriceps following injury with a joint effusion.

To regain quadriceps function and hence to restore normal and safe walking you must control the swelling (see earlier post on this topic), avoid increasing it by careful activity modification and do specific exercises to regain normal quadriceps function.  Physical therapists will instruct you in specific neuromuscular reeducation exercises to restore the quadriceps recruitment pattern.  Such exercises may include seated quad sets, straight leg raises or short arc quad recruitment.  These may be done with neuromuscular electrical stimulation (not TENS – that’s for pain and totally different type of current form) to facilitate recruitment of the muscle.  In addition, you will be given terminal knee extension exercises in standing such as straightening the knee against a wall with a towel roll behind your knee against the wall or fully extending your knee against tension created by an elastic sports cord.

So, controlling swelling in a joint is necessary to regain function of the muscles moving that joint.  This process is used in all knee injuries that result in joint effusions as well as in all postoperative rehabilitation, for example, following ACL reconstruction, meniscus repairs and debridement as well as total knee replacements.

What have you found helpful in the past?

What worked for you?  What didn’t?

Post your comments here so other people can learn from your experiences.  We would love to here from you.

Motivated to Get Healthy Via the Cost of Healthcare.


My last post on hip pain suggests the need for us all to be educated healthcare consumers and takes us back to the original goal of this blog – to be a credible, unbiased (by selling, advertizing or marketing products, for example) healthcare information source within the expertise of the writer.  Clearly, if it takes 21 months and three providers to correctly diagnose hip pain, we must all be willing and able to ask questions of our healthcare providers (doctors, physical therapists, physicians assistants, nurses, hospitals, insurance companies).

$2.8 trillion ($2,800,000,000,000 – enough zeros?) is estimated to be spent on healthcare in 2013. In 2010, we spent just over $8000 per capita in the US and our life expectancy at birth ranks below countries that spend far less. Spain spends about $3000 per capita and has a life expectancy at birth of 82 and Japan spends $4000 per capita and has a life expectancy of 83.

Consider that the healthcare industry spent $5.36 billion lobbying Congress from 1998 to 2012 while the defense lobbyists spent $1.53 billion. Will this system change to your benefit as a patient?  I do not think it will change in the near future and will thus continue to cost us all way more than we can afford.

I suggest we make the healthcare system challenges a mute point by using this reality as motivation to take charge of our own health. For example, what small lifestyle change can you make to start on the road to a healthier you today?

As a physical therapist I am partial to movement so why not move more each day. That means doing little things such as walking stairs, walking at lunchtime, taking family time and walking around your neighborhood after work with your kids, standing up from your office chair 10 times every two hours, anything you can think of that will increase your activity level.

A dietician may have ideas such as portion control, cutting out refined and fatty foods, eating more fruits and vegetables, drinking more water.  All you dieticians out there, feel free to post your ideas of simple, easy ideas people can use to start the process of improving their health.

What about a wellness visit to your primary care doctor?  Dr Ronald Hicks in Sparks, Nevada has been my primary care physician for almost 17 years.  Every visit I have with him involves discussions about some form of healthy living (sun block, exercise, diet, stress), and I am a health person.  He tells me he has many diabetic patients who do not control their blood glucose using simple dietary restrictions, exercise, regular montoring and medication use.  I am floored by this.  If we know what we need to do to control a disease which is potentially fatal, why do we not do it? (A lead into a future post maybe?)

In conclusion, at Custom Physical Therapy I have the priviledge of working with a variety of wonderful people all of whom have different needs.  Everyday, there are people who can make small changes in lifestyle and thus have large gains in health.  However, such lifestyle changes do not come easy and require motivation.  With this post, I am suggesting we use the cost of healthcare as motivation to make the needed changes to become healthier.  You will save on  healthcare costs down the road as we will only use the expensive healthcare system when we truly need to.  Prevention is the word.

YOUR TO DO LIST:

  1. What one aspect of your lifestyle will you change today to start on the road to a healthier you? 
  2. Post your idea on this blog – I would love to read about it.
  3. Send this post to someone you would like to join with on the quest to save $$$ by becoming a healthier you.
  4. Schedule a wellness checkup with your primary care physician – let the doc know your desire to become healthier.
  5. Be happy and get healthy!

Hip pain – 21 months to diagnosis?


A study by Burnett et al in the Journal of Bone and Joint Surgery (2006) documented an average time from injury to accurate diagnosis for hip pain due to labral tears as 21 months.  People with this type of hip pain saw an average of 3.3 providers before definitive treatment was initiaited.  In 17% of their study group of 66 patients, surgery was recommended on a different anatomic site.  Once the correct diagnosis was made and the hip arthroscopy was performed, 89% of the patients were clinically better off than before surgery.  That is positive.

Hip pain can originate from a number of structures and as a result can be easily misdiagnosed.  Low back pain can refer pain to the hip area.  Sacroiliac joint dysfunction can too.  Hip pain can be due to bony problems such as impingement or due to damage to the cartilage structure around the socket, that is the labrum (similar to the shoulder – see an earlier post on this blog).  It can originate from strain or tearing of the lignaments around the hip joint as well as from all the many muscles which control the hip joint.  In addition, pain may originate from the pubic area where the abdominal muscles and the hip adductors attach, commonly called athletic pubalgia or a sports hernia.  Finally, hip pain can be a consequence of referred pain from the leg.

Hip pain is typically localized to the groin area.  It may also be felt laterally over the outside of the hip or in the buttock.  There may be clicking, popping and snapping in the hip joint associated with the pain.  Walking, running, ascending and descending stairs, putting shoes on (figure 4 sitting) and lying on the affected side may be challenging.

Your to do list:

  1. If you have back pain that radiates to the hip area (buttock, side of your leg, groin) ask your doctor or physical therapist to evaluate the hip.  At Custom Physical Therapy we check the hip with every low back pain patient so we do not miss the diagnosis.
  2. Educate yourself on the hip so you can ask questions of your doctor and physical therapist.  Do not let your hip pain get misdiagnosed and take 21 months to be correctly treated.
  3. Call us at Custom Physical Therapy if you have any questions regarding your hip pain.  Mention you are calling with specific questions regarding this post on hip pain.  We can answer your questions.
  4. There are some really top notch hip doctors in Reno, Nevada.  Call us if you want to know who they are.
  5. Please forward this on to your friends, family and coworkers via email, Facebook, Twitter or word of mouth.

Thank you for being part of Custom Physical Therapy.  Here’s to your healthy hips!

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