“Is this a model or is it the real thing?”


I had the pleasure of meeting with one of our local orthopedic surgeons, Dr. Benjamin Bjerke, and the Zimmer-Biomet rep, Christina Escobar, to talk Mobi-C Disc Replacement technology and surgical technique developed by Zimmer-Biomet. Incredibly interesting.

Seeing the prosthesis, my first question was, “Is this a model or the real thing you are showing me?” It was much smaller than I anticipated!

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Secondly, I found the specificity of the patient suitable for this intervention impressive – someone with neck pain and or radiculopathy (pain down the arm originating from nerve root compression in the neck) without much cervical spondylosis (degeneration of the discs and joints in the neck) and good vertebral alignment. The Mobi-C can replace discs at one or two levels of the cervical spine between the third and seventh cervical vertebrae.

So lets take a look in more detail.

Anatomy and Pathology of the Neck

  • The cervical spine has discs between each bone that provide cushioning for movements and body loads. The discs and bones in a healthy neck allow bending from side-to-side and front-to-back, and turning left-to-right. Disc problems can start from over-use, an accident, or just the wear and tear of daily life.  When a disc degenerates it becomes thinner and provides less padding to absorb movement.  Degenerated discs can also bulge (herniate) and pinch the spinal cord or nerves, which causes loss of feeling, weakness, pain, or tingling down the arms and hands. Below  you can see the normal cervical spine anatomy and adjacent is a graphic of what a spine with pathology may look like:

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Treatment Options

  • Before artificial discs were available, patients would traditionally receive an Anterior Cervical Discectomy and Fusion procedure to alleviate the pain from a herniated disc. In a fusion surgery, the disc is removed and either a bone spacer or a plastic implant is placed in the disc space to restore disc height and remove pressure on the pinched nerves or spinal cord.   A metal plate and screws is placed on the front of the vertebral column to hold the implant in place.  The result – a segment that no longer moves, or is “fused”.  The potential downside of a fusion procedure, in addition to the loss of motion, is that it can create additional stress on the spinal levels above and below it.  This can cause degeneration at those levels and potentially result in another future surgery.
  • An artificial disc like Mobi-C is an option instead of a fusion that will also be placed inside the disc space to restore height and remove pressure on the pinched nerves. However, the Mobi-C device is designed to allow the neck to maintain normal motion and thus limit adjacent levels from degenerating, possibly preventing future surgeries.

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Since Mobi-C cervical disc replacements are preferred over fusions because they preserve movement in the spine, lets take a look at this video to see what happens in the spine when a patient with the Mob- C implanted flexes and extends his/her neck versus a two level fusion:

Cervical disc replacement procedures are anticipated to experience rapid growth in the near future, due to multiple factors:

  • A growing library of clinical evidence demonstrating the long term safety and efficacy of cervical disc replacement.
  • Cervical disc replacement is being shown as a superior treatment to fusion for use at two cervical levels.
  • Better outcomes of cervical disc replacement over fusion such as reduced re-operation rates, reduced adjacent segment degeneration rates and surgeries, as well as a faster return to work.
  • Most patients return to work within six weeks of surgery. In the U.S. Mobi-C clinical trial, the return to work time was 20.9 days shorter for Mobi-C patients compared to fusion patients for two-level surgery and 7.5 days shorter for Mobi-C patients compared to fusion for one-level surgery.

What about physical therapy after the Mobi-C disc replacement?

  • Wear a neck collar to lessen neck movement for around a week after the surgery.
  • Avoid heavy lifting, repetitive bending, and prolonged or strenuous activity for up to 6 weeks after surgery.
  • When your surgeon releases you to start physical therapy the physical therapist will do a comprehensive evaluation to assess your cervical, scapular and shoulder range of motion as well as cervical, arm and trunk strength. Based on the data collected, you will be given specific exercises to address any deficits to ultimately improve your function. You may start of with cervical isometrics and progress to upper thoracic and arm strengthening exercises as well as neuromuscular reeducation of the deep neck muscles. The physical therapist will also utilize soft tissue mobilization techniques to limit scar formation and address any myofascial pain and muscle trigger points, present from inactivity. You will need to participate fully by being totally compliant with the home exercise program you are given by the physical therapist at your very first visit.

Successful outcomes are determined by multiple factors which include choosing the right surgical procedure done by a skilled surgeon, following post operative activity limitations and brace use as well as being totally compliant with physical therapy instructions and exercises. It is a 3 person team that makes your recovery work: you (and your home supporters), the surgeon (and their staff) and the physical therapist (and their clinical team members).

Thank you to Zimmer-Biomet for help with supplying me with information and photographs.

Battling El Nino with Your Core in 10 minutes.


El Nino is arriving with massive amounts of snow and rain, right? We all hope for drought relief but with the forecasted “big winter” comes the need for strength and control of your hidden muscles to weather (pun intended) the wet, cold, white, slippery Reno-Sparks-Lake Tahoe area.

A generally accepted definition of “the core” is the muscles from below the neck and above the upper thigh (shoulders to hips). The importance of these muscles is in injury prevention, maintaining erect, “regal” posture and providing a base for functional strength (the ability to push a heavy door open, get in and out of a car, stand up out of a chair or lift a box form the floor to a counter). Training all the core would take all day if you try to isolate each muscle individually. So, do 3 exercises and get nearly all of them done in less than 10 minutes!

“YTWL” – shoulder and back muscles.

Keeping your body straight over a therapy ball beneath your lower abdominal-pelvic area and feet against the wall, raise your arms in 4 different planes noted by “YTWL”. Arms overhead at a 45° angle between head and shoulders, in line with shoulders, elbows tucked into your sides flexed 90°, and finally rotation of shoulders up with upper arms at shoulder level. No therapy ball? Just do it off the corner of your bed.

The Y of the YTWL Series

The Y of the YTWL Series (see YouTube channel for video)

Front Plank – abdominals, butt and shoulder.

Lying prone, support your body in a straight line from shoulders to ankles resting on your elbows and toes. Pull your navel in and up (“make yourself skinny”) and pinch your glutes together while rounding out your shoulders. Hold this position for up to a minute (must have perfect technique the entire hold). Repeat three to five times.

Front plank

Front plank (see YouTube channel for video)

Clamshell Progression – Hip muscles.

Lay on your side, knees bent to 90° and hips at 45°, one leg atop the other. Rotate your hip out by lifting your top knee while keeping feet together, 10 times. Rotate foot up keeping thighs together 10 times. Lift top leg parallel to bottom and rotate 10 times around the axis of the femur. Straighten your hip, keeping knee at 90° and rotate 10 times around the femurs axis. Tough people, repeat 3 times on each side.

Clamshell # 4

Clamshell # 4 (see YouTube channel for video)

To see a video of each exercise on our YouTube channel, go to The El Nino Core Program .

El Nino dump your snow, your rain and whatever icy weather you care to bring us. Our core is now ready for shoveling snow, lifting and carrying sand bags (hope not!) and preventing falls when slipping on ice. Bring on those pressure changes that make my back ache – El Nino we got the work done before you came!. See you when you arrive, that’s if you don’t chicken out again!

The Custom Physical Therapy Challenge Rules


If you dare ….. get fitter, stronger and healthier with the monthly Custom Physical Therapy Challenge.

Every month we will have a daily series of exercises to do for anyone and all who would like to join us. Employees, friends and family may join in.

Here are the rules:

  1. You complete all repetitions of each exercise every day and check it off the schedule of exercises.
  2. If you miss a day you may double up the next day – not advisable particularly towards the end of the series.
  3. It is purely the honor system.
  4. If you complete all exercises for the entire month you let us know by faxing the checked schedule to Custom Physical Therapy (775-331-1180) or emailing it to us with your name on it and contact number: customptchallenge@gmail.com
  5. Prize: $50-$75 gift certificate from a local business (Previously: Great Full Gardens Restaurant, 1 hour massage).

Exercise technique can be seen on our Youtube Custom Physical Therapy Challenge Channel. Here is the URL:

Let us know how you like it and what you would like to challenge in future months. For example, an arm challenge, butt challenge, core challenge, chest challenge, aerobic challenge, rope jump challenge.

If you have any concerns about doing the exercises and need help modifying them feel free to call us at the Sparks location: 775-331-1199. You can also email us with questions: customptchallenge@gmail.com

Have fun, be safe and get strong!

The Custom Physical Therapy Challenge Department

www.custom-pt.com

http://www.customphysicaltherapy.wordpress.com/

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.

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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