To observe.... or not to observe... isn’t that the question?

Treatment before evaluation seems to go against standard practice. To understand how to treat a patient, we need to find out what it is that we need to treat. In the field of osteoporosis, however, treatment before evaluation is often the norm. Physicians often give medications before bone density testing. Even Medicare measures osteoporosis testing as “prescribed a bone protecting medication”. Until recently, the fragility of the osteoporosis patient has lead to therapists following procedures that limit physical function testing in these patients. The extreme concern about the fragility of the patient with osteoporosis is not unfounded. More than 30% of female patients over the age of 65 are not tested (via DXA) for bone loss and more than 79% of patients who have a fracture, never get a DXA…let alone get prescribed a bone protecting medication- how many of these patients do we as therapists work with? Do you always know that your patient has bone loss? This disease has been associated with fractures that have occurred under very low trauma conditions. In contrast, the method by which many of these fractures have been diagnosed has come under scrutiny.

From the first major osteoporosis medication trial (FIT trial), a large substudy (N=6,084) of patients was examined to see if vertebral fractures reported in the non-clinical event group were actually fractures by applying a strict use of a “20% deformity or 4mm loss” measure. This non-clinical event group consisted of patients in the original FIT study that did not associate pain with fracture or they never had pain and therefore never reported an event (i.e. fracture). In addition, this study was cross-sectional, including patients from both treatment groups – placebo or alendronate. So, results of this analysis can be generalized to pharmaceutically treated and not treated populations. The study found that only 1/4 of radiographic vertebral deformities identified were actually fractures according to the strict measure. It appears that many vertebral fractures that have been categorized as such really are not vertebral fractures. It is from this study, and those similar, that we gain our information regarding vertebral fracture prevalence. It can be easily argued that vertebral fracture prevalence is not as severe as we may have been lead to believe.

If a 65 year female with back pain came to your clinic, and an x-ray did not reveal osteoporosis or fracture, would you do some standard spine ROM and strength assessments. Would you look at her movement patterns to understand more about what she is doing to increase her back pain during her daily life? Would you ask her to bend over to see flexibility? Is this really safe? If we are going to determine that we should not ask a patient to bend over when we know they have bone loss, what do we do if we don’t know, what if we don’t even suspect bone loss? Would that change the way you test? It might. You may decide, however, that the benefits of testing to determine what is wrong far outweigh the very low risk of injury during testing. It can be argued that to avoid testing, and “assume the worst” could result in unnecessary treatment. What if you could assess physical performance in the patient with osteoporosis in a safer way and streamline treatment to just what the patient needs?

While physical performance testing is far from the rigors and risk of cardiac stress testing, it is a stress test of sorts. In fact, one may argue that the risk of injury while observing a patient’s natural activity patterns is far lower than the risk of injury during a cardiac stress test. By doing physical performance testing with a patient, we can observe how well their musculoskeletal system performs in the context of natural activities. We can also understand if the patient is engaging voluntarily in excessive loading conditions that can lead to fracture.

Moreover, impaired physical performance is associated with increased fracture prevalence. If physical performance is not observed, related fracture risk could be missed.

During the Bone Safety Evaluation (BSE), a physical performance test that is designed specifically to evaluate performance safety while protecting patients with bone loss during testing (hence the term “Bone Safety Evaluation”), the patient is not asked to do anything he/she would not normally, and naturally do on their own. In 10 years of use, there has not been one case of fracture, vertebral or other, during the physical performance testing conducted on patients with bone loss at UOC (over 1600 tests have been conducted). At UOC, fracture incidence has actually gone down with ongoing BSE testing (2007: 26%, 2008: 11%). And physical performance on the BSE is independently associated fracture prevalence.

As an occupational therapist, I find it is critical to observe a patient’s performance. If I don’t understand how the patient is moving naturally, I can’t work effectively to change their movement. Furthermore, if the patient does not understand how they are moving unsafely, they don’t effectively engage in changing that movement.

As therapists, we inherently want to treat without much testing. It’s in our nature to heal even before we have the whole picture. Would we refuse to treat a patient with obvious hemi paresis without an MRI to confirm a diagnosis of stroke? Of course we would not. Conversely, would we begin treatment of hemi paresis without knowing how the impairment is affecting our patient’s function? Again, we would probably not. Yet, if we understood from the MRI the severity, type and location of the stroke and we knew that our patient wanted to resume independence with self-care, we could apply our treatment more effectively; even be able to plan a better long term treatment plan because expected and desired outcomes are better understood. Is it fair to not offer the same expectations for the patient with bone loss? I believe all patients, regardless of disease state, deserve comprehensive assessment and care.

I think we all realize that every time we initiate treatment with a patient whether it is ultrasound, exercise, or anything else, there is an inherent risk of injury, however small. We temper those risks with knowledge, experience, and judgment. The knowledge part of the equation includes various tests and evaluations conducted before therapy. I don’t think it serves the patient to assume anything about their condition when there is a tool that can give us answers. Of course, it goes without saying that when we use the tool, whatever it is, we must use that tool wisely, carefully, and judiciously.

[Via http://sgrantotr.wordpress.com]

Where The Sun Don't Shine: Vitamin D & Vitamin B12

You’ve heard the term ’sun worshippers’ referring to those people who live their lives in the sun scantily clad with the only goal of getting the darkets tan they can. As a photographer, I am also a sun worshipper, but for a different reason. I’m not so much worried about the sun itself, but it’s reflective light. Most day’s when I’m photographing, I’m either waiting on the light to change or hurrying up before it does. Seems like I’m constantly chasing the sun.

But now, more so than ever, it seems my relationship with the sun is leaning towards the former. There’s much to be said about soaking up the sun, and I am realizing more and more how true that is in my research and journey with B12 deficiency.

In addition to being diagnosed with B12 deficiency and Pernicious Anemia, I was also told I was Vitamin D deficient. Which is not too surprising since I lived in a city and latitude notorious for Vitamin D deficiency; Boston. At 42 degrees north latitude, there isn’t sufficient UVB radiation several month out of the year for adequate vitamin D synthesis. Which is the case for people living in other cities in that range and north.

The combination of being Vitamin B12 deficient and Vitamin D deficient, in retrospect, for me was a vicious cycle. How long this was going on, I’m not sure; but indeed well before I moved to Boston. In my research and reading thus far, I have yet to find solid information correlating vitamin B12 & D deficiency, or that one causes the other. But, I do know the symptoms are similar, especially in respect to fatigue and cognitive functions.

Technically, vitamin D is a fat soluble vitamin which encourages the absorption of calcium and phosphorous. People who are exposed to normal quantities of sunlight do not need vitamin D supplements because sunlight promotes sufficient vitamin D synthesis in the skin. (Reference)

Even when I lived in sunny, Austin, Texas prior to living in Boston for a year, I went to work when it was dark and came home when it was dark. I was working 60-80 hour weeks, working late nights on emails, conference calls and meetings with our overseas supplies and factories. I did get my share of Texas sunshine as I am more of an ‘outdoor’ girl by nature, but just not feeling well and healthy in general despite following several doctor recommendations and chiropractic visits, kept me from having the energy from doing as much outdoor stuff as I wanted. The effects of the B12 deficiency (and Vitamin D, I would think), including never waking up feeling refreshed after sleeping, made it hard to stick with an exercise plan and effort it takes to change to and stick with lifestyle of eating healthy.

Of course some days were better than others, and all my attempts were not futile, just short-term; not ever getting better at the big picture level. With ample amount of coffee and sucking it up and making myself do the things I needed to do despite how I felt, I got by. The important things got done. Other things didn’t. Some didn’t get done very well despite my natural tendency to be anal and somewhat of a perfectionist. Frustrating for me to say the least.

Recovering from Vitamin D deficiency

After receiving the diagnosis of the B12 deficiency and Vitamin D deficiency together from my doctor in Boston, I have to admit I honed in more on the B12 in my research and reading. Not that the Vitamin D didn’t seem important, just not as monumental as the B12.

Vitamin D? Yeah, yeah yeah….bring on the B12 I say!

I couldn’t be more wrong.

Along with the series of B12 injections I took a prescription dose, 50,000iu, of Vitamin D once a week for 12 weeks. Luckily, I only had to take it once a week, since the supplements are $3 each (yikes!). After I finished the prescription dose, I continue to take over the counter supplements combined with calcium twice a day.

I’m sure this happens to most people, but I start to pay attention when the same things continually, and randomly come across my plate. Which has been the case with Vitamin D just in the past few weeks. Articles I just happen upon reading, conversations with various people, blogs I’ve come across and a doctor’s visit I went on with my mom.

In one of my recent blog posts I explained that after my B12 diagnoses, I had my mom get checked for B12 deficiency. It worked out, thankfully, that she was able to see my doctor in Boston, but needed to take her treatment here in South Dakota, but was having trouble finding a doctor who was willing to treat her for the B12 or knew anything about B12 deficiency.

So from recommendations from friends, my mom found a doctor she was hopeful would be knowledgeable about the subject. So I went with her to her appointment; I wanted to hear what he had to say. In the discussion, he talked about the B12, but he told her that the Vitamin D was much more important at this point. I’m not sure it’s because she didn’t have as severe of symptoms of the B12 deficiency as I did or because she was also being treated for her thyroid. But regardless, made me reconsider my thoughts about Vitamin D. I left there wanting to do more research and reading about the ’sunshine vitamin’.

According to the Mayo Clinic website:

‘Vitamin D is found in many dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun also contributes significantly to the daily production of vitamin D, and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies.’

and

‘The major biologic function of vitamin D is to maintain normal blood levels of calcium and phosphorus. Vitamin D aids in the absorption of calcium, helping to form and maintain strong bones. Recently, research also suggests vitamin D may provide protection from osteoporosis, hypertension (high blood pressure), cancer, and several autoimmune diseases.’

Another good resource I found for information is WebMD.

Symptoms of Vitamin D Deficiency:

• Chronic Fatigue
• Cognitive impairment
• Weak bones (Osteoporosis)
• Bone pain (Osteomalacia [similar to rickets])
• Muscle weakness
• Increased risk of death from cardiovascular disease
• Severe asthma
• Cancer
• Type 1 & Type 2 Diabetes
• Hypertension
• Glucose intolerance
• Multiple Sclerosis

Vitamin D Me Please!

As a result of the constant ‘in your face’ Vitamin D propaganda coming at me these past few weeks, as I mentioned earlier, has given me a new perspective and education about Vitamin D.

I continue to take my prescribed supplements faithfully, and with the weather being subzero lately living in the Midwest with the sun nowhere to be found, I have decided to also go to a tanning bed at least one time a week. I am aware of the controversy about skin cancer and tanning beds, but at this point I have to weigh my risk and reward.

I go in the tanning bed for 10 minutes at the most and will guarantee I will not be looking like some of the people I see coming in and out the tanning salon who have similar characteristics like my brown leather purse. Nothing like matching accessories. (Yikes!) No thank you. However, I will like the fact that I won’t be blinding the people anymore at the gym with white legs. I’m sure they’ll appreciate that as well. 

[Via http://b12chronicles.wordpress.com]

Humbug?

Two less than cheery stories to take us up to Christmas this week.

Firstly, organ transplants and skin cancer. One of the unintended effects of improvements in treating once-fatal conditions, is that patients live long enough to get something else. In this case, the longer lives that people can now expect after heart transplant mean that more of them suffer from skin cancer, as a result of the immunosuppressive drugs they need to take to prevent organ rejection. On the (slightly) brighter side, the most common skin cancers are squamous cell carcinomas, which are easily treated by surgery so long as they’re spotted quickly.

My second Guardian story looked at the downside of the injectable contraceptive, Depot Provera, which is known to weaken bones, potentially leading to osteoporosis and fractures. Researchers in Texas looked at risk factors to find out which women were most at risk. They concluded that smoking, eating little dietary calcium, and not having had children were all risk factors – although the associations were weak when you look at them in isolation.

I know, I know. I should have followed the herd and written about Father Christmas as a poor role model for children, or had something to say about the calorie content of mince pies. But there’s only so much Christmas one can take, after all! Have a good one.

Image: Humbugs, by Cari Wallis, from Cari Wallis photostream on Flickr.com, with CCL.

[Via http://annasayburn.wordpress.com]

Falls Disseases and Medicares Role in Treating these Conditions

In seniors who experience diseases such as arthritis and osteoporosis, it is very important to prevent falls from occurring. This is because a fall, even a very small one, can end up being very serious and result in a fracture. If this happens, it can be very difficult for the senior to recover from the accident and in many cases, it will mean a move to an assisted living situation or nursing home. Often, these stays will be covered by Medicare, but this depends on the patients Medicare Eligibility ad what types of benefits they receive.

With such serious ramifications from even a very small fall, protecting against these types of accidents is very serious.

Why Osteoporosis Can Be Dangerous

Osteoporosis is a disease that is most common among the elderly, but can affect those of all ages. However, usually in younger people, it is caused after some sort of injury. Osteoporosis causes the bones to loose some of their density, which makes them very brittle and prone to fracture. It is caused by a lack of calcium and vitamin D and is much more common in post-menopausal women, although it can also affect males.

Osteoporosis is not itself does not cause injuries, but because the bones begin to become more brittle and loose their density, it is more likely for them to break or fracture, even after a very small fall.

Why Arthritis Can Be Dangerous

Arthritis can cause a number of problems and is not actually just one disease, but rather more than 100 different disorders that primarily affect the bodies joints. While, depending on the kind of arthritis, the effects can greatly vary, typically, arthritis causes the joints to become damaged, inflamed, and tender. This can mean that bending the joints becomes much more difficult and even painful.

Unlike osteoporosis, arthritis by itself can cause the affected person to experience dramatic losses to maneuverability and often results in disability. Arthritis can also greatly increase the risk of a fall and if the senior also has osteoporosis, this means that there will be a much bigger chance of injury.

Protecting Against Falls

To protect against falls, there are several options, but often it is important to first take measures to treat the arthritis and osteoporosis. For osteoporosis, maintaining a healthy diet of foods that contain calcium and vitamin D is important, with most seniors also taking vitamin supplements.

In the case of arthritis, treatment is not always as straightforward and depends on what type of arthritis the patient has. Many times, proper diet and exercise are as important as taking medication when it comes to treating arthritis. It is also very important to find ways to make life easier for the patient, as there is no way to work backwards and reverse the effects of arthritis.

In addition to assuring that there is proper treatment, there are also a number of helper aids that are used by seniors with arthritis and osteoporosis. This includes a number of different types of home medical equipment that is designed to either make life easier or safer for the senior. Having a proper pair of shoes with non-skid soles is very important, as is using a walker or rolling walker, and ensuring that all areas of the home can be easily accessed. Lift chairs are also often used, which are like recliners, but are designed to make it easier for the senior to stand.

Medicare’s Role in Treating Osteoporosis and Arthritis

In addition to actually being important for providing treatment, such as covering the cost of medicine and doctors visits, Medicare also covers the cost of a number of different types of home medical equipment. These items are covered under Medicare Part B Benefits and covers a wide variety of medical equipment, including wheelchairs, walkers, mobility scooters, eye glasses, and much more.

Usually, Medicare will provide 80% reimbursement for these items, but this is not always the case. For example, lift chairs Medicare do not qualify for full reimbursement and instead only part of the cost of the device is covered.

Usually for a device to be covered by Medicare, it must, of course, be on their approved list of items (PDF), but it will also require that the individual has a doctors prescription and sometimes also a Certificate of Medical Necessity. A Certificate of Medical Necessity is similar to traditional prescription, but is more detailed and must describe the reasons the senior needs the type of equipment. Usually, if a doctor feels there is a need to offer the patient a prescription for the device, it is not a problem for them to also fill out a certificate of medical necessity.

[Via http://medicarenewsnow.wordpress.com]

Una de cada dos mujeres y uno de cada cuatro hombres mayores de 50 años sufrirán una fractura ósea a causa de la osteoporosis

La cuarta parte de las personas que se rompen la cadera fallecen antes de cumplirse el primer año tras la lesión.

 

Un estudio de la Sociedad Española de Cirugía Ortopédica y Traumatología advierte de que una de cada dos mujeres y uno de cada cuatro hombres mayores de 50 años sufrirán una fractura ósea debido a la osteoporosis. La rotura de hueso es la consecuencia “más grave” de esta enfermedad, ya que “una de cada cuatro personas que se fracturan la cadera fallece antes del año”, apuntó el coordinador del estudio, el doctor Manuel Mesa Ramos.

Los autores del trabajo insistieron en la importancia de prevenir una dolencia que afecta de forma mayoritaria al sexo femenino a partir de la menopausia. Una vez que se pierde la menstruación, se origina un déficit en la producción de estrógenos u hormonas femeninas que, entre otras funciones, tienen la misión de fijar el calcio a los huesos. Esto explica que el paciente tipo de osteoporosis sea una mujer que supera los 60 años y acude a la consulta porque le duele la espalda, en la zona de las vértebras dorsales, a la altura de los omoplatos, detalló el jefe de servicio de Cirugía Ortopédica y Traumatología del hospital Quirón de Bilbao, Iñaki Mínguez.

La primera medida médica suele ser una radiografía para analizar si el motivo del dolor es la precaria salud ósea, debido a la pérdida de densidad. Si la prueba radiológica confirma la sospecha, se recomienda a la paciente una vida activa, que incluya la práctica de deporte no agresivo, una dieta equilibrada que se refuerza con tratamientos a base de calcio, y tomar el sol para que el calcio se fije a los huesos gracias a la vitamina D.

“En algunas mujeres, la desmineralización del hueso se produce a un ritmo alto a partir de la menopausia, que suele tener lugar en torno a los 51 años”, comentó el jefe de servicio de Ginecología y Reproducción Asistida de la misma clínica, el doctor Gorka Barrenetxea. Aunque la mayor fragilidad ósea está relacionada de manera directa con el déficit de producción de estrógenos, existen otros factores de riesgo. El primero es la excesiva delgadez. Sin llegar al sobrepeso, la masa corporal protege frente a la osteoporosis, apuntó Barrenetxea. El tabaquismo es otro punto en contra. “Las fumadoras sufren más osteoporosis”, señaló el doctor, que también recomendó la práctica ejercicio moderado. El consumo abusivo de alcohol también es un factor negativo, añadió.

Importancia de la alimentación
“La alimentación es fundamental, pero a lo largo de toda la vida”, aclaró Íñigo Sainz-Arregui, médico especializado en Nutrición y en Medicina de Familia. “Consumir adecuadas cantidades de calcio está demostrado que protege contra la osteoporosis”, aseguró. Aunque el pico de masa ósea está determinado por la genética, la densidad está relacionada con la ingesta de calcio durante el periodo de acumulación ósea, que se produce desde el nacimiento hasta los 25 ó 30 años. Por eso es importante asegurar una ingesta adecuada de calcio para evitar riesgos, explicó Sainz-Arregui.

El calcio no sólo se encuentra en los productos lácteos como la leche, el yogur o el queso, sino también en verduras de hoja verde como la col, la acelga o el berro. Además, hay que consumir alimentos ricos en vitamina D como pescados, huevos o cereales y productos lácteos fortificados para ayudar a la absorción del calcio. El fósforo de pescados, huevos, legumbres, carne y cereales también en juega un papel importante en la salud de los huesos. “En definitiva, una dieta variada y equilibrada, con poca sal y acompañada de ejercicio físico es la mejor opción”, resumió el nutricionista.

Autor: Consumer-Eroski
Fuente: www.consumer.es
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Etiquetas: Medicina Biológica, Medicina Osteoarticular, Osteoporosis

Lower Back Strengthener

Hi everyone,

As a Pilates teacher, I see many people who have lower back pain and problems.   I would estimate that 90% of these problems come from poor posture and from sitting way too much.    Our bodies are not designed for sitting but too many of us sit for hours and hours each day.   I dare you to calculate how many hours a day you sit – from eating breakfast, commuting, working at your desk, eating dinner and watching television.   It’s not uncommon to hear that people are sitting for 8 – 12 hours a day!  No wonder their backs hurt.

Here’s an easy exercise that you can do just about anywhere and anytime.  It’s not a classical Pilates exercise although you could say that it’s a version of Joseph’s swimming or flight exercise.   It’s known as a McKenzie exercise, named after Robin McKenzie who is one of the world’s leading authorities on lower back pain.

To do the exercise, follow these cues:

1. Stand with your feet a bit wider apart than your hips
2. Keep your knees straight
3. Place your hands in the small of your lower back, fingers turned inward
4. Imagine doing a back dive over your hands, lifting your heart out of your chest
5. Hold for a couple of breaths
6. Repeat three times

Try to do this exercise every hour or so when you need to sit.   If you’re at the office, you can do it in the washroom where it is private.   It will help to strengthen your lower back safely.

Questions?  Don’t hesitate to email me.   I’m here to help.

And please check out the downloadable MP3 workouts on my website.   They’re easy to follow and very effective.   Plus, if you input promo code 4001 when you place your order, you’ll get 10% off your entire order!     

Sherry

Beating Cancers, Step One: Eliminate Animal Milk

For years the animal milk industry has told us that milk is good for us. This was because one ingredient, calcium, is required by our bodies. What the milk industry has never explained is what all the rest of the ingredients in animal milk do to our bodies. Numerous studies, including ones conducted by the animal milk industry, have shown a direct link between consumption of animal milk products and a loss of bone density, not a strengthening of them. There goes the number one selling point, so what’s left? Maybe habit, and the investment of industry. Consumption of animal milk has also been linked to heart disease, cancers, obesity, allergies, diabetes, and other health conditions though, so like stopping smoking, it’s time we began asking ourselves why we are letting advertisements run our lives. Why are we doing this to our bodies, to the environment, and certainly to the animals themselves? Consumption of animal milk has been linked directly to breast cancer, ovarian cancer, colon cancer, and prostate cancer. Here’s a recent press release from the chairman of the Cancer Prevention Coalition. Smoking doesn’t kill you immediately; it’s a slow painful death. Despite this knowledge people find it difficult to quit because they’re addicted. Consumption of animal milk has also been linked to health risks and terminal disease, but in this case quitting is much easier: there’s no addiction to break, only habits. Now almost all markets have products such as almond milk, soy milk, rice milk, oat milk, or others that come in a wide variety of flavors (yes, chocolate too!) and can be used in coffee, on cereal, in recipes, in baking, in anything just like the animal milk we grew up with.

Our parents’ generation smoked, but our generation learned better. Our parents’ generation drank animal milk, but our generation learned better.