Seminar Adolescent Idiopathic Scoliosis

San Juan De Dios Physical Medicine and Rehabilitation has a seminar today October 13 2013 on Adolescent Idiopathic Scoliosis. For those who attended you can download a copy of the first part of the lecture here it is in PDF format. Hope you learned something new.

ADD Ads Exercise at Home

Here in the Philippines, may it be at daytime or night time, the major TV/Network channels have their way of luring viewers to watch. Their technique is to have what they call “Telenovelas” or “Teleseryes”. People get to be glued either in the afternoon or even during and after supper to watch local or foreign (usually Korean) translated to tagalog series. Now why in all of the topics I am covering this time has got to do with such series?

I usually see patients in the clinics wherein the relatives, caregivers or even the patient themselves complain that home exercises taught to them are not being done. Reasons usually range from there is no more time, they are tired already, no one is able to monitor the exercise, or the home exercises are too many.

My highly recommended time is then to add the exercises during “telenovela” time.

 How come? Since these major networks want to get your viewing time, they will make you watch a 30 mins to an hour show BUT their style is that they will have the “teleserye” show for around 4 to 5 mins and then followed by a 4 to 5 minute set of advertisements ranging from 10 to 15 commercials. After which the cycle begins again. 5 mins show, 5 mins advertisements until the show ends for the day. Then you will watch it again the next day, Monday to Friday. Sure you can get glued to the show for the 5 minutes but what do you do on the 5 minutes of advertisements?

My highly recommended activity, Add Ads Exercises at home!

Simply stated, you add exercises during ads time. The set of exercises that are given by the physical therapist can be done during the advertisement time. How many times? Do 1 repetition of an exercise during 1 commercial. Once that particular 5 minutes is through, you have done 1 set of 10 to 15 reps of that exercise. On the next set of advertisements, do another type of exercise or another set. By the time you are finished with 1 show, you completed it. If you are glued the whole night, then the more you have done your exercises.

Advantages:

1. It solved the no time to do it at home.

2. You won’t get tired. By doing 1 exercise per advertisement which is around 10 to 15 seconds per advertisement most likely is not that hard. And what else would you do to make your time more meaningful during those commercial breaks.

3. Monitoring. The companion of the patient can be glued to the show but during breaks can help out with the patient. It is a win-win situation.

4. Too many exercises dispersed during the whole series of shows made you enjoy your night in watching and at the same time been able to do what is needed. What more can you ask for!

Conclusion:

 Home exercises are given to help the patient carry out the program even at home. But in order to make it easier, simpler and even convenient is just by doing 1 rep of exercise per advertisement time. It may be not enough to look on a short term goal but it will be meaningful in the long term. As the saying goes, “One step at a time and you will get there eventually”.  In this case, Add 1 Ads Exercise at a time and it will make you reach your goal at the convenience of your HOME!

Neurological and Functional Recovery: The Difference

Having a stroke is one of those medical conditions with a devastating effect on a person as well as for the family. I will not go into detail on this for this article but just to provide a general view a stroke is a medical/neurological condition wherein the brain gets injured due to sudden block of blood flow or due to rupture of a blood supply to it. The effect in terms of what happens to a person is generally affectation of the strength usually on the half side of the body. This is called hemiparesis(partial) or hemiplegia (complete) which is the paralysis of half of the body. i.e affectation of the left upper and left lower limb  or vice versa.

Now just to give a rundown, the cost for medical treatment is definitely something of a blow to any family. It not only disrupts the savings of the family but it may also affect the income especially if the one affected is the breadwinner. Not only that, the family members who will skip work or go on leave also looses their productivity/earnings. Do I need to say more?

Now after the patient becomes stable and is discharged, the question now arises if how much did the patient recover? I will define first neurological recovery. I will simplify this, a patient prior to a stroke has a normal strength on both upper and lower limbs. A Normal grade is 5 over 5(5/5). When the patient has a stroke the left side as an example lost its strength and became poor (2/5). Not only that but also his sensation to touch on the left side decreased by 80 percent. The patient also had difficulty in speaking. All of the above findings show a neurological deficit. If after 4 days of treatment the patient regained his strength from poor (2/5) to fair (3/5), his sensation to light touch improved from 80% less to 50% now while his speech became normal. Those improvements are what we call neurological recovery. See table below.

As for functional recovery, it is the ability of the patient to do activities with or without neurological deficits. Using the example above the patient has initially been fully functional, working, typing, eating, dressing independently etc. He had a stroke wherein he has 2/5 strength, 80% sensory deficit and affected speech. So he became confined to bed, unable to go to the bathroom, feed himself etc. He became fully dependent. Now lets change the situation after 4 days. He still has the same deficit but he is now able to sit by himself, he is able to sit for 30 mins with minimal support, and now able to eat with partial assistance. He has recovered functionally even if his neurological deficit is still the same after 4 days. See table below.

Why am I pointing out these differences? It is because it is often thought that being unable to move a limb means one cannot adapt and become functional. There are patients who had superb neurological recovery as they can move the upper and lower limbs after a stroke and yet are in wheelchair and fully dependent in their activities. While those who have 2/5 lower limbs strength are now able to ambulate with a cane and do self care activities with minimal assistance.

CONCLUSION: The point I am driving is that the functional recovery on an individual is not based solely on the neurological recovery. By undergoing physical rehabilitation and with the proper motivation a patient can recover functionally even with a poor neurological recovery.

Importance of Physical Therapy

A local advertisment simply says it all, "Mahal ang magkasakit." (Getting sick is expensive). This is especially true for those who got hit by devastating or debilitating conditions such as strokes or similar conditions that affect the physical strength of a patient. Lets try to enumerate the would be expenses: Hospitalization, medicines, laboratory and imaging/diagnostice procedures, and profesional fees for physicians

Now comes the second part of the expenses, upon discharge of a patient and brought home its time to deal with the refitting of the residence to the present needs of the patient. Then one will include continuation of medicine, needed diagnostic test for monitoring and scheduled checkups with their physician.

Now why am I trying to enumerate all of these and yet the title is importance of Physical Therapy. Well simply stating it, a patient who is brought home and has lost the ability to be independent in activities of daily living (walking, dressing, eating, walking, bathing, working etc), needs assistance and caregiving. Which in order to achieve independence partial or complete, needs to undergo physical therapy. Now the other concern is, did physical therapy start while in the hospital or just an afterthought upon dischage?

Unfortunately, this is something that is not sometimes discussed to the patient/relatives and if by any chance discussed, may be considered as a miscellaneous expense and not a required expense. What am I pointing out? If a patient is asked to buy medicines and/or undergo physical therapy, what will the patient/relative do? The patient/relatives may opt to have both but oftentimes will opt to have the medicine and forego the physical therapy. The would be possible reasoning is, "Pwede naman yan pag lumabas na ng hospital" (That can be done already once the patient is discharged).

Again unfortunately, it may be initially less expensive if physical therapy is not done during confinement but how is it in the long run? An article done by Ruth M. Kleinpell, Kathcy Fletcher and Bonnie Jennings in Patient Safety and Quality: An Evidence-Based Handbook for Nurses pointed out the ff:

1. I quote " A dissonance exists between the hospital environment and therapeutic goal for the hospitalized elderly." (This means the goal is to make them medically stable but not functionally recovered upon discharge)
2. By Day 2 deconditioning and functional decline was evident on elderly individuals.
3. Elderly patients who was assessed during confinement showed that from day 2 to discharge, 67% showed no improvement and 10 percent showed further decline.

It then just shows that if an individual further declines in functional status that means, EXTRA care/assistance. Which is equivalent to a caregiver or nurse stay at home. If the patient is fully dependent you might need 2 caregivers in 1 duty shift. Or even to the point that the relative/love one would stop or not work in order to take care of the patient. That is lost productivity not only for the patient but also for the relative taking care of him/her.

And study shows that a deconditioned muscle (due to disuse or non use), needs 2 to 3 times the duration to be strengthened back to its original condition as compared to its deconditioning. So for example, the lower limbs lost its strength for 2 weeks of bedrest/immobility, it will need 4 to 6 weeks before it regains its former strength. And that is for young individuals, what more for elderly or those who became debilitated?

The Evidence Based Review of Stroke Rehabilitation (ESBSR), states that there is strong evidence that greater intensities of physiotherapy and occupational therapy resulted in improved functional outcomes after stroke. This then points to the fact that in the long run, which is the usual duration for those who have a stroke will benefit on early intervention to minimize potential prolonged bedridden and immobilization complications management. These complications, such as bedsores, pulmonary conditions, lower limb edema, joint stiffening, fully dependent on all activities, depression etc, may then prove more costly than having early intervention.

Table 1 shows the effect of prolonged bed rest. (click Table to enlarge)
*Source/Table were it was taken from is noted at end of article.

Conclusion: Patients who had debilitating conditions that affect their functional status during confinement should be assessed properly if early physical therapy intervention is needed or not. Talk to your attending physician so that the recommended Physical Medicine and Rehabilitation specialist can discuss and provide the benefits and consequences or early physical/occupational therapy. Know your options so that you can decide on what would be more beneficial for the patient as well as for the love ones.


* Ruth M. Kleinpell, Kathcy Fletcher and Bonnie Jennings in Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Next article would be the difference between neurological and functional recovery.

Runner's Feet Seminar Presentation

Just today, I had the opportunity to share my insights on a seminar conducted in San Juan De Dios Hospital in Pasay. The topic is Runner's Feet. I was given the task to share about the anatomy of the shoe as well as the biomechanics of the foot that affect an individual during running. It also included some history of the running shoe as well as the evolution of the shoe.
So as promised to the attendees, I am providing a link to the presentation slides for your own personal use. As I have mentioned, with so much paper used, I went the paperless route and hopefully you just place this in your electronic device, (ipad,computer,smartphone) and minimize the unnecessary use of paper if you can store it digitally and electronically.
By the way, I will make this available for download for only the month of December 2011. After which I will remove it already. So make sure you get it and save it before the end of the year. It is in pdf file already.
Enjoy and here is the link. Just click on it. Does the shoe "feet"? presentation

Falls in the elderly: Exercises done at home

Your patients or love ones who have been not so  active at home will succumb sooner or later to the what we call deconditioning. Due to their condition such as poor balance or affected by other ailments, they become confined in bed, or wheelchair or chair. Definitely such situations will leave their upper and lower limbs weaker. As the saying goes, "Use it or lose it."

So here are some simple exercises that you can ask your patient or love one to do at home. We will start with some exercises for the upper limbs done during sitting.

1. Forward Arm lift
While the patient is sitted. Make the patient do an arms forward position. Then let the patient lift the arms alternately beyond the head level or as high as they can go. Just make sure the patient breathes in and out while doing the exercise. Do not make them hold their breath.

Do this without or with weights being held on the hand depending on the patients capability.


2. Backward pull exercise

Again patient in an arms forward position and then let the person imagine as if pulling a stick backward. This can be done with or without weights or even holding a stick. Remind the person to just breath in on starting position and breath out during pull position. Do not make them hold their breath.

Arms forward starting position

Backward pull position

3. Shoulder shrugs

Let the person keep the arms and hands on the side (with or without weights) and then let the person shrug the shoulders. Breath in during starting position and breath out on shrug position.

Shoulder shrug starting position

Shoulder Shrug up position

Reasons of doing this?

1. To keep the upper limb in good condition or at the least not deteriorate its strength.
2. Keep the joints moving and not become stiff
3. Strengthen the muscles that help the person stand during pull up to stand as well as keep the tone of the upper back muscles.
4. Prevent stooping forward during sitting.

How many times to be done?

Depending on the condition of the patient, you can start at 10 counts per exercise and progress accordingly.
It is advised to do it 3 times a day, morning, afternoon and early evening.

Extra Tip:

The simpliest weight you can use are just plastic water bottles. A 250ml water bottle is equivalent to 1/4th kg. (100ml water is equivalent to 100gms) So no need to buy gym weights.

The next set will be standing exercises.

Special Thanks to Mr. Jayson Javier, PTRP. Upon this blog post, he is  a PT faculty instructor in The College of Physical Therapy of San Juan De Dios Educational Foundation, Incorporated, Pasay City.

Falls in the elderly: Prevention

Now we will deal with simple things in the household to prevent accidents that may lead the elderly people to lose balance. Also included are some things to consider to do when you have them checked by their physician.

Here in the Philippines, it usually have an extended type of family structure which of course consists of the grandparents or older population. So what are those simple steps to consider.

1. Keep the wires off the floor.

Tangled wires

Usually extension cords, phone wires or internet wires, appliance wires criss-cross all over our houshold. It is thus obvious that the foot of an individual may be snagged while crossing over these wires.

2. Make sure rugs or floor mats will not cause snagging of the foot. If this is not kept flat off the floor then again catching the foot while crossing over it is very highly likely.

3. Make sure the floors are not slippery. We should reconsider if waxing and making the floor too shiny is not a potential fall factor for the elderly.

4. Use of non-skid shoes/slippers.

5. Use of night light in bedroom, stair lights. For some general "phenomenon" the elderly usually do not want to open lights going to the bathroom when they wake up at night. Again this is a potential risk for falls due to a) less ability to see in the dark b)balance and equilibrum problems c)weaker lower/upper limbs

6. Use of bedside commode instead of going to the bathroom during night time.

7. As for stairs, make sure there is contrasting colors of the steps and wall in order for them to discern the steps and not get confused or have a misstep.

8. Have their eyes checked. If only 1 eye is really able to see. i.e. cataract on 1 eye causing less vision, the depth perception of the individual is compromised.

9. Polypharmacy: Elderly individuals usually have a LOT of meds to take in the morning, lunch, evening and even in between. So try to visit their physician and ask what can be reduced or removed if possible. The potential for cross interactions is very high for multiple medicine intake that may affect their balance.

Alright, now the next blog will be some exercises that can help out the elderly. Stay tuned.
* Picture c/o MS online clipart from Fotolia