Activity level as predictor of recovery

Activity level predicts how well patients recover from injuries after treatment
Published on July 23, 2014 at 3:19 AM ·

According to a literature review in the July issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), patients’ activity level is a strong predictor for how well they will do with certain treatments and how well they recover from injuries after treatment. Patients are encouraged to ask their orthopaedic surgeon if activity level is an important factor in their treatment decision. For example, more active patients are at a higher risk of re-injury after an anterior cruciate ligament (ACL) reconstruction, and activity level should be considered when deciding which graft to use in the ACL repair.

Easily administered, standardized scales for the shoulder, hip, knee and ankle are commonly used in orthopaedics to quantify a patient’s activity level. But, the measures of how often, rather than how well, a task is performed do not account for symptoms, functional disabilities, age, weight, overall health and other factors which also may impact prognostic and outcome variables.

“In orthopaedics, we want to restore function to take away pain and to help patients return to activity,” said orthopaedic surgeon and lead study author Robert H. Brophy, MD. “We’re still learning about how to best use, quantify and measure activity levels to optimize prognostics and outcomes.”

Other literature review highlights:


The strongest predictors for failure in rotator cuff tears were patient expectations on the efficacy of physical therapy and baseline activity level.
After a rotator cuff tear, patients who were active were less likely to respond to nonsurgical treatment.

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Preoperative activity levels, age, male gender and lower body mass index (BMI) were predictors of higher activity level at one and five years following total hip replacement surgery.
Physical activity-including occupational lifting and standing-may accelerate the development and increased risk of osteoarthritis (OA).


Higher baseline activity, lower baseline BMI and higher level of athletic competition were associated with higher activity levels two years after ACL reconstruction.
Female gender, smoking in the 6-month period before surgery, and revision ACL reconstruction were associated with lower activity level.

Following ACL reconstruction, patients were significantly less satisfied if they had a lower post-surgical activity level.

Increased incidences of knee injury and trauma in the athletic population, rather than participation in physical activity, may cause an increased risk of knee OA.

“There’s not just one activity level variable” in these measurements, said Dr. Brophy. “It depends on the population, the injury you’re studying, etc. We’re making progress, and the progress varies depending on what you’re looking at.”

American Academy of Orthopaedic Surgeons

New tests for Alzheimer’s

(CNN) — Approximately 44 million people live with dementia worldwide, according to the Alzheimer’s Association. By 2050, that number is expected to more than triple to 115 million.

In the fight against these fast-growing numbers, experts from all over the world discussed the latest research at the Alzheimer’s Association International Conference in Copenhagen, Denmark, this week.

Here are five things we learned about Alzheimer’s disease and other forms of dementia:

Hypertension in old age may save your brain

High blood pressure is usually called the “silent killer.” However, a new study from the University of California now suggests that if you’re over 90, hypertension can save the life of your brain cells.

Hypertension may protect against dementia in people over age 90, the study authors say.

The researchers followed 625 participants who developed high blood pressure in their 90s for up to 10 years and found that their risk for dementia was 55% lower than people without a history of hypertension.

Nevertheless, the study doesn’t promote hypertension in the elderly, given that high blood pressure is related to other bad outcomes.

“I don’t think it says if I find somebody who’s doing well at age 90, whose blood pressure is 120/80, we should feed them salt to bump their blood pressure up,” says William Klunk, vice chair of the Alzheimer’s Association Medical and Scientific Advisory Council.

The study simply shows that when it comes to normal levels of blood pressure, it might not be a one-size-fits-all with respect to age, he says.

Better late than never

Seniors can lower their risk for late-life cognitive impairment and Alzheimer’s disease with a number of lifestyle changes, new research suggests.

A two-year clinical trial from Karolinska Institutet and the Finnish Institute for Health included 1,260 participants aged 60 to 77. One part of the group received a “lifestyle-package,” including nutritional guidance, physical exercise, management of heart health risk factors, cognitive training and social activities. The control group received standard health advice.

After two years, the lifestyle-intervention group did much better in tests of memory and thinking.

We know from past studies that implementing those lifestyle factors in midlife can hedge against Alzheimer’s disease later on, says Ralph Nixon, chairman of the Alzheimer’s Association Medical and Scientific Advisory Council. “The good news from this particular study is that these kind of changes can be implemented in your 60s and 70s.”

Playing games makes your brain bigger

Middle-aged people who were avid game-players (think crosswords, checkers, cards) tended to have bigger brains than people who did not play games, according to a recent study that looked at brain scans.

“It’s like looking at someone’s muscle mass,” said Dr. Laurel Coleman of the Maine Medical Center Geriatric Assessment Center. “It’s bad when it’s smaller, good when it’s bigger.”

Researchers looked specifically at certain parts of participants’ brains. The volume among game-players was greater in areas that tend to be damaged by Alzheimer’s disease, suggesting the potential for delaying — maybe even avoiding — the disease. People who kept their brains pumped scored higher on tests of their thinking ability.

Coleman suggests mixing it up: Try potentially stimulating activities like learning a new language or switching from reading nonfiction to fiction — anything that poses a cognitive challenge.

Exercise benefits the mind too

Exercise seems to slow the descent toward dementia as well.

Two sets of data from the Mayo Clinic Study of Aging suggest that exercise may positively influence how mild cognitive impairment (a precursor to dementia) and dementia develop.

In one group of patients with mild cognitive impairment, exercising seemed to protect against developing dementia. Data on a different group of healthy patients who exercised — either lightly or vigorously — showed they were less likely to be diagnosed with cognitive impairment.

“We would never say that these things totally prevent Alzheimer’s, that they will cure you,” said Coleman, a geriatrician. “But they’re going to help your brain.”

smell test may detect Alzheimer’s

In the future, a test of your sense of smell may help doctors predict your risk of developing Alzheimer’s disease.

In two separate studies, scientists found that people who were unable to identify certain odors were more likely to experience cognitive impairment. The researchers believe that brain cells crucial to a person’s sense of smell are killed in the early stages of dementia.

Researchers say this information could help doctors create a smell test to detect Alzheimer’s earlier. Early detection means early intervention and treatment to slow the progression of the disease. Doctors today can only diagnose Alzheimer’s disease once it has caused significant brain damage.

“In the face of the growing worldwide Alzheimer’s disease epidemic, there is a pressing need for simple, less invasive diagnostic tests that will identify the risk of Alzheimer’s much earlier in the disease process,” Heather Snyder, director of medical and scientific operations for the Alzheimer’s Association, said in a statement.

Blood test predicts Alzheimer’s disease

10 warning signs of Alzheimer’s

CNN’s Jacque Wilson and Stephanie Smith contributed to this story.

Yoga poses for runners

Editor’s note: Dana Santas is the creator of Radius Yoga Conditioning, a yoga style designed to help athletes move, breathe and focus better. She’s the yoga trainer for the Philadelphia Phillies, Pittsburgh Pirates, Tampa Bay Lightning, Orlando Magic and dozens of pros in the MLB, NHL, NBA and NFL.
(CNN) — If you’re a runner, you’ve probably been told you “should do yoga.”
While generic yoga classes can help with recovery, one of the best ways runners can use yoga is by applying it specifically to correct and prevent chronic issues, such as achilles tendonitis, plantar fasciitis, IT band syndrome, knee discomfort, quad strains and hip pain.
Ask a runner about their past or present physical complaints and you can expect to hear about one or more of these conditions. So what’s behind these ongoing problems?
Consider this: Running is a symmetrical activity and human beings aren’t symmetrical. We all have a dominant side. Which side of your hips is your weight resting on as you read this? How about when you drive your car? Or sit on your couch?
Consequently, spending hours doing a symmetrical activity without awareness of your asymmetrical tendencies can wreak havoc on weight distribution and muscle firing patterns, resulting in compensations that feed all the issues listed above.
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“Most runners’ issues are due to an inability to transfer their center of gravity out of their dominant side,” said Mike Cantrell, president of the Cantrell Center for Physical Therapy and Sports Medicine in Warner Robins, Georgia, and a faculty member at the Postural Restoration Institute in Lincoln, Nebraska.
Lack of acknowledging the problem causes “a cascade of mechanical breakdown, particularly in elite runners.”
Here are three yoga-based moves I use with running athletes to help them address compensations. These can be integrated into overall training programs or used as part of a dynamic warm-up.
How to warm up and cool down
Step-forward and step-back lunges
From standing, inhale and raise your arms as you step forward with your right leg into a lunge. Exhale to hold. Inhale as you step back to standing and lower your arms. Repeat on the left side the same way. Once back to center, repeat on both legs, but exhale as you raise your arms and step forward, inhale on the hold and exhale to return back to standing.
Next, switch to step-back lunges, incorporating the same breathing pattern; begin stepping back on the inhalation and do the second set stepping back on the exhalation.
While practicing these, avoid rolling your forward foot inward or to the outer edge, and maintain knee alignment above the ankle. Be sure both hips point forward and your back-leg-glute area fires.
Pay attention to your breath and core stabilization. If your pelvis and diaphragm function properly, you should be able to stabilize and absorb the shock of stepping backward or forward on either side, regardless of phase of breath.

Flowing bridge
Begin on your back with your knees bent and feet on the floor hip-distance apart. Be sure your feet are pointed forward and aligned horizontally. Your knees/feet indicate hip position, so a forward knee/foot means your hip on that side is pushed forward. Position yourself to place your hips, knees and feet in alignment. Exhale and lift your hips. Inhale and release to the floor. Repeat 8-12 times.
Pay attention to weight distribution in your feet and whether your hips lift evenly; you shouldn’t rely on one side more.
Like the lunges, this move allows you to establish awareness and work to correct favoring one side of your body while also counterbalancing quad and hip-flexor dominance with proper hamstring and glute firing.
Windshield wipers
Start in a bridge position, but place your arms out to the sides and feet wider than hip distance with knees dropped inward. Exhale and allow both knees and legs to drop to the right, coming as close to the floor as comfortable without pain. Inhale and bring the knees together again. Exhale and take the knees left. Repeat 10 times (five each side).
This move stretches and inhibits runners’ overactive hip flexors and quads.

Guidelines for the management of concussion

Sue Hughes | Disclosures

The American Academy of Neurology (AAN), the American Neurological Association, and the Child Neurology Society have joined together to produce a document on the legal and ethical implications on the evaluation and management of sports-related concussion.

The document is published online July 9 in Neurology to coincide with The Sports Concussion Conference taking place July 11-13, 2014, in Chicago, Illinois.

Lead author Matthew Kirschen, MD, The Children’s Hospital of Philadelphia, Pennsylvania, told Medscape Medical News that this is the first time an organization has put forward ethical guidelines for the management of concussion.

“The paper outlines the ethical duty and responsibilities of the physicians caring for athletes with concussion so that they prioritize the current and future physical and mental health of the patient,” Dr. Kirschen explained.

“Doctors have an ethical duty to provide information on concussion risk factors and symptoms and possible neurological impairments in both the short and long term,” he added.

In an accompanying editorial, Ellen Deibert, MD, Wellspan Adult Neurology, York, Pennsylvania, points out that with 1.6 to 3.8 million concussions occurring every year in the United States, this is a rapidly growing public health concern. She welcomes the new document, saying it is “a refreshing reminder of the issues surrounding the treatment of sports-related concussion and the need for continued education and research on this topic.”

The paper also tries to tackle some of the hurdles a physician may face when dealing with a concussed athlete, including the shared decision-making process with the athletes themselves, team coaches, parents, and schools. “The doctor has to protect the athlete from harm but at the same time respect the views of family and those managing the team,” Dr. Kirschen comments. “This can be a difficult line to tread sometimes.”

This document is designed to be used together with the clinical concussion guidelines issued by the AAN last year. “We do not delve into the science of concussion and specific clinical advice in this paper,” Dr. Kirschen says. “That was all dealt with in the guidelines paper. This document deals with legal and ethical issues that may be relevant when treating a concussed athlete and is seen as a companion paper to the clinical guidelines.”

Confidentiality Waivers

One of the recommendations, for example, deals with the situation when athletes are overmotivated to get back to play. “This can be a common occurrence as most athletes do not want to lose their place on the team and there is often big pressure from the coach/school or parents to get them included again,” Dr. Kirschen explains. “They often do not appreciate that they may have a cognitive deficit and this may worsen if they return too soon. Physicians need to balance these factors with the need to protect the athlete from worsening brain injury.”

Dr. Matthew Kirschen

He acknowledges that physicians are aware that they should protect the patient from further harm, but points out things can get complicated in a sports-related field. “Lines can get blurred. It is helpful to have reminders,” he said. “The goal of this document is to remind physicians that they have an ethical obligation to protect the athlete. If they do not feel it is in the best interest of the athlete to return to play they need to be able to express this to the patient, the coach, and the family.”

He noted that sometimes athletes visit numerous physicians until they get the result they want. “We call this ‘doctor shopping,’ and because of confidentiality rules, sometime legitimate concerns are suppressed.”

To deal with this situation, the new document suggests that physicians ask athletes and their families to sign a waiver before the consultation stating that the information can be shared with the athletic coach or school. “Being up front in the loop like this will minimize problems down the line,” Dr. Kirschen says.

He reports that some institutions have such waivers in place already, but normally only when dealing with an affiliated doctor. “It is not yet normal for them to apply to outside practitioners, but we think they should be standard practice.”

He adds: “This document gives physicians things to think about and questions to ask within their practice. Each physician practices in a different environment, so they need to look at what legislation is in place in their state, along with privacy laws and availability of waivers and decide if they need additional waivers or legal documentation in place in their practice.”

The document also calls for all physicians who are likely to encounter concussion patients to undertake new specialist training in the subject.

Athletes with concussion could be seen by a variety of physicians and other healthcare personnel, including those in sports medicine, physical therapy, neurology, family medicine, pediatrics, and emergency medicine. Few of these specialties have had concussion fellowships, although these are starting to be put in place now, Dr. Kirschen noted.

“The AAN has created a lot of CME [continuing medical education] courses to teach doctors about treating concussion. This will bring up to speed physicians who will have first point of contact with these patients.”

Role of the Neurologist?

In her editorial, Dr. Deibert notes that neurology residents are trained to deal with most of the symptoms encountered in a concussion patient.

“When it comes to residency and fellowship training, the argument could be made that neurology residents would be the best prepared to treat concussion patients compared to our medicine colleagues,” she says.

But she points out that because of a limited number of neurology training programs and a “paucity of neurologists comfortable with treating concussion patients,” most concussions are currently managed by other subspecialties, such as primary care, pediatrics, and psychiatry, with athletic trainers and nurse practitioners also playing a large role.

The document also recommends the development of a concussion registry in order to track and better understand the natural course of the injury. Dr. Deibert points out that this would need to be developed together with the many subspecialists already involved in concussion management, and this process would help define the role of the neurologist.

Neurology. 2014;83:352-358. Published online July 9, 2014. Abstract Editorial 


ACL injuries in young female athletes

Laird Harrison | Disclosures

An Epidemic of ACL Injuries
In the mid-1990s, Bert R. Mandelbaum, MD, realized that his practice at the Santa Monica Orthopaedic and Sports Medicine Group in Santa Monica, California, was changing.
“I saw a flip,” he says. “My practice had been about 80% male and 20% female. And then it went to 80% female and 20% male.”
Over in Ohio, renowned knee surgeon and orthopedic sports medicine specialist Frank Noyes, MD, was noticing something similar at the University of Cincinnati and among Olympic soccer players. The number of anterior cruciate ligament (ACL) injuries had more than tripled among National Collegiate Athletic Association (NCAA) soccer players from 1990 to 2000.[1] Researchers crunched the numbers and confirmed what the surgeons had noticed: Women suffer ACL injuries at 4-10 times the rate of men.[1]
Noyes, Mandelbaum, and others like them investigated this phenomenon. They found the cause, devised preventive exercise programs to address the situation, proved that the programs work, and shared them with the world. But their work has hardly staunched the tide of athletic knee injuries, leaving them groping for a next act. “We feel that it’s a very unmet need,” Noyes says.
Noyes estimates the incidence of ACL injuries in the United States at 300,000 per year. And the injuries can be devastating. One study found that only 44% of athletes are able to return to competition after ACL surgery.[2]
While men still suffer the majority of ACL injuries, the incidence of such injuries has risen as more people — particularly more women — participate in sports.[3] From the 1981-1982 school year to the 2012-2013 school year, the NCAA added 3071 women’s sports teams and 749 men’s sports teams to its roster, with the highest growth in women’s soccer.[3]

Diagnosing the Problem
Noyes has some theories about why women, especially teenage girls, are blowing out their ACLs. “I observed that the way they moved in jumping and landing and cutting, the so-called ‘wiggle-wobble knee,’ made it apparent that there were balance and control issues that made them vulnerable to knee injuries,” he says.
But not every female athlete is suffering this way. “I noticed that Olympic volleyball players had really good knee control,” Noyes says. The reason, he theorizes, is the plyometric training that volleyball players do. “They jumped off mattresses,” he observes.
To confirm the theory, his team videotaped men and women, injured athletes and noninjured athletes, as they jumped onto force plates that measured the impact of their landing. The investigators found significant differences. Among the most striking: Women — and people who had suffered knee injuries — were more likely to land harder, with their knees less flexed and more valgus.
In 1994, Noyes and colleagues at the Cincinnati SportsMedicine Research and Education Foundation, of which Noyes is President, began to develop Sportsmetrics™, a program of exercises aimed at reducing the risk for injuries. They were able to show that the training can change biomechanical metrics, such as the distance between the athlete’s knees when landing from a jump.
A few years later, at a meeting of the American Orthopaedic Society for Sports Medicine, Mandelbaum and others who had noticed the trend toward knee injury watched hours of video showing athletes getting injured. They too noticed the awkward landings of the athletes who hurt their knees.
“I was the national team physician for US men’s soccer and I felt it was my duty to put together a program,” Mandelbaum says. Soon the Santa Monica Sports Medicine Foundation, of which he is Director, was testing the Prevent Injury Enhance Performance (PEP) program, which consists of a warm-up, stretching, strengthening, plyometrics, and sport-specific agilities to address potential deficits in the strength and coordination of the stabilizing muscles around the knee joint.
New Programs Focus on Prevention
Around the world, other regimens were cropping up as well, and they have proliferated. Sue Barber-Westin, Director of Clinical and Applied Research at the Cincinnati Foundation, counted 50 of them in a recent literature review.[4]
Many of these regimens have proved themselves in clinical trials, in which some teams do the exercises and other teams stick to their usual warm-ups. Noyes and Barber-Westin showed that Sportsmetrics reduced the risk for noncontact ACL injuries by 88%-100% in soccer, basketball, and volleyball.[4-12]

“It definitely works,” Barber-Westin says. “You can see in 6 weeks that you really can change these dangerous movement programs that you see in female athletes.”
PEP achieved similar success, reducing the risk for ACL injuries by 82% in soccer alone.[4]
But the success of a program depends partly on the outcome measured. The HarmoKnee Preventive Training Program, developed by Swedish researchers, reduced the combined incidence of all types of acute knee injuries, including contact injuries, by 90% in soccer.[13] And exercises developed by researchers at the Norwegian University of Sport and Physical Education in Oslo, Norway, reduced the combined risk for lower extremity injuries in team handball by 47%.[14]
Other programs have reduced injuries in male athletes as well. Mandelbaum went on to help develop FIFA11+, a program for soccer’s governing body, the Fédération Internationale de Football Association (FIFA), which cut overall injuries — not just knee injuries — roughly in half for male soccer players.[15]
The number of competing programs can be bewildering. But they have a lot in common.[4] They train athletes to land softly on the forefoot and roll back to the rearfoot, engaging the knee and flexing their hips on landing and when making lateral cutting maneuvers. They demonstrate how to avoid excessive genu valgum (“knock knee”) on landing, squatting, and running.
Most of the programs also feature jumping exercises (plyometrics), as well as hamstring, gluteus medius, core, and hip abductor strength exercises aimed at correcting imbalances.[4]
“Soccer athletes are quad-dominant,” says Holly Silvers, MPT, who worked with Mandelbaum on the PEP and FIFA programs. “They don’t use their hip adductors a lot. And if the quad pulls against the ACL, if they don’t have enough hamstring co-contraction, that creates an imbalance.”
Some of the programs include stretching exercises; others don’t.
The programs work differently, and their developers are each ready with arguments for why theirs is the best. For example, Sportsmetrics differs from most of the other programs in offering a six-week program of training for 90 minutes, three times a week at the beginning of the season. The Cincinnati foundation certifies instructors in the program.
In contrast, most other programs are based on participation throughout the season — for example, as a 15-minute warm-up before practices. Barber-Westin argues that repeating the exercises multiple times per week will lead to poor compliance. “The athletes get bored,” she says.
Holly Silvers has the opposite perspective. If athletes don’t keep up the exercises, they become less effective over time, she says. “The reality is you lose compliance,” she notes. “If you abandon them, you get recidivism. There is a benefit to continuous development over the season.”
To prevent boredom, the FIFA11+ program offers 3 levels of some exercises so that athletes can challenge themselves to improve.
Will Athletes Take ACL Prevention Seriously?
The debate about compliance gets at the key problem facing all knee injury prevention programs: Not enough athletes are doing them.
“We’re doing a study to try to get a handle on how many clubs are implementing injury prevention,” Mandelbaum says. “So far, the numbers are extremely disappointing.”
It’s not as if these experts haven’t tried to spread the word. “We’ve been preaching this for 15 years,” says Frank Noyes.
Dozens of journal articles have shown the efficacy of the knee injury prevention programs, and lay publications, such as Sports Illustrated and the New York Times, have reported on them. “It’s not that people don’t know the information,” says Bert Mandelbaum. “It’s that people don’t pick up the information.”
Lately professional organizations have started getting on board. In April, the American Academy of Pediatrics endorsed neuromuscular training for young athletes to prevent ACL injuries.[16] It also published a list of resources for these programs[17] and a report on diagnosing and treating ACL injuries.[18]
Noyes has heard that other organizations are working on similar statements. But it’s not doctors — but rather coaches, trainers, parents, and the athletes themselves — who need convincing.
“Part of it is the nature of athletics today, and part of it is human nature,” says Noyes. “If you have a 15- or 16-year-old daughter and she participates in soccer, would she rather go to a summer skill camp to learn how to manage the ball and learn how to do all the skills for six weeks, or is she going to take a six-week performance neuromuscular training camp?”
Experts offer these tips to physicians who want to help reduce knee injuries:
• Reach out to trainers and coaches in your community;
• Make the argument that the programs will not only prevent injuries but also enhance athlete performance; and
• Point out that the training programs don’t take extra time, because they can replace traditional warm-ups, such as toe-touches, that have not been shown to reduce injury.
Consciousness-raising is a slow process, but statistics suggest that even convincing one team to undertake these exercises can save several athletes from physical and emotional pain and loss of fitness.

Sent from my iPhone

Do you think you need a knee replacement?

Study: 1/3 of knee replacements are questionable
Whether to replace aging knees can be a tough decision. More than 650,000 Americans underwent total knee replacement surgery last year, but a new paper from researchers at Virginia Commonwealth University suggests that a third of those were not “appropriate,” based on standard medical criteria.

The study authors analyzed 175 cases, looking at imaging tests to find the degree of arthritis, as well as each patient’s age and reported pain level. Only 44% of the operations were rated “appropriate.” Thirty-four percent were “inappropriate,” while 22% were inconclusive.

But appropriateness is in the eye of the beholder, says Dr. Jeffery Katz, an orthopedic surgeon at Brigham and Women’s Hospital in Boston. When the current criteria were developed in the late 1990s, knee replacement “was considered a treatment of last resort,” Katz writes in an editorial published alongside the study in the Journal of Arthritis and Rheumatism. Today, many are being done in relatively healthy people in their 50s and 60s.

Is fake knee surgery as good as the real thing?

What’s more, some doctors say, safety and effectiveness have improved significantly since the criteria were first developed.

“Knee replacement is very effective,” says Dr. Joshua Jacobs, an orthopedic surgeon at Rush University Medical Center and a former president of the American Academy of Orthopaedic Surgeons. “The increasing demand is a marker of how well it improves function and relieves pain.”

Whether knee replacement should be used to preserve function and not just restore it “is worthy of debate,” says Dr. Daniel Riddle, the paper’s lead author and a professor in the Department of Physical Therapy and Orthopedic Surgery at VCU. “Some patients play nine holes of golf and they want to play 18, and knee replacement can help with that.”

He says the real question is whether it’s worth the cost – which typically runs between $20,000 and $40,000 – and the potential risks.

A knee replacement is major surgery; potential dangers include infection, deep vein thrombosis and pulmonary embolism. There’s even a non-negligible chance of death, although it’s less than 0.5%, according to the paper.

With younger patients, other factors come into play. Those who undergo the operation early are more likely to achieve a high level of function than patients who wait for their knees to deteriorate. New knees can also help support a higher level of activity and the health benefits that go with it. One analysis cited by Jacobs says there’s a typical lifetime benefit of $10,000 to $30,000 due to lower absenteeism, better overall health and other factors.

On the other hand, anyone getting a knee replacement in their 50s or 60s has a good chance of experiencing a re-run: approximately 10% wear out within 15 years and need to be replaced again, says Riddle.

For more, check out the American Academy of Orthopaedic Surgeons’ guide for patients.

Post by: Caleb Hellerman – CNN Medical Supervising Producer
Filed under: Aging • Arthritis • Conditions • Orthopedics

Do you drink coffee? Here are some benefits.

Editor’s note: Registered dietician Cynthia Sass is Health magazine’s contributing nutrition editor.
( — Half of Americans start their day with coffee, and according to recent study, working out after downing a cup of java may offer a weight-loss advantage.
The Spanish study, published in the International Journal of Sport Nutrition and Exercise Metabolism, found that trained athletes who took in caffeine pre-exercise burned about 15% more calories for three hours post-exercise, compared to those who ingested a placebo.
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The dose that triggered the effect was 4.5 mg of caffeine per kilogram of body weight. For 150-pound woman, that’s roughly 300 mg of caffeine, the amount in about 12 ounces of brewed coffee, a quantity you may already be sipping each morning.
If you’ve always thought of coffee as a vice — one you’re simply not willing to give up — you’ll be happy to know that it’s actually a secret superfood. And if you exercise, caffeine can offer even more functional benefits for your workouts.
Here are five more reasons to enjoy it as part of an active lifestyle, along with five “rules” for getting your fix healthfully. 12 surprising sources of caffeine
Improved circulation
Recent Japanese research studied the effects of coffee on circulation in people who were not regular coffee drinkers. Each participant drank a 5-ounce cup of either regular or decaffeinated coffee. Afterward, scientists gauged finger blood flow, a measure of how well the body’s smaller blood vessels work.
Those who downed “regular” (caffeinated) coffee experienced a 30% increase in blood flow over a 75-minute period, compared to those who drank the “unleaded” (decaf) version. Better circulation, better workout — your muscles need oxygen!
Less pain
Scientists at the University of Illinois found that consuming the caffeine equivalent of two to three cups of coffee one hour before a 30-minute bout of high-intensity exercise reduced perceived muscle pain. The conclusion: caffeine may help you push just a little bit harder during strength-training workouts, resulting in better improvements in muscle strength and/or endurance. 15 natural back pain remedies
Better memory
A study published this year from Johns Hopkins University found that caffeine enhances memory up to 24 hours after it’s consumed. Researchers gave people who did not regularly consume caffeine either a placebo, or 200 mg of caffeine five minutes after studying a series of images. The next day, both groups were asked to remember the images, and the caffeinated group scored significantly better.
This brain boost may be a real boon during workouts, especially when they entail needing to recall specific exercises or routines.
Muscle preservation

In an animal study, sports scientists at Coventry University found that caffeine helped offset the loss of muscle strength that occurs with aging. The protective effects were seen in both the diaphragm, the primary muscle used for breathing, as well as skeletal muscle. The results indicate that in moderation, caffeine may help preserve overall fitness and reduce the risk of age-related injuries. 14 reasons you’re always tired
More muscle fuel
A recent study published in the Journal of Applied Physiology found that a little caffeine post-exercise may also be beneficial, particularly for endurance athletes who perform day after day.
The research found that compared to consuming carbohydrates alone, a caffeine/carb combo resulted in a 66% increase in muscle glycogen four hours after intense, glycogen-depleting exercise. Glycogen, the form of carbohydrate that gets stockpiled in muscle, serves as a vital energy “piggy bank” during exercise, to power strength moves, and fuel endurance.
Packing a greater reserve means that the very next time you work out, you’ve upped your ability to exercise harder and/or longer.
Is coffee good or bad for you? How Anderson really feels about coffee Coffee cup revolution is coming 11 ways to boost your energy with food
But this news doesn’t mean you should down as much coffee as possible — your good intentions may backfire. In my work with athletes, I recommend five basic rules to best reap caffeine’s rewards:
Don’t overdo it. The maximum amount of caffeine recommended for enhancing performance with minimal side effects is up to 6 mg per kg body weight, which is about 400 mg per day (or about 16 ounces of coffee) for a 150-pound woman.
Incorporate it in healthy ways. Doctor up coffee with almond milk and cinnamon instead of cream and sugar, or whip coffee or tea into a fruit smoothie, along with other nutrient-rich ingredients like almond butter and oats or quinoa.
Be consistent with your intake. Research shows that when your caffeine intake is steady, your body adjusts, which counters dehydration, even though caffeine is a natural diuretic. In other words, don’t reach for two cups one day and four the next.
Keep drinking good old H2O, your main beverage of choice.
Nix caffeine at least six hours before bed to prevent sleep interference, and listen to your body. If you’re relying on caffeine as an energy booster because you’re tired, get to the root of what’s causing fatigue. Perhaps it’s too little sleep, overexercising, or an inadequate diet. If something’s off kilter, you won’t see progress, and you’ll likely get weaker rather than stronger. Striving for balance is always key!

Gluteal tendinopathy: pathology of lateral hip pain

When you hear the words lateral hip pain, what is the first thing you think of?


That’s OK, most people do.

Examination of the hip and pelvis often does reveal an inflamed trochanteric bursa, but evidence suggests that this may just be a symptom, rather than the underlying pathology.

Dr Henry Wajswelner (FACP) is a Specialist Sports Physiotherapist, and he recently visited Perth for a series of presentations on this subject. Those that attended the WA Symposium went home pretty inspired to examine more patients with lateral hip pain.

Henry gave a great overview of the presence of gluteal tendinopathy, as the underlying pathology in these lateral hip pain presentations.

Mechanisms of lateral hip pain

Did you know one in four women over the age of 50 have been shown to have gluteal tendinopathy?1

One in four!

As has been described in recent models of tendon pathology, it is thought that these gluteal tendons undergo the same failed adaptation to persistent load.

Without adequate time to rest and unload, these tendons undergo an increase in proteoglycan production, resulting in a separation and disorganisation of the matrix2.

Clinically, we observe this progressive overload as a difficulty in bearing load during weight-bearing tasks (particularly single leg tasks).

Kong et al (2007) presented an interesting visual illustration of the changes found on magnetic resonance imaging (MRI) and ultrasound (US)3. They show evidence of direct pathology (tendinopathy, tendinosis, partial and complete tendon tears) as well as indirect pathology (bursal fluid, bony sclerosis and fatty atrophy of muscles)3.

Bursitis, although present, may be a secondary manifestation of this primary gluteal tendinopathy.

Henry gave generously of his clinical experience, and described commonly reported mechanisms such as:

An increase in exercise (e.g. walking, running), particularly in active woman, 40-60 years of age.
Pain associated with side-lying, both on the affected side (compression), as well as lying on the unaffected side. This is because the symptomatic limb can rest in a position of flexion and adduction.
Prolonged sitting, particularly in low chairs. Sitting with crossed legs will further increase tension and compression of lateral hip structures.
Compression of the deep surface of gluteus medius and minimus tendons can often occur in the stance phase of weight bearing exercise. This compression, combined with repeated overload (without adaptation), may be a key component in this continuum of tendon pathology.

Movements that create the most compression (and provocation):

hip flexion
hip adduction
hip internal rotation
Tendinopathy: What to look for on examination?

Examining functional tasks, such as standing (single/double leg) and walking, may demonstrate a positive trendelenberg sign.

Patients may demonstrate a waddling gait, compensating for this impaired muscle function in the horizontal plane.

A strong waddling gait, may indicate more than weakness of gluteus medius, such as a tear or complete tendon rupture.

Gluteal tendinopathy management

Henry describes that the factors you avoid, are just as important as the aspects you facilitate in rehabilitation.


Low sitting.
Crossing legs.
Standing with more weight on one leg, such as carrying a child on your hip.
Position of hip flexion, adduction and internal rotation. This includes trying to stretch the iliotibial band, which Henry reminds is not possible, being a non-contractile tissue.
Corticosteriod injections. This may create disagreement, however evidence suggests that corticosteroid use in the tendon dysrepair phase may promote further matrix breakdown.
Rehabilitation Principles

Strengthen gluteus medius and gluteus minimus with the focus on restoring normal functional movement.
Dry needling can provide short term pain relief.
Exercise Prescription

Start with slow, sustained holds (isometric) at inner range for gluteus medius.

This can be performed in crook lying, sitting or standing.

You can test this yourself in sitting or standing by having your feet shoulder-width apart, and initiating an isometric squeeze of your legs into abduction (push sideways on the floor). You can feel gluteus medius activating on palpation.

A good measure of performance before progressing, is to perform 10 sets of 10 second holds, without symptom provocation.

Exercise progressions are vast, but general guidelines could include:

Progress from bridging, to sit-to-stand, ensuring engagement of gluteus medius, minimus and maximus.
Progress with appropriate variations of squats.
More advance functional retraining can be aided with different gym-based equipment, such as pilates reformers.
The aim is to promote pain-free load bearing capacity of the gluteals in single and double leg functional positions.
Further progression can be tailored for sports-specific purposes.
Patients should be encouraged to work into fatigue and discomfort (<5/10), as this is needed to create a training effect.

Important factors to consider

As part of your clinical reasoning process, it is also important to identify any other contributing factors in each patient’s presentation.

This includes considering psychosocial factors, particularly cognitive factors around the patient’s thoughts and perceptions of their condition.

Various lifestyle factors can contribute to ongoing lateral hip pain, such as poor sleep.

It is also important to identify any workplace variables that may be continuously provoking symptoms, most importantly around prolonged sitting and any repeated compression of gluteus medius tendon.


The primary pathology in lateral hip pain is tendinopathy, not bursitis.
Use known models for tendinopathy to guide your exercise rehabilitation.
Avoid hip flexion, adduction and internal rotation.
Structured and progressive strength training is necessary to condition these tendons.
Always consider a biopsychosocial approach to help identify all contributing factors.
Many thanks to Dr Henry Wajswelner (FACP) for sharing his knowledge in this area. Be sure to check out any future education opportunities with Henry.

Additional Resources

Physio Edge Podcast – Lateral hip pain interview with Alison Grimaldi.


Segal et al 2007, ‘Greater trochanteric pain syndrome: epidemiology and associated factors’, Arch Phys Med Rehabil, vol. 88, no. 8, pp. 988-992. [PMID: 17678660]
Cook J and Purdam C 2009, ‘Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy’, British Journal of Sports Medicine, vol.43, no. 409-416. [PMID: 18812414]
Kong et al 2007, ‘MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome’. Eur Radiology, vol. 17, no. 7, pp. 1772-1183. [PMID: 17149624]
Creative Commons image courtesy of Robert Bejil.

How smartphone can help prevent falls

Every year, 1 in 3 adults aged 65 and over in the US experiences a fall. In 2010 alone, 2.3 million nonfatal fall injuries among older adults resulted in emergency department visits, and 662,000 of these patients were hospitalized. But a study by researchers from Purdue University details how a smartphone could prevent falls from occurring. The Purdue team, including Babak Ziaie, a professor in the School of Electrical and Computer Engineering and the Weldon School of Biomedical Engineering, will present their findings at the International Society for Posture & Gait Research 2014 World Congress in Canada next month. The researchers explain that people with slower gait (the pattern of walking) speeds and irregular stride patterns are more likely to fall. But they note that at present, there is no way of measuring this information as individuals go about their daily routines. As such, the team created a portable smartphone tool – called SmartGait – that is worn on the waist and can measure a person’s gait length (the distance between the tip of the front foot to the tip of the back foot), gait width (the distance between each foot) and walking speed. To create the device, the researchers took a standard smartphone with a downward-looking wide-angled lens and added an app that enables the phone to record and calculate a user’s gait measurements. The app records gait measurements through colored “foot markers” worn on the tip of each shoe. Device ‘will help health care professionals assess patients’ fall risk’ To test the effectiveness of SmartGait, the team compared it with a “gold standard” laboratory system that measures gait using sensors and infrared-emitting diodes. The researchers say the SmartGait device should help health care professionals better assess patients and recommend measures that may prevent falls. Image credit: Purdue University/Mark Simons They report that the smartphone tool was able to calculate a person’s step length with 95% accuracy and width length with 90% accuracy. Ziaie says he became interested in this area of research after his grandfather suffered a fall and broke his hip. He later passed away as a result of his injuries. The team believes this new device may help reduce the occurrence of falls, not only for elderly individuals, but for those who have conditions that affect their balance, such as Parkinson’s disease. They explain that health care professionals could use the information from the SmartGait device to better assess patients and recommend measures that may prevent a fall, such as physical therapy, exercise or vision correction. In addition, they say the patient could wear the device over time so a health care professional can determine their walking confidence. “The beauty of SmartGait is that it gives you results similar to a system that costs several tens of thousands of dollars. People can wear it walking upstairs, downstairs, outside, shopping, whatever they do during a normal day,” says Ziaie. “We believe this device will be highly beneficial for researchers and clinicians who conduct gait assessments in the field,” he continues. “Reducing the fall rate has so many benefits – preventing injuries, minimizing pain, maintaining independence and saving lives.” The team says they have a filed a US patent application for the device through the Purdue Office of Technology Commercialization. Last year, Medical News Today reported on a study published in the BMJ, which claimed that exercise may prevent fall-related injuries in older adults. Written by Honor Whiteman View all articles written by Honor, or follow her on: Copyright: Medical News Today Not to be reproduced without the permission of Medical News Today.

How can Physical Therapists help someone with BPPV?

Physical Therapist’s Guide to Benign Paroxysmal Positional Vertigo (BPPV)

Jump to:

What Is BPPV?
How Does it Feel?
How Is It Diagnosed?
How Can a Physical Therapist Help?
Can this Injury or Condition be Prevented?
Real Life Experiences
What Kind of Physical Therapist Do I Need?
Further Reading
Every year, millions of people in the United States develop vertigo, a spinning sensation in your head that can be very disturbing. Benign paroxysmal positional vertigo (BPPV) is one of the most common types of vertigo. If you’ve been diagnosed with BPPV, you’re not alone—it’s estimated to affect at least 9 out of every 100 older adults. The good news is that BPPV is treatable. Your physical therapist will use special exercises and maneuvers to help.
What Is BPPV?
Benign paroxysmal positional vertigo (BPPV) is an inner-ear problem that causes short periods of dizziness when your head is moved in certain positions. It occurs most commonly when lying down, turning over in bed, or looking up. This dizzy sensation is called vertigo.

A layer of calcium carbonate material is present naturally in one part of your inner ear (the utricle). BPPV occurs when pieces of this material break off and move to another part of the inner ear, the semicircular canals (usually the posterior canal). These tiny calcium crystals (otoconia) are sometimes called “ear rocks.”

When you move your head a certain way, the crystals move inside the canal and stimulate the nerve endings, causing you to become dizzy. The crystals may become loose due to trauma to the head, infection, conditions such as Meniere disease, or aging, but in some cases there is no obvious cause. It’s possible that BPPV might run in families. Some people report that their BPPV symptoms recur predictably, perhaps seasonally or with changes in the weather.
Inner Ear: See More Detail

How Does it Feel?
BPPV occurs most commonly when lying down, turning over in bed, and looking up. This dizzy sensation, called vertigo, usually lasts only a few seconds up to a minute but can make you feel like the room is spinning around you. It may also make you feel lightheaded, off balance, and nauseous

How Is It Diagnosed?
The diagnosis of BPPV is based on whether you have a particular kind of involuntary eye movement (called “nystagmus”) and whether you have vertigo when your head is moved into certain positions. Your physical therapist will perform tests that move your head in specific ways to see whether vertigo and involuntary eye movement results. If you have neck or back problems, the therapist might use a test that allows you to lie on your side while movements are made. These tests will help the therapist determine the cause and type of your dizziness and whether you should be referred to a physician for any additional testing.

How Can a Physical Therapist Help?
No medication has been found to be effective with BPPV and, in some cases, medication could cause more harm. Fortunately, most people recover from BPPV with a simple but very specific head and neck maneuver performed by a physical therapist. The maneuver is designed to move the crystals from the semicircular canal back into the appropriate area in the inner ear (the utricle).

The most common treatment is called the Epley maneuver. The physical therapist shows you how to move your head through a series of 4 positions, with the head staying in each position for about 30 to 60 seconds. In the Semont maneuver, the body is rapidly moved from lying on one side to lying on the other.

Depending on information from your test results, you might be asked to perform Brandt-Daroff exercises, which need to be performed several times per day for several days; however, these exercises have not yet been shown to be effective in clinical trials.

In a very few cases, BPPV cannot be managed with treatment maneuvers, and a surgical procedure called a “posterior canal plugging” may be considered—but that’s usually a last resort. It’s rarely ever done.

Can this Injury or Condition be Prevented?
There is no known way to prevent BPPV. Symptoms can return if new crystals break off and get into the semicircular canal or if you dislodge loose crystals by placing your head in a certain position.

It’s estimated that within 3 years of having BPPV, about 50 percent of people may have a recurrence. If a head injury caused your BPPV, your risk of recurrence is even greater. Although your BPPV might return, you’ll be able to recognize the symptoms and keep yourself safe until you can get help. Your physical therapist will apply the appropriate maneuver to return the crystals to their correct position in the inner ear and also will teach you how to do exercises that can reduce or get rid of the problem.

Real Life Experiences
Laura B. is a 68-year-old woman with vertigo that began one morning 2 weeks ago when she got out of bed and the world started to spin. Since then, she’s been having vertigo, nausea, and problems with her balance. When she visits her physical therapist, he gives her a special questionnaire to find out exactly what brings on her dizziness and balance difficulty. Turning over in bed and bending over or looking up cause her the most severe symptoms.

The physical therapist reviews Laura’s medical history to make sure that there is no past condition that might be important to her problem. He performs an examination, explaining what tests he will use and that Laura should try to keep eyes open and stay in position. The tests show that in certain positions, Laura’s eyes move when they shouldn’t, and she has vertigo that lasts 5 seconds. The therapist determines that she has the “canalithiasis form” of vertigo, which means that some crystals are displaced and are located in her semicircular ear canals, causing her vertigo.

The therapist uses “canalith repositioning” to move the crystals into a proper position, using the Epley maneuver. Afterwards, he asks Laura to wait in the waiting room for a while. He then does a re-test. Laura no longer has the symptoms that she had when the therapist tested her the first time, so he shows her how to do the canalith repositioning maneuver at home. She is to do the maneuver once every day in the morning for one week and then will return to the clinic to make sure that she is progressing as expected.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat people who have dizziness and balance problems. You may want to consider:

A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological or a vestibular rehabilitation focus.
A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in Neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with inner ear injury.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence about treatment of BPPV. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2011;16;(2):CD005397. Systematic Review. Article Summary on PubMed.

Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90:663–678. Free Article

Cohen HS, Sangi-Haghpeykar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2010;143:405–412. Free Article.

Clinch CR, Kahill A, Klatt LA, Stewart D. Clinical inquiries: what is the best approach to benign paroxysmal positional vertigo in the elderly? J Fam Pract. 2010;59:295–297. Review. Article Summary on PubMed.

Authored by Susan J. Herdman, PT, PhD; Shannon L.G. Hoffman, PT, DPT; Marcia Thompson, PT, DPT; Bob Wellmon, PT, PhD, NCS; and APTA’s Section on Neurology. Reviewed by the editorial board.