Category Archives: Aging

how do falls happen

How Do Falls Happen?

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Statistics show that the majority (60 percent) of falls happen on the same level resulting from slips and trips. The remaining (40 percent) are falls from a height. This document will summarize information on “falls on the same level” (slips and trips). Falls from an elevation, such as falls from ladders, roofs, down stairs or from jumping to a lower level, etc., will discussed in another document since each type of fall requires different features in a fall prevention program.

Slips
Slips happen where there is too little friction or traction between the footwear and the walking surface.
Common causes of slips are:
• Wet or oily surfaces
• Occasional spills
• Weather hazards
• Loose, unanchored rugs or mats, and flooring or other walking surfaces that do not have same degree of traction in all areas

tripping

Trips
Trips happen when your foot collides (strikes, hits) an object causing you to lose the balance and, eventually fall.
Common causes of tripping are:
• Obstructed view
• Poor lighting
• Clutter in your way
• Wrinkled carpeting
• Uncovered cables
• Bottom drawers not being closed, and uneven (steps, thresholds) walking surfaces

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For more information about balance and fall prevention click the links below:


    
Tips for Seniors: How to Avoid Injuries During Sports and Exercise

Tips for Seniors: How to Avoid Injuries During Sports and Exercise

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Tips for Seniors: How to Avoid Injuries During Sports and Exercise

Our bodies change with age. It may not be a pleasant thought, but at least most changes are gradual. One thing that does not change as the body ages is the need for physical activity. Physical activity promotes physical and mental well-being. Before you head out the door, learn why your risk for injury is higher as you get older.

As you age it’s possible to notice a couple of significant changes:

  • Tendons and ligaments lose some of their elasticity. This can lead to reduced range of motion in the joints, making these areas more prone to injuries. And unfortunately, older bodies tend to take a bit longer to recover from injuries.
  • A loss in muscle. This loss usually begins in the mid-40s (earlier if you are inactive) and may decline as much as 10% after the age of 50. This muscle loss can certainly mean a decline in physical abilities and make it easier to gain weight. Fortunately, regular exercise can significantly slow this muscle loss. If you do not use your muscles regularly, the tissues become weaker and less compliant.

Although older adults accumulate a variety of injuries, the most common injuries involve sprains (stretching or tearing of a ligament) and strains (stretching or tearing of a muscle or tendon) around the shoulders, knees, and ankles. These injuries may only cause minor soreness or stiffness. People often do not recognize soreness as a problem, and they work through the pain. This may lead to more soreness and injury. Other common injuries include tennis elbow, Achilles tendinopathy, and shin splints.

How to Avoid Injuries During Sports and Exercise

To live a longer, more productive life, you have to exercise. You may need to exercise at a lower pace or for shorter periods of time than you did when you were younger. Remember that you may not be able to play hoops to the level of your 30-year-old colleagues, or play as many back-to-back tennis matches as you once could. This is a great time to make some changes to your routine and play smart. Before you get started, follow these tips so you can avoid injuries during sports and exercise:

  • Get a basic medical screening. Talk with your doctor. Find out if you have any conditions that would put you in jeopardy while exercising. If you have a chronic condition that is limiting, you may be able to work out an activity plan within the scope of your ability.
  • Find a balanced exercise program. Do not rely on one sport to keep you in shape. Follow a program that includes cardiovascular activity, strength training, and stretching.
  • Warm up before and cool down after physical activity. Adding a few minutes to your warm up can make your workouts smoother. Cold muscles are more prone to injury, which is why you are asking for trouble if you skip the warm-up. Try some light jogging or walking.
  • Keep it regular. You will not make gains in fitness by cramming your activity into the weekend. Aim for 30 minutes of physical activity every day.
  • Take lessons. Hire a trained professional such as a physical therapist or licensed athletic trainer to help you attain and maintain proper form in your sport, even if it is weight training.
  • Get the right equipment for your sport. You want to make sure the gear you use for your activity is in good shape and used properly. Think about the condition of your shoes, or if you will need a helmet.
  • Follow the 10% rule. When you are ready to increase your activity level, do so in 10% increments. In other words, increase activity small increments per week. This rule also applies to working with weights.
  • Be cautious about adding new exercises. Whether you are a seasoned fitness enthusiast or new to exercise, avoid taking on too many activities at once. Add activities gradually.
  • Listen to your body. Pay attention to the messages your body is sending you. If your knees hurt after you ski, find an easier ski run or maybe think about a different activity that does not hurt your knees.
  • Be careful about jumping right back into your routine. Gradually return to your workout routine if you had to take a brief time out because of illness or injury. If an injury requires additional help make sure to follow the return-to-play guidelines provided by your physical therapist.
  • Seek professional help if you injure yourself. Consult your physical therapist for injuries that are not relieved with home care. Some injuries require medical treatment and will not go away on their own.

Old age no longer means less activity. In fact, it means quite the opposite. The more active you are the better your body will age. Play smart, listen to your body, and you will find more abilities than limits. For help finding a workout that fits your lifestyle and ability levels don’t hesitate to call your physical therapist. They have the expertise and skills needed to help keep you active and safely avoid injuries during sports and exercise.

RESOURCES:

Office of Disease Prevention and Health Promotion
www.health.gov

Sports Med—American Orthopaedic Society for Sports Medicine
http://www.sportsmed.org

CANADIAN RESOURCES:

Healthy Canadians
http://www.healthycanadians.gc.ca

Public Heath Agency of Canada
http://www.phac-aspc.gc.ca

REFERENCES:

Effects of aging. Ortho Info—American Academy of Orthopaedic Surgeons website. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00191. Updated September 2009. Accessed October 26, 2016.

Making physical activity a part of an older adult’s life. Center for Disease Control and Prevention website. Available at: http://www.cdc.gov/physicalactivity/everyone/getactive/olderadults.html. November 9, 2011. Accessed October 26, 2016.

Physical activity guidelines for Americans. United States Department of Health and Human Services website. Available at: http://www.health.gov/PAGuidelines. Accessed October 26, 2016.

Sports injury prevention for baby boomers. Ortho Info—American Academy of Orthopaedic Surgeons website. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00178. Updated August 2011. Accessed October 26, 2016.

Last reviewed October 2016 by Michael Woods, MD  Last Updated: 12/10/2014

Arthritis: Facing the Facts

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There are several types of arthritis, which can be defined as an inflammation, degeneration, or infection of a joint. Some types of arthritis just affect a few joints and are called oligoarthritis. Others affect many joints in the body and are called polyarthritis. Arthritis can be symmetric, meaning the pain and inflammation is roughly the same on both sides of the body. It can also be asymmetric, affecting just about any joint in the body at any given point in time. This article will talk about several of the major types of arthritis, including osteoarthritis, rheumatoid arthritis, septic (infectious) arthritis, and crystal arthritis (which includes gout).

OSTEOARTHRITIS (OA)

Osteoarthritis (OA) is slowly-developing form of arthritis that can affect nearly every joint and that can affect individuals as they age. Joints that take a lot of pressure or that have repetitive motion are at the greatest risk for OA. The disease can be relatively asymptomatic or severely debilitating, affecting the patient’s ability to participate in activities of daily living.

The primary problems with OA are joint pain and stiffness. Symptoms can affect just one joint or several joints. The pain is worse with movement and relieved by rest. There are three stages of pain. The first is stage 1 (predictable, sharp pain with movement). The second is stage 2 (more constant pain that affects daily activities). The third is stage 3 (constant dull/aching pain with unpredictable sharp flares). The pain is usually worse in the late afternoon and evening but can also be worse after awakening. It may interfere with sleep.

OA can be localized or generalized and can affect one single joint or multiple joints at a time. The joints that are particularly a problem for OA include the knees, hips, interphalangeal (hand) joints, facet joints of the neck and back, first great toe joint, and thumb joints. The other joints are less commonly affected, particularly if they are not moveable joints.

Patients with generalized arthritis usually have the distal interphalangeal joints of the fingers involved, the base of the thumbs, the first great toe joint, the spinal facet joints, knees, and hips. Gradually, more joints become involved and the patient becomes more debilitated. The main clinical marker for OA is Heberden’s nodes, which are hard lumps at the distal finger joints.

Diagnosis of OA

Imaging can help diagnose OA. The best test for osteoarthritis is the conventional x-ray. It allows for detection of the usual features of OA (including osteophyte formation, cysts on the bone, and joint space narrowing). An x-ray, however, isn’t very sensitive and doesn’t often correlate with symptoms.

As to specific joints seen on x-ray, the hands are usually bilaterally and symmetrically involved. The distal interphalangeal joints at the tip of the fingers are characteristically affected. Other joints affected are the other finger joints and the base of the thumb. There is a lot of aching and stiffness of the joints. The patient with Heberden’s nodes has nodal OA. Most individuals with nodal OA are female with a family history of the disease.

Erosive osteoarthritis is a rare but aggressive type of hand OA. There is subacute or insidious pain with soft tissue swelling and numbness of multiple finger joints. There is tenderness, redness, and soft-tissue swelling of the hands that is not seen in ordinary OA. Erosive OA is not connected to generalized OA as it affects mostly the finger joints and spares the thumb and metacarpal phalangeal joints. Erosive OA has a worsened outcome than regular OA and can be seen on x-ray showing joint erosions (wearing down) in up to 8% of patients.

The knee is a common site of OA and the most common cause of lower-limb disability in older adults. It is usually bilateral to some extent. The patellofemoral joint or the medial tibial femoral joint is most affected. Pain from patellofemoral joint OA is made worse by prolonged sitting, standing up from a low chair, and climbing stairs or inclines (coming down often being more painful than going up).

Osteoarthritis of the hip can be seen as increased pain, stiffness, aching sensation, and restricted movement of the hip joint. Pain secondary to hip arthritis is felt in the anterior groin but may involve the upper thigh and buttocks. It commonly radiates down the leg with thigh pain and knee pain common complaints. The pain is made worse by rising from a seated position and during the initial phases of walking.

Facet joint arthritis generally goes along with intervertebral disc degeneration—a term called “spondylosis”. The pain is localized primarily to the lumbar or cervical spine and, in the low back, the pain radiates to the groin, buttock, or thighs, ending at the knees. It is worse in the morning and when active with rotation or bending motions (or with neck rotation and lateral flexion in the neck).

OA can be differentiated from other diseases by clinical history and physical examination. Rarely are things like lab tests and x-ray recommended. The clinical findings are of persistent pain in overused joints, age older than 45 years, and stiffness of less than 30 minutes in the morning. Imaging and lab tests can be done if the person doesn’t meet the obvious clinical features (by history or physical examination). Constitutional symptoms (like weight loss and fatigue) or signs of inflammation of the joint point away from OA and need further evaluation.

Risk Factors for OA

OA has been found to be a complex interaction of many factors, including genetics, mechanical forces, joint integrity, and certain biochemical processes. Genetics is probably the rarest interaction, while things like occupation, aging, trauma, and repetitive movement play a stronger role. These are stronger for the hand and knee and less strong for OA of the hip. Common risk factors include age, being female, being obese, having no osteoporosis, certain occupations, playing certain sports, having an injury, muscle weakness, and proprioceptive deficits. Less common risk factors include genetics, having acromegaly, and having CPPD disease. Advancing age is the strongest risk factor. It occurs in less than 0.1 percent of those under 34 years but is present in more than 80 percent in those older than 55 years.

Previous injury seems to increase the risk of osteoarthritis of the knee and having congenital hip dysplasia enhances the risk of hip arthritis. Long-distance runners have an increased risk of knee injury and knee osteoarthritis. Having an injury during this sport will increase the risk of osteoarthritis of the knee. Knee meniscus injuries are common in OA of the knee. Having an amputation of one leg increases the pressure to the other leg and increases the chances of OA of the unaffected leg. Genetics play a small role in getting osteoarthritis. There is a genetic influence in getting osteoarthritis of the hands and knees.

Treatment of OA

The goals of the treatment of osteoarthritis are to decrease pain, improve function, and modify the process of joint damage. This depends on changing modifiable risk factors as there are no disease-modifying OA drugs. Usually a combination of treatments is recommended. Things like hyaluronic acid injections in the knee are not recommended because they do not work any better than placebo.

The mainstay of treatment for OA is nonpharmacologic interventions. These include weight management, orthotic devices, braces (if necessary). Exercise has been found to be as good as NSAID therapy with strengthening and aerobic exercises good choices. A loss of 10 percent of the body weight will decrease pain by 50 percent with knee arthritis and hip arthritis. Splints and knee braces are good for thumb and knee arthritis, respectively.

Second-line things for osteoarthritis include drugs, such as capsaicin, nonsteroidal anti-inflammatory drugs, duloxetine, and intra-articular corticosteroids. A combination of these can be tried. Duloxetine is also called Cymbalta, which is an SSRI antidepressant that works for arthritic and musculoskeletal pain disorders. If a few joints are affected, a topical NSAID is recommended, with oral NSAIDs used only if topical medications don’t work. Acetaminophen has a risky side effect profile and a negligible effect on OA pain, so it isn’t recommended. Opioids are not recommended as they don’t work well for OA and have a long-term dependence and abuse potential.

Surgery usually means total joint replacement—usually done for advanced hip and knee arthritis. Other surgical options include a partial meniscectomy or debridement of cartilage but these have no clinical benefit over placebo. Hip arthroscopy can be done but may not be beneficial in OA.

RHEUMATOID ARTHRITIS (RA)

RA is a symmetric, inflammatory, peripheral arthritis, affecting many joints. The untreated patient will have degeneration of the cartilage and deformities of the joints in a symmetrical way. The prompt recognition and treatment of the condition with DMARDs, which are disease-modifying antirheumatic drugs, will help manage but will not cure the disease. The presentation in the beginning is similar to other arthritis patients but, over time, there will be distinctive evidence of RA, with joint erosions, extraarticular manifestations, and rheumatoid nodules.

Clinical Findings in RA

The synovial joints are what are affected most in RA. The arthritis is usually symmetrical, leading to destruction of joints secondary to bony and cartilaginous erosion. It starts in the hands and feet and moves centrally so locomotion becomes difficult within 10-20 years after onset. The onset is gradual and involves many joints, although some people will have a single joint involved in the beginning. Systemic symptoms occur in about 33 percent of patients and include muscle aches, low-grade fever, depression, weight loss, and fatigue.

In “classic” RA, the patient has morning stiffness, joint pain, and swelling of joints. The MCP (metacarpophalangeal) joint and the PIP (proximal interphalangeal) joints of the hand are the main joints involved initially; however, a few patients can have thumb, wrist, or metatarsophalangeal (MTP) joint involvement. Eventually other synovial joints of both the upper and lower limbs eventually become affected. Morning stiffness is the most common feature of active RA. It tends to last longer than an hour in RA and less than an hour in people with other inflammatory diseases.

Physical signs and symptoms include joint pain and swelling of the small joints (primarily), plus the typical morning stiffness and decreased grip strength. The spine is usually not involved. There is progressive joint damage and deformities, with loss of physical impairment. Late findings of untreated disease include anemia, rheumatoid nodules, eye inflammation, blood vessel inflammation, neuropathy, and pericarditis.

The hands are typically involved at the MCP and PIP joints. Redness and thickening of the flexor tendons may be seen in the palm; nodules may be seen in these tendon sheaths, causing trigger finger and possible tendon rupture. In established RA, there may be an ulnar deviation of the MCP joints.

The second most common areas of involvement are the wrists. Loss of extension happens early on in the disease process and, later on, there is volar subluxation and radial drift of the wrist. The elbow may become fixed in the flexed position. Olecranon bursitis is very common. Shoulder involvement is a late finding, seen in just half of patients after 15 years.

Lower extremity involvement is usually with the forefoot and ankles. Hip involvement is a late finding. Knee involvement can lead to Baker’s cysts. The MTP joints of the feet are the primary joints in early disease with eventual lateral drift of the toes and plantar subluxation of the metatarsal heads. Heel pain will show itself and the ankle may be swollen. Knee swelling is also common and restriction of flexion can be seen. There will be weakness of the quadriceps muscles.

Lab and Imaging Studies in RA

Lab findings in RA include those things seen in the synovial fluid and blood, indicating that the disease is both local and systemic. Things that are seen include inflammatory joint fluid, anemia of chronic disease, and lab tests that are positive for rheumatoid factor (RF) and ACPA (anti-citrullinated peptide antibodies). About 80 percent of patients will be positive for RA and/or ACPA. About 25 percent will have a positive antinuclear antibody titer.

Plain films can tell a lot about the state or RA. There will be joint space narrowing and bony erosions—especially of the hands and feet. These erosions are cardinal findings in RA. MRI testing is more sensitive in detecting synovial inflammation. It is also more sensitive for bony erosions than plain films. Ultrasound is also sensitive for detecting joint inflammation. Doppler ultrasound is nearly as good as an MRI and is cheaper than the MRI examination.

Evaluation of Suspected RA

This disease is usually present in adults and the main finding will be inflammatory polyarthritis. The affected person will have joint pain and at least thirty minutes of stiffness in the morning. Peripheral joints tend to be prominently involved. Symptoms lasting less than six weeks might be a viral polyarthritis instead of RA. In such patients, an anti-cyclic citrullinated peptide (CCP) antibody titer, rheumatoid factor, and acute phase reactants can be done. It may take many visits to get a clear diagnosis.

The examination includes a thorough joint evaluation, expecting symmetric polyarthritis, limited ROM of the muscles, and some extraarticular findings, like rheumatoid nodules. The lab tests will often include an RF and anti-CCP antibodies as a positive result that will increase the chances of it being RA. In an initial evaluation, however, these will be positive only in 50 percent of patients with early disease.

Other tests that are done include the ANA titer (which can exclude lupus and other rheumatic diseases). The ANA titer, however, will be positive in a third of RA patients so follow-up testing, like the anti-dsDNA and the anti-Smith antibody test should be done as these are highly specific for lupus. The CBC is done to check for anemia of chronic disease, liver and kidney function tests are done, and a serum uric acid level is drawn.

Baseline plain x-ray will be done of the hands, feet, and wrists in order to document a baseline so as to monitor disease progression. Joint erosions may or may not be seen initially. There are other specific findings seen in other joint diseases that will point to other diagnoses as well. Arthrocentesis is done to exclude crystal disease like gout. Gram-staining, cell counts, crystal search, and cultures are done on the fluid. MRI and ultrasound are not routinely done but they are more sensitive tests and can be done in patients with normal plain x-rays.

Treatment of Rheumatoid Arthritis

The treatment of RA depends on controlling the synovitis in the joint and preventing injury to the joint. Treatment strategies have changed remarkably over the last twenty years with the institution of DMARD therapy earlier in the course of the disease process. The goals include early diagnosis, care by a rheumatologist, early use of DMARDs, and tight control having a goal of remission or significantly reduced activity. Now, NSAIDs and glucocorticoids are adjunctive therapies instead of primary therapies. DMARDs have become the primary therapy.

Making the diagnosis as early as possible is important because DMARD therapy works best if there isn’t any joint damage. Once diagnosed, the patient needs a rheumatology referral and follow-up care performed by a rheumatologist (as the disease outcome is better). These patients need comprehensive care that includes drug therapy, education, psychosocial interventions, physical and occupational therapy, nutrition counseling, screening for osteoporosis, and things like vaccines to prevent disease in their immunosuppressed state.

Therapies include NSAIDs and intraarticular steroid injections, biologic and nonbiologic DMARDs, and an oral janus kinase inhibitor. Conventional, nonbiologic DMARDs include hydroxychloroquine, sulfasalazine, methotrexate, and leflunomide. There are a number of biologic DMARD drugs, including TNF-alpha inhibitors (etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol), anakinra (an IL-1 receptor antagonist drug), and tocilizumab (an IL-6 receptor antagonist drug).

DMARD therapy is started as soon as possible. With active RA, an NSAID and corticosteroid are used along with methotrexate (as a first line agent). Patients who can’t take methotrexate should have hydroxychloroquine, sulfasalazine, or leflunomide. Nonbiologic DMARDs can be taken with biologic DMARDs. NSAIDs and prednisone are used temporarily as adjunctive therapy.

RA will naturally have flareups that need management. DMARD therapy may need adjusting. Flareups of just one or a few joints can be treated with intraarticular glucocorticoid injections. Widespread flareups are treated with an increased glucocorticoid dose (oral or IM). IV methylprednisolone done three times daily can be effective in reducing a flareup. Increased doses of methotrexate can help as will increased doses of infliximab.

SEPTIC ARTHRITIS

Septic arthritis is an infection in the joint, usually caused by a bacterial organism; however, it can be caused by mycobacterial species or fungi. These types of infectious processes can result in severe joint destruction and later arthritis. Among adults presenting with an acutely painful joint, septic arthritis represents 8-27 percent of cases, depending on the location in the world. The average is about 10 percent of cases. Some patients will have gonococcal disease, while others will have prostheses that get infected.

Risk Factors for Septic Arthritis

About ten percent of cases of patients with an acutely painful joint have septic arthritis. Risk factors for the disease include age greater than 80 years, having a diagnosis of diabetes mellitus, having rheumatoid arthritis, having a prosthetic joint, having recent joint surgery, IV drug use, being an alcoholic, having a concurrent skin infection, and having a previous corticosteroid injection. Each of these risk factors is small but together they add up.

If a patient has bacteremia, they are more likely to have the bacteria harbor in an arthritic joint when compared to a normal joint. About 40 percent of septic arthritis patients had preexisting RA or OA in the joint affected by sepsis. RA predisposes the patient to septic arthritis to a greater degree than OA but less common joint problems, like gout, pseudogout, and Charcot joint disease can be predisposing factors. Being on immunosuppressive therapy for RA is a predisposing factor, making RA a slightly higher risk than the other joint diseases.

Most cases of septic arthritis come from a blood infection that spreads to the joint. Trauma, direct inoculation, extension of bone infection, or animal/human bite are other less common causes. Risk factors for bloodborne spread include IV drug use, the presence of indwelling catheters, immunocompromised states (like HIV), being a neonate, and being older.

When the infective organism is Staphylococcus aureus, enterococcus, or streptococcus, endocarditis should be suspected and IV drug use is the most common reason for this infective endocarditis. Most of these patients will have negative cultures of the blood because the bacteremia was transient and self-limited. It is unknown why only a small percentage of patients with bacteremia develop septic arthritis.

Bacterial arthritis can occur along with bacterial meningitis. The most common organism associated with both septic arthritis and bacterial meningitis is meningococcus. Rare cases of septic arthritis can stem from catheter insertion (such as hip arthritis and sternoclavicular arthritis). A ruptured colonic diverticulum can also cause septic hip arthritis by spreading through the tissues.

While many pathogens can cause nongonococcal bacterial septic arthritis, the most common bacterial species causing this in adults is MRSA (methicillin-resistant S. aureus). Less common organisms include S. pneumoniae, Enterococcus, Escherichia coli, and other gram-negative bacilli. Almost all cases are from a single organism (except for those caused by penetrating trauma to the joint space, polymicrobial bacteremia, or ruptured diverticulum causing a hip infection).

Clinical Signs and Symptoms of Septic Arthritis

These patients tend to present with a single inflamed, painful, and swollen joint. There is usually warmth and restricted movement. Crepitus would not be noticed and there are no nodules. Many patients are feverish but will not have chills or spiking fever. There may be evidence of other infections present that point toward the original source of the infection.

The knee is involved in more than half of all septic arthritis cases, with lesser joints being the hips, ankles, and wrists. Rarely, the pubic symphysis can become infected after pelvic surgery. About 20 percent of the time, the situation is oligoarticular or polyarticular, especially with those individuals having RA or another connective tissue disease (and in severely septic patients).

Diagnosis of Septic Arthritis

The definitive test is to identify the bacteria in the synovial fluid. There should be a joint aspiration before starting antibiotics with synovial fluid sent for Gram stain, culture, leukocyte count (and differential), and crystal analysis. The tap may need to be done under fluoroscopic, ultrasound, or CT guidance. The results of the fluid analysis would be as follows:
• There will be purulence with a WBC count of 50,000-150,000 cells per microliter (mostly neutrophils). The higher the WBC count, the greater is the chance of sepsis.
• The Gram-stain is positive in 30-50 percent of cases.
• The culture should be done and will be positive in most patients who haven’t recently been on antibiotics. Blood cultures are generally positive in 50 percent of cases so they should be done.

Treatment of Septic Arthritis

The two components of acute bacterial arthritis include antibiotics and drainage of the joint. The choice of antibiotic depends on the presentation, Gram stain, and probable organism. Gram-positive cocci deserve vancomycin as an empiric treatment as this might be MRSA. If it is found not to be MRSA but to be methicillin-susceptible S. aureus, then the agents of choice include cefazolin, nafcillin, or oxacillin. Second-line treatments for MRSA include daptomycin, linezolid, or clindamycin.

If the Gram stain shows gram-negative bacilli, the treatment is a third-generation cephalosporin, such as ceftriaxone, cefotaxime, and ceftazidime. IV drug users are at risk for Pseudomonas infections and should have a combination of ceftazidime or ciprofloxacin plus gentamicin (or another aminoglycoside). Immunocompetent patients with negative gram stain should be treated with vancomycin. Ultimately, the culture and sensitivities will help detect the correct antibiotic choice. Intraarticular antibiotics are not recommended.

GOUT

Gouty arthritis is a type of arthritic condition that causes extreme pain and swelling in the joints. It stems from having high uric acid levels in the bloodstream that form crystals of monosodium urate (MSU) in the joint space. The crystals are very irritating to the joint and will cause swelling and redness of the affected joint space. About a third of all patients with high uric acid levels will develop gouty arthritis. It isn’t clear why some people get gouty arthritis and why others will not get gouty arthritis.

It should be noted that the joints aren’t the only place where uric acid crystals can develop. They can precipitate in the kidneys (impairing kidney function) or in other parts of the urinary tract, causing pain and possible obstruction of the urinary system.

Gout is completely different from CPPD (calcium pyrophosphate dihydrate) deposition disease or “pseudogout”. The crystals are completely different and the etiologies are different. Some of the symptoms are the same, however, so it pays to have an arthrocentesis and crystal analysis in order to define what type of crystal disease a person has.

Risk Factors for Gout

Gout is an adult disease that usually is first manifest in men between the ages of 30-45 years or in women over the age of 55 years. There is no gender difference above 65 years. The prevalence is about 4 percent of all adults in the US. Risk factors for gout include hypertension, obesity, chronic renal insufficiency, fasting, and consuming alcohol on a regular basis. Overeating, especially those things with high fructose corn syrup, meats, and seafood, will increase the risk of gout. Diuretics will increase the uric acid level.

Flareups of gout in patients already known to have gout can include fasting, recently having surgery or an injury, drinking too much alcohol (especially wine), overeating, and taking certain medications.

Symptoms of Gout

Gouty arthritis flares or gout attacks involve the sudden onset of joint pain that is relatively severe and associated with tenderness, swelling, and redness of the joint. It usually affects one joint but can affect a few. The flareups are worse in the middle of the night and in the early morning hours. The inflammation reaches its peak at 12-24 hours and can improve within a few days or weeks. No one knows how the body resolves a gouty flare. The white blood cells increase in the joint space because of the crystals causing irritation of the lining of the joints.

Gouty Arthritis Phases

There are three basic phases of gout: the gout flare, intercritical gout, and tophaceous gout. In a gout flare, the big toe or knee becomes inflamed to begin with or multiple flareups can occur—accompanied by a fever. Some osteoarthritic patients will have flareups in the fingers instead of the toes. Intercritical gout is the time between flareups, which is generally less than two years, even with treatment.

Tophaceous gout is the type of gout where urate crystals build up around the joints, bursae, skin, bones, and cartilage. The buildups are called “tophi”. They may have bony erosion and joint damage called gouty arthropathy as a result. They usually aren’t painful but can inflame like joints, causing redness and tenderness. Tophaceous gout is rare with current treatment protocols except if a person cannot tolerate the medications, is taking cyclosporine for organ transplant, or is a woman past menopause on diuretic pills.

Diagnosis of Gout

Gout can mimic many other diseases. It is strongly suspected when a joint or few joints become acutely inflamed and then resolve within a few days, leaving behind no symptoms. The best way to confirm gout is to take a quantity of synovial fluid using an arthroscopy. The fluid can be evaluated under specialized light microscopy to see if the characteristic needle-shaped crystals can be seen. There will also be an excess of white blood cells in the synovial fluid. Crystals can be extracted from tophi as well. If arthroscopy cannot be done, the diagnosis is based on acute onset of symptoms, inflammation of one joint (usually the great toe), elevated uric acid levels, and complete resolution of symptoms between flareups.

Treatment of Gouty Flareups

The goal of treating gouty flareups is to decrease pain and inflammation. This is a short-term process that is based on the presence or absence of bleeding disorders, history of stomach ulcers, or history of kidney disease. If these are negative, NSAID drugs are the treatment of choice as well as glucocorticoid drugs. Corticosteroids can be given orally, injected into the joint or by injection. Commonly-used glucocorticoids include prednisolone, prednisone, and methylprednisolone. They can be used when NSAIDs or colchicine aren’t tolerated.

NSAIDs are okay if there are no bleeding problems (no warfarin), no stomach ulcers, and no kidney disease. Aspirin is not recommended because it can affect the uric acid level in the bloodstream. Colchicine is good with decreased kidney function and ulcer risk but can cause abdominal symptoms (like nausea, vomiting, diarrhea, and abdominal cramps). It is only taken orally.

There are preventative drugs that will decrease or reduce the number of gouty flareups. Colchicine is one drug that can do this and can be given in lower doses than is necessary to treat gouty arthritis flareups.

Some patients require long-term uric acid-lowering treatment. Lifestyle changes can help the situation. Medications can increase the uric acid excretion by the kidneys, decrease the production of uric acid, or can convert urate to allantoin (which is more easily excreted). These drugs are used when a flareup has resolved itself. Allopurinol works by preventing uric acid formation and is the most commonly used drug for this problem. Febuxostat does the same thing but cannot be used by people at risk for heart disease.

Probenecid increases uric acid excretion by the kidneys. Losartan is an antihypertensive drug used to decrease uric acid levels. Lesinurad is a second-line drug used with allopurinol or febuxostat. Pegloticase works by turning uric acid into allantoin, which is then excreted. It is given by IV and is used to rapidly lower the uric acid level. Allergic reactions and high cost make this prohibitive in many situations. The goal is a uric acid level of below 6 grams per deciliter. It shouldn’t be done too quickly and the individual requires excess fluid during the treatment time.

Arthritis- An infographic by GeriatricNursing.org

Website Sources for Arthritis

1. Understanding Arthritis. This is the site to start your search for arthritis answers. It’s a site created by the Arthritis Foundation and has a wealth of information on the site.
2. What is Rheumatoid Arthritis? This is a site designed by the Arthritis Foundation specifically about rheumatoid arthritis. It’s a good site for people who know they have RA and want to know the latest in diagnosis and treatment of this joint disease.
3. Let’s Dig Into Everything about RA-This is a site put out by a RA support organization that delves into rheumatoid arthritis and its management. They have resources for experimental RA treatment.
4. Septic Arthritis– This is a comprehensive review of septic arthritis designed for people who are health professionals or learned patients wanting to learn all they can about this condition.
5. Gout and Pseudogout– The patient with crystal arthritis will learn all they want to know on this comprehensive site. It’s designed for the person who wants to know the science and medicine behind these two types of arthritis.
6. The American College of Rheumatology puts out this information site for patients and caregivers who want to know about osteoarthritis and its manifestations.
7. Find a Rheumatologist – It isn’t always easy to find a rheumatologist near you if you have an arthritic condition. This site from the American College of Rheumatology will help you get the help you need from a board-certified rheumatologist.
8. Rheumatoid Arthritis – This is a medical site that shows pictures of patients with rheumatoid arthritis plus a comprehensive review of the pathophysiology, presentation, workup, and treatment of this type of arthritis.
9. Gout – This is a lecture series on gout that gives many slides showing pictures of gout and images that easily explain the disease state.
10. Osteoarthritis – This is a picture-filled slide presentation on osteoarthritis. For individuals wanting a visual image of what this disease looks like plus valuable information on the disorder, this is the site to visit.

True or False: Changes in the Weather Can Make Your Joints Stiff or Achy

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For many people, the flare-up of an arthritic knee or shoulder appears to signal a change in the weather—usually hinting that a storm is imminent.

The belief that achy joints accompany a weather change is so widespread, in fact, that it has just about been accepted as reality. Many doctors listen to patients complain that they experience stiff or aching joints before, during, or after changes in temperature, barometric pressure, or humidity.

Yet, in spite of the widespread belief in a connection between aches and pains and inclement weather, medical researchers have come up with little evidence to support it.

Evidence for the Health Claim
Changes in the weather such as barometric pressure, humidity, and temperature could theoretically affect the synovial fluid that lines and lubricates the joints if, for example, they had a chemical effect on the fluid which somehow increased inflammation (which causes pain). However, there is no conclusive evidence that supports this theory.

Since at least the mid-1800s, a number of medical, and so-called bio-meteorologic research studies have been carried out in an effort to establish a connection between health and changing weather conditions.

The results of these studies have been varied. Based primarily on a compilation of patient anecdotes (reports of arthritis sufferers, for instance), increased barometric pressure (in fair weather conditions) has been associated with increased joint pain. Conversely, others studies have shown a relationship between increased joint pain and decreased barometric pressure (in stormier weather). Still other studies have suggested that changing weather conditions can cause immediate pain in some patients and delayed pain in others.

weather changes

Evidence Against the Health Claim

It is important to note that because most studies on this subject have been based on anecdotal reports rather than carefully designed observational studies, their conclusions don’t constitute reliable scientific evidence. Furthermore, many doctors claim that the wide variety of arthritic conditions and sheer complexity of atmospheric variability makes coming up with meaningful connections between joint pain and weather conditions next to impossible.

There is also a psychological aspect to this belief. What are the chances that the connection between health and the weather is simply coincidental? Is it possible that arthritis sufferers link their stiff and achy joints to changes in the weather as a way of explaining an otherwise mysterious exacerbation of their condition? Some doctors suggest that patients who observe weather conditions when they experience pain may pay little or no attention to the weather when they don’t have any pain.

Furthermore, there is no definitive evidence that moving to a warmer or drier climate provides a cure for aching joints. Some doctors report that many patients claim that the pain disappears for a while, only to return a few months later.

by Rhianon Davies

REFERENCES:
Aches and Pains Index. UK Weather Channel Interactive Web site. Available at http://uk.weather.com/activities/health/achesandpains/achesandpainsindex.html. Accessed July 25, 2006.

Cold Weather Can Cause More Aches and Pains for Arthritis Sufferers. Marshall University Orthopaedics Web site. Available at http://musom.marshall.edu/medctr/orthopaedics/cold weather.asp. Accessed July 25, 2006

Shmerling RH. Whether Weather Matters For Arthritis. Available at http://www.intelihealth.com/IH/ihtIH/8799/9273/35323/341624.html?d=dmtHMSContent. Accessed July 25, 2006.

Weather and Joint Pain. Any Connection? Mayo Clinic Web site. Available at http://www.mayoclinic.com/health/joint-pain/AN00102. Accessed July 25, 2006.

Weather and Our Physical Health. BBC News Web site. Available at http://www.bbc.co.uk/weather/weatherwise/living/effects/. Accessed July 25, 2006.

EBSCO Information Services is fully accredited by URAC. URAC is an independent, nonprofit health care accrediting organization dedicated to promoting health care quality through accreditation, certification and commendation.

Fall Prevention Physical Therapy

Physical Therapy for Balance & Fall Prevention

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“Falls are the leading cause of injury death for Americans 65 years or older. Each year, about 35–40% of adults 65 and older fall at least once.”
— Center for Disease Control

Physical Therapy for Fall Prevention
Physical therapy fall prevention programs are tailored around each individual’s needs. The length of the program is dependent on the severity of the symptoms and the goals of each individual. Most patients will follow a gradual path of three distinct phases. After an initial evaluation to determine needs and goals of patient and we will set up treatment plan with patient input. The first phase typically includes therapeutic interventions designated to decrease symptoms and the establishment of a Home Exercise Program (HEP). We will then Continue the use of therapeutic interventions with the addition of ADL modifications, and energy conservation techniques. Finally we will continue the program until the patient’s goals are met.

The main objectives in a fall prevention program are to:

  • Increase independence with Activities of Daily Living (ADLs)
  • Increase independence with functional mobility
  • Decrease fall risk
  • Prevent future fall
  • Increase safety

Pain Relief
Our PTandMe licensed physical therapists are skilled in helping patients significantly reduce the risk of falls so that seniors can continue to age independently. If you or someone you know may benefit from a fall prevention program – call a clinic near you today and see what options are available for you! To find a PTandMe partnering location in your area click here.

PREHAB Knee Replacement

PREHAB Move to Improve Your Goals: Total Knee Replacement

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PREHAB Home Preparation
Before total knee replacement surgery there are a few simple things you can do in your home to make it safer and more comfortable during recovery.

  • Consider keeping a cordless phone near you or carry your cell phone in your pocket.
  • Move furniture to keep a clear wide path to your kitchen, bathroom and bedroom.
  • Remove throw rugs that may cause you to slip or trip. Tape down any loose edges of large area rugs that cannot be removed. Make sure extension cords are out of traffic areas or tape them down if needed.
  • Wear rubber sole shoes to prevent slipping.
  • Keep commonly used items in your home at waist level within easy reach. This will prevent you from bending over to reach items. Use a reacher to grab objects and avoid excessive bending at the knee.
  • Make sure there is adequate lighting in the house. Add night lights in hallways, bedrooms, and bathrooms.
  • It may be helpful to have temporary living space on the same floor if your bedroom/bathroom is located on the second floor of your home. Walking up/down stairs will be more difficult immediately following surgery and could increase your risk for falls.
  • Arrange for someone to collect your mail and take care of pets or loved ones if necessary.
  • Prepare frozen meals in advance to assist you with cooking.
  • Stock up on groceries, toiletries, and any needed medications you might need.
  • A shower chair or a tub bench will make bathing much easier. Do not take soak baths until your physician allows you to do so.
  • An elevated toilet seat will be helpful with toilet transfers and with following post surgical precautions or guidelines.
  • Assistive devices for dressing such as a reacher, extended shoe horn and / or sock aid may be necessary during your post operative recovery.

While it’s important to prepare your home before surgery, PREHAB should also include physical therapy. Physical therapists will work with patients to create an exercise program before surgery that can help improve performance and decrease recovery times after a total knee replacement. Talk to a PT near you and learn about the benefits of PREHAB before total joint replacements.

Industrial Rehab Physical Therapy PTandMe

Health Aging for a Sustainable Workforce

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What Can Employers Do to Protect an Aging Workforce?

Employers can start by revisiting job descriptions and knowing every detail each work task entails in order to help prevent costly and unnecessary workers’ compensation claims. Meanwhile, they should continue to promote health and wellness programs for all employees. Because older workers bring many benefits, from their experience and knowledge to their motivation and good work ethic, the advantages of employing older workers will outweigh the possible worker’s compensation claims, with preparation and planning.

Companies must utilize and implement preventative safety efforts. Specifically, companies should develop slip-and-fall prevention tactics, considering that slips and falls account for 33 percent of all injuries sustained by workers 65 and older, according to the National Safety Council. Safety training should consist of more than just scripted lectures, distributed
pamphlets and orientation videos. Employees should be taken through the physical movements and tasks that are specific to their job description–a hands-on learning experience. Because younger workers account for the majority of accidents while older workers have longer recovery periods, safety training benefi ts all employees and the employer. Bring in external experts such as physical therapists from the community to teach proper techniques and protocols.

  • Modification of work environment
  • Ergonomics and wellness programs
  • Industrial Athlete approach to exercise
  • Return to work accommodations

AGING WORKFORCE SERVICES:

Education:
A full battery of educational programs are available for both the professional staff of an employer to that of the general employee population such as slip and fall or back injury prevention.

Preventative Maintenance Testing:

A brief test – approx. 15 minutes that looks at the essential and critical factors of the job – usually body part specific and set up as a repeated test – every three to four months on a high risk job position – looking for trends or patterns of degradation of range of motion or strength of employees.

Fitness Programs for the Industrial Athlete:
Detailed stretching programs are customized per high risk job based upon historical injury determinations. The program is set up for employee participation prior to work, returning from lunch and at the end of the workday.

Physical Ability Maintenance:
A custom built strengthening program designed to maintain the physical abilities necessary to perform everyday work.

For more information about staying healthy and injury free in the workplace – try the links below:


       

Adapted from Fit2wrk Article 1.10   For more information on Fit2wrk click here.

Total Knee Replacement Prehab: Move to Improve Your Outcomes

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Many people with arthritis favor their joints over time in an effort to relieve pain and thus become weaker in their leg muscles or lose range of motion. However, the better shape you are in before surgery the better your results will be after surgery so it is important to strengthen your leg muscles and work on your range of motion. Before surgery your physical therapist will teach you appropriate exercises to help improve strength, range of motion, and balance. They will also teach you how to walk with an appropriate assistive device such as a walker or cane in the immediate post operative recovery period. Finally, they will discuss precautions and advise you in a few short term home adaptations such as removing loose rugs to help make your recovery easier and safer.

Prehab Goals
• Develop an exercise program with your PT to help you
• Improve strength
• Improve range of motion
• Improve balance
• Gait training — Review walking with an appropriate assistive device such as a walker or cane in the immediate post operative recovery period
• Discuss precautions and review a few short term home adaptations that can help make your recovery easier and safer

walker lady

Pre Surgery Exercise Plan
Make every effort to begin these exercises as early as possible before your surgery. Only do what you are able to do without increasing your pain. It is important for you not to exacerbate your pain prior to surgery. Ice packs for 15 minutes following your exercises may be helpful to reduce any soreness in your knee.

This information was written by STAR Physical Therapy, an outpatient physical therapy group with 60 locations in Tennessee, offering more than 15 comprehensive specialty services. STAR Physical Therapy was established in 1997 with one clinic and one mission – to serve. Today, they’ve grown to offer that direct service in more than 60 clinics. While they’ve grown, one thing that has not changed is their commitment to you, their communities, and their employees. For more information click here.

More about knee replacements and physical therapy can be found here:

total knee replacement

heart healthy physical activity

Heart Healthy Physical Activity

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The heart is often used as a symbol of vitality for good reasons. The heart pushes blood and oxygen to every cell in the body to be used as fuel and carries waste away. Without this process, the body cannot function. The heart plays a role in many aspects of your health and wellness.

Efficiency Matters
The heart beats an average of 60-80 beats per minute, which can add up to millions of beats in just one month. When something works this hard, it is important that it also works efficiently. Well-conditioned athletes can have resting heart rates below 50 beats/minute. Even though their heart beats slower, it can do the same amount of work or more than a heart that beats 60-80 beats/minute. An athlete’s heart pumps stronger during each beat, needing fewer beats to get the job done. Over a lifetime, a difference of 10-30 beats/minute can add up to quite a few beats.

An Ounce of Prevention…
The heart can be affected by physical and mental stressors. You can feel your heart speed up when you sprint across a busy road or when you have a burst of emotion like anger or surprise.

Physical activity can decrease the effect of stress on the heart and body. A fit body and mind will help improve heart health. Regular physical activity can:

Improve physical abilities by:
• Improving the heart’s ability to pump blood
• Increasing energy levels
• Increasing muscle strength and endurance
• Improving agility

Change physical appearance by:
• Toning your muscles which gives you a tighter appearance
• Burning calories which helps with weight loss or maintenance

Improve overall wellness by:
• Helping with stress management
• Improving self-image
• Helping to decrease anxiety and depression
• Improving relaxation
Improving the ability to sleep
• Creating a social activity opportunity
• Promoting healthier cholesterol levels

If you have heart problems, physical activity can still play an important role. A strong and healthy body can help you manage your condition. Physical activity can help reduce the stress on a sick or weak heart and decrease secondary risks like obesity and diabetes. If you do have heart health issues, talk to your doctor before starting an exercise program.

Even if you are healthy, but have not exercised in a long time, you may need to talk to your doctor to make sure that you are in good physical condition to exercise.

heart veggies

Where to Start
For most people, you can begin right away. Find an activity program that you enjoy. Do not pick an activity that does not fit into your schedule, does not fit in with your personal preferences, or has too many obstacles, because you may lose interest quickly. A program that starts with too much intensity is also likely to lose your interest.

Work towards reaching these basic goals:
• 30-60 minutes of physical activity on most days of the week (total of at least 150 minutes/week)
• Include some strength activities at least 2 times/week

Make It Stick
Long-term regular physical activity will count more than a brief and spectacular burst of activity. Most people do not plan to become sedentary. It creeps up on you. Work to increase your physical activity the same way. Gradually add steps. Find activities you enjoy that can replace more sedentary activities.

Here are more tips that have been shown to be useful:
• Find an exercise partner. You are less likely to skip the activity if someone is waiting for you.
• Write it down or use a fitness tracker. Keep a log of your activities and how much you accomplished either by distance or time. It will help keep you honest.
• A long-term goal is fine, but also make short-term goals, because they provide quicker feedback.
• This is important, make it a priority. Plan it out. Find a time in your daily routine when you can regularly fit the activity in.
• Consider doing your activity in 10-minute spurts throughout the day. Spurts can be as effective as being active for 30 minutes straight.
• Be flexible. Life happens and you may find that you need to make adjustments to your routine. A rigid schedule and goal may not be worth the stress. Keep an open mind to new activities and schedules.

Make It Count
Any physical activity is better than none. But at least a few days per week you should aim for more than a leisurely stroll. A moderate intensity level is best to help you make health changes. Moderate intensity activity is enough to get your heart rate up and make you feel a little out of breath but not feel worn out when you are done.

Do not forget to enjoy your activity for the daily benefits it can bring and know that your heart appreciates it as well!

by Pamela Jones, MA

RESOURCES:
American College of Sports Medicine
http://www.acsm.org

American Heart Association
http://www.heart.org

CANADIAN RESOURCES:
Health Canada
http://www.hc-sc.gc.ca

Public Health Agency of Canada
http://www.phac-aspc.gc.ca

REFERENCES:
American Heart Association guidelines for physical activity. American Heart Association website. Available: http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/StartWalking/American-Heart-Association-Guidelines-for-Physical-Activity_UCM_307976_Article.jsp. Updated September 10, 2014. Accessed October 22, 2014.

Guide to physical activity. National Heart and Lung and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/phy_act.htm. Accessed July 21, 2016.

Haskel W, et al. Physical activity and public health, updated recommendations for adults from the American College of Sports Medicine and the American Heart Association. Circ. 2007;116(9):1081.

How much physical activity do you need? Centers for Disease Control and Prevention website. http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html. Updated June 4, 2016. Accessed July 21, 2016.

Promoting physical activity with a public health approach. American College of Sports Medicine website. Available at: http://www.acsm.org/about-acsm/media-room/acsm-in-the-news/2011/08/01/promoting-physical-activity-with-a-public-health-approach. Accessed July 21, 2016.

2008 physical activity guidelines for Americans. United States Department of Health and Human Services website. Available at: http://www.health.gov/paguidelines/guidelines/default.aspx. Accessed July 21, 2016.

Last reviewed July 2016 by Michael Woods, MD Last Updated:10/22/2014

EBSCO Information Services is fully accredited by URAC. URAC is an independent, nonprofit health care accrediting organization dedicated to promoting health care quality through accreditation, certification and commendation.

postoperative physical therapy

Postoperative Physical Therapy

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Postoperative physical therapy after a Total Hip Replacement is essential to your recovery. Your physical therapist will follow your physician’s protocol and will focus on range of motion exercises, progressive strengthening exercises, gait training, balance training, and activity specific training to meet your specific needs. Modalities such as ice and e-stim may be used to help reduce discomfort and swelling. It is very important to complete your home exercise program as directed by your physical therapist and physician.

RANGE OF MOTION EXERCISES
Swelling and pain can make you move your knee less. Your physical therapist can teach you safe and effective exercises to restore the range of motion to your knee so that you can perform your daily activities.

STRENGTHENING EXERCISES
Weakness of the muscles of the thigh and lower leg is typical after surgery. Your physical therapist can determine the best strengthening exercises for you with the goal of no longer needing a cane or walker to walk.

post op

BALANCE TRAINING
Specialized training exercises can help your muscles “learn” to adapt to changes in your world such as uneven or rocky ground. When you are able to put your full weight on your knee without pain, your physical therapist may add agility exercises so that you can safely and quickly change directions or make quick stops or starts. They may use a balance board that will challenge your balance and knee control. These exercises will be safe and fun.

GAIT TRAINING
Your physical therapist will work with you in retraining your gait following your surgery using appropriate assistive devices such as a walker or cane. They will make sure that you will be able to safely and confidently go up and down stairs, negotiate curbs, and inclines, etc.

ACTIVITY SPECIFIC TRAINING
Depending on the requirements or your job or the type of recreational activities you enjoy, your physical therapist will tailor your program so that you can meet your specific demands.

This article about postoperative physical therapy was written by STAR Physical Therapy, an outpatient physical therapy group with over sixty locations in Tennessee. Established in 1997 with one clinic and one mission – to serve. Today, they have grown to offer that direct service in more than 60 clinics, and while they’ve grown, one thing that has not changed is their commitment to you, their communities, and their employees. For more information click here.