Saturday, December 24, 2011

Start Good Habits Early

Starting off with the right approach is really important for two reasons: First, it’s usually easier to get your diabetes under good control in the early stages of the disease, and secondly, clinical studies show that achieving good control early provides benefits to your body that can last for decades.

Also, the diabetes habits you develop now will stick with you in the long-run. Really, we all know how hard it is to change behavior once we’re set in our ways!

So for example, you might want to take some time to look at the user’s manual that came with your glucose meter in order to learn how to set the alarms that will remind you to test at different times of day: before meals, about two hours after, and at wake time and bed time. You want those test times to become habit!

You’ll also want to set up some kind of reminders to get your essential medical tests done regularly:

the A1c blood test - every three months
blood pressure - every six months at least (take advantage of every doctor’s appointment to have this checked, especially if it’s been elevated or you’ve had concerns)microalbumin, lipids, and eye exam—all annually (unless concerns call for more frequent checks)

Another “habit” that you’ll want to nurture early on is keeping an upbeat attitude. The voice in your own head is very, very important: you’ll want it to act as a “cheerleader,” rather than a negative force always telling you that you’ve failed.

There’s no question that it’s hard to stay upbeat when you’ve been diagnosed with a chronic illness.

You might be thinking: How do I stay positive when I feel like I’m being punished? Or when I feel so overwhelmed by having a disease that requires so much attention?

Taking care of yourself with diabetes is indeed a “mental game,” requiring you to learn to function comfortably on a number of levels:

Personal (Emotional)—fighting off negative thoughts
Social—interacting with others in social situations without stress
Behavioral—preventing yourself from doing things you wish you wouldn’t, sometimes even self-destructive things

If you do find that you’re experiencing a mental struggle with your diabetes, connecting with other people walking in your shoes is often very comforting – and helpful.

Connecting with other PWDs (people with diabetes) regularly, either online or offline, is a habit worth forming!

Friday, December 23, 2011

Should I Pick Up the Pace?

Q: My doctor told me that I need to get more aerobic exercise, but I hate going to the gym! I do like to walk, but how fast and how long should I go to improve my cardiovascular health?

A:
I understand exactly what you mean about going to the gym; I'm not a big fan of it either. Personally, I prefer to exercise outdoors or at home. And like you, I really enjoy walking.

Recently, I've begun recommending what's known as interval walking to many of my patients. With interval walking, you alternate between short bursts of intensive effort and easier recovery periods, as opposed to walking at a steady, continuous, and potentially monotonous pace. In fact, studies show that you can get better results in 20 minutes of interval exercise than you would in an hour of steady-state exercise. And you can apply the principles of interval walking to a treadmill or elliptical trainer, to biking or swimming, or even to doing jumping jacks in your living room.

So how do you do interval walking? Instead of walking at a constant pace for your entire workout, as you've probably been doing, you should mix it up. That is, after a three-minute warm-up where you walk at an easy or moderate pace, you should alternate short bursts of very fast walking (15 to 60 seconds, depending on your conditioning) with recovery periods of slower walking after each fast burst. You can repeat each interval six to 12 times, or more depending on your fitness level. Aim for walking a total of 20 minutes to start. In general, the more intense the workout (in other words, the faster you go), the shorter the duration of that interval and the longer the recovery period. Conversely, when you're not working as hard, your work period will be longer and your recovery period will be shorter. For example, if you like taking an hour-long walk on weekends, you can certainly do intervals, but don't try to spend the entire hour working at high intensity. And always end with a two-minute cooldown at an easy pace.

I recommend that you do interval walking every other day, alternating it with some core-strengthening exercises. Not only will this type of walking improve your cardiovascular health, it will boost your metabolism so you burn more calories and fat, and that translates into faster weight loss.

Interval training is not only for the very fit. It works just as well for people who are less fit, and is even being used to help cardiac patients and people with lung disease get back in shape. That said, I do recommend that you talk with your doctor before embarking on this or any other exercise program.

Thursday, December 22, 2011

Meal Schedule for Type 2 Diabetes

Q: What’s the best meal schedule for a diabetic? When should snacks be included?

A: I recommend eating a meal or snack every four to five hours. This allows enough time for your blood sugar to come back down to a healthy baseline after eating, but it’s frequent enough to help you manage your appetite and keep hunger pangs at bay, which is especially important if you’re trimming calories to lose a few pounds. In general, you can meet this guideline by eating breakfast, lunch, a mid-afternoon snack, and dinner, evenly spaced throughout your day. At all meals and snacks, combine a small to moderate amount of high-quality carbohydrates (vegetables, fruit, whole grains, beans/lentils) with a good dose of lean protein from foods like skinless turkey or chicken, egg whites, seafood, low-fat dairy, or beans/lentils (beans and lentils count as both a carb and a protein). The protein helps slow your body’s absorption of carbs and prevent spikes in your blood sugar. Here’s an example of an A+ day of eating designed for optimal blood-sugar control.

Breakfast:
Egg-white omelet with vegetables (spinach, mushrooms, peppers and/or onions)
One orange
Coffee with skim milk

Lunch:
2 cups hearty, low-sodium soup (lentil, black bean or minestrone) topped with ¼ cup shredded
reduced-fat cheese
Crunchy red-pepper sticks
Water

Snack:
Nonfat yogurt
1 apple

Dinner:
Homemade shrimp-and-broccoli stir-fry
¾ cup cooked brown rice
Zero-calorie seltzer

After Dinner:
Handful of almonds or pistachio nuts
Cup of decaf or herbal tea

Wednesday, December 21, 2011

Stop the Progress of Prediabetes

You can prevent this precursor to type 2 diabetes from developing into full-blown disease.

Nearly 24 million American adults are living with diabetes, according to figures released last month by the International Diabetes Federation. But what may be even more alarming is that there are also about 79 million Americans with a condition known as prediabetes — and many aren't aware of it.

Prediabetes means that while your blood sugar levels are higher than normal, that level isn’t high enough to warrant a diabetes diagnosis. However, a prediabetes diagnosis means it is time for action to prevent diabetes.

"In simple terms, there is a gap between what we call diabetes, which is a fasting blood sugar of 126 and above, and normal, which is less than 100 fasting," explains Vivian Fonseca, MD, a professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans. "In between, you have impaired fasting glucose. If you do a glucose tolerance test, and you are in the gap, you have prediabetes. You are at risk for getting diabetes in the future and you are also at risk for heart disease."

Research has also found that prediabetes may be more common in men than in women.

Type 2 Diabetes: Prevention

If you are told your blood sugar is abnormally high, you’ve just had a red flag waved in front of you. You’re being warned that unless you make some changes in your life today, your future will probably include a diabetes diagnosis.

"Walking 30 minutes a day and reducing weight by 5 percent can decrease the risk [of getting type 2 diabetes] by 60 percent over three years," says Dr. Fonseca. While there are medications that have the same effect, lifestyle change is less expensive and has fewer side effects, Fonseca says.

Cutting your weight is crucial. "One of the links with obesity is that fat induces a mild low-grade inflammation throughout the body that contributes to heart disease and diabetes," Fonseca explains. Without making any changes, you could develop type 2 diabetes within 10 years of first developing prediabetes.

Type 2 Diabetes: Who Should be Tested?

Prediabetes is a "silent" condition, says Fonseca. While some people may experience symptoms of diabetes such as fatigue or increased urination, most people’s blood sugar rises without any outward signs at all. This means you might not know you need to be tested for prediabetes — and even if you are screened, your doctor might not give you all the information you need to prevent it.

For these reasons, diabetes experts developed criteria for those who should be tested. The American Diabetic Association recommends that any adult age 45 or older should be tested for diabetes and prediabetes.

The ADA also recommends that any adult under age 45 who is overweight and has at least one of the following risk factors should be tested:

Family history (especially parent or sibling with diabetes) Physically inactive lifestyle Native American, African-American, or Hispanic heritage Prior gestational diabetes diagnosis Birth of a baby over nine pounds in weight High blood pressure or treatment for high blood pressure Polycystic ovarian syndrome (PCOS) diagnosis Dark, velvety rash around the armpits or neck History of heart disease If your test reveals that you have prediabetes, you should be tested again in one to two years, depending on your doctor’s recommendations.

Type 2 Diabetes: Types of Tests

There are two tests used to screen for diabetes and prediabetes:

Fasting plasma glucose: a test of your blood after you haven’t eaten for eight hours (usually overnight) Oral glucose tolerance test: a comparison of your blood taken first after eight hours without food (fasting) and then two hours later after you have consumed a sugary drink given to you by the lab technician. If you fit the screening criteria listed above, make an appointment to get tested as soon as possible. It could be the first step toward preventing the development of type 2 diabetes.

Monday, December 19, 2011

Why Are My Feet Hurting When I Walk?

Q: My feet have started to hurt a lot — so much that when I wake up in the morning I cannot walk barefoot for at least the first 20 minutes. I can't be on my feet too much anymore without pain. What might be causing this, and what can I do to get some relief?

A: What you are describing sounds like a painful condition known as plantar fasciitis. This is a situation where there is inflammation of the soft tissue along the sole of your foot, all the way from your heel to your toes. It may be caused by high-impact exercise, structural problems such as being flat-footed, arthritis, or ill-fitting shoes. It is also more common in people with diabetes. The most characteristic symptom of plantar fasciitis is severe shooting or burning pain in the feet in the morning. The pain typically improves after some movement, only to recur after periods of prolonged rest or intense activity.

Preventive measures include always wearing shoes that fit well, stretching in the morning, afternoon and evening and before any exercise, limiting high-impact exercises, and maintaining ideal body weight, as obesity does predispose to plantar fasciitis. The key is to exercise carefully rather than eliminating exercise altogether. Treatment includes surgical and nonsurgical approaches, though surgery is a last resort and is rarely necessary. Night plints, orthotics, and physical therapy may hasten your recovery, but if the condition is left untreated, it will not resolve itself. In severe cases, injections with steroids or treatment with ultrasound may be warranted.

Sunday, December 18, 2011

Foot Anatomy: Your Amazing Feet

Despite delicate foot anatomy, your feet are able to take a pounding every day. Help them go the distance by identifying and correcting common foot problems, from corns and calluses to Athlete's foot and hammertoes.

The human foot has 42 muscles, 26 bones, 33 joints, and at least 50 ligaments and tendons made of strong fibrous tissues to keep all the moving parts together … plus 250,000 sweat glands. The foot is an evolutionary marvel, capable of handling hundreds of tons of force — your weight in motion — every day. The foot’s myriad parts, including the toes, heel, and ball, work in harmony to get you from one place to another. But the stress of carrying you around puts your feet at high risk of injury, more so than other parts of your body.

Many foot problems, including hammertoes, blisters, bunions, corns and calluses, heel spurs, claw and mallet toes, ingrown toenails, toenail fungus, and athlete’s foot, can develop due to neglect, ill-fitting shoes, and simple wear and tear. Your feet also can indicate if your body is under threat from a serious disease. Gout, for instance, will attack the foot joints first.

Foot Problems: Athlete's Foot
Caused by a fungus that likes warm, dark, and moist environments like the areas between the toes or on the bottoms of the feet, athlete’s foot can inflame the skin and cause a white, scaly rash with a red base. The athlete’s foot fungus also causes itching, burning, peeling, and sometimes a slight odor; the infection can also migrate to other body parts. You can avoid athlete’s foot (also called tinea pedis) by keeping your feet and toes clean and dry and by changing your shoes and socks regularly. Over-the-counter antifungal creams or sprays can be used to treat athlete’s foot. If these remedies do not work, however, you may need to see a podiatrist and ask about prescription-strength medication.

Foot Problems: Hammertoes
If your second, third, or fourth toe is crossed, bent in the middle of the toe joint, or just pointing at an odd angle, you may have what’s called a hammertoe. Hammertoes are often caused by ill-fitting shoes. Early on, wearing inserts or foot pads can help reposition your toe, but later it becomes fixed in the bent position. Pain then sets in and you may need surgery. Because hammertoes are bent, corns and calluses often form on them.

Foot Problems: Blisters
It’s this simple: If your shoes fit well, you won't have blisters. Soft pockets of raised skin filled with clear fluid, blisters are often painful and can make walking difficult. It’s important not to pick at them. Clean the area thoroughly, then sterilize a sewing needle and use it to open the part of the blister located nearest to the foot’s underside. Drain the blister, slather with antibiotic ointment, and cover with a bandage. Follow these same care steps if a blister breaks on its own.

Foot Problems: Bunions
A bunion is a crooked big-toe joint that sticks out at the base of the toe, forcing the big toe to turn in. Bunions have various causes, including congenital deformities, arthritis, trauma, and heredity. A bunion can be painful when confined in a shoe, and for many people, shoes that are too narrow in the toe may be to blame for the formation of bunions. Surgery is often recommended to treat bunions, after conservative treatment methods like over-the-counter pain relievers and footwear changes fail.

Foot Problems: Corns and Calluses
Corns and calluses form after repeated rubbing against a bony area of the foot or against a shoe. Corns appear on the tops and sides of your toes as well as between your toes. Calluses form on the bottom of the foot, especially under the heels or balls, and on the sides of toes. These compressed patches of dead skin cells can be hard and painful. To relieve the pain, you may want to try placing moleskin or padding around corns and calluses. Don’t try to cut or remove corns and calluses yourself — see a podiatrist for care.

Foot Problems: Plantar Fasciitis and Heel Spurs
It’s common for doctors to confuse heel spurs and plantar fasciitis when a patient comes to them with heel pain. Heel spurs are found in 70 percent of patients with plantar fasciitis, but these are two different conditions. Plantar fasciitis is a painful disorder in which the tissue that connects the ball of the foot to the heel – the fascia – becomes inflamed. Heel spurs are pieces of bone that grow at the heel bone base and often develop after you’ve had plantar fasciitis. The heel spurs themselves are not painful; it’s the inflammation and irritation caused by plantar fasciitis that can hurt. Heel spurs are often seen on X-rays of patients who do not have heel pain or plantar fasciitis.

Foot Problems: Claw Toes and Mallet Toes
Claw toe causes all toes except the big toe to curl downward at the middle of the joints and curl up at the joints where the toes and the foot meet. Calluses and corns may often form when someone has claw toes. While tight shoes can be blamed for claw toes, so can nerve damage to the feet (from diabetes or other conditions), which weakens foot muscles.

With mallet toes, the last joint of the toe bulges, and a painful corn will grow near the toenail. Generally the second toe is affected because it’s the longest. Injuries and arthritis are among the causes of mallet toe.

Foot Problems: Gout
Gout is a type of arthritis caused by a build-up of uric acid in joint tissues and joint fluid, which happens when the body is unable to keep uric acid levels in check. One of the first places for this build-up to occur is in the big toe joint — temperature-wise, the toes are the body’s coolest parts, and uric acid crystallizes with temperature changes. You’ll know a gout attack when it happens: The toe will get warm, red, and swollen and will be painful to even the slightest touch. The best way to prevent a gout attack is to learn to identify triggers, including high-purine foods, red meat, seafood, and alcohol. Applying ice, keeping hydrated, and staying bed may help, too.

Foot Problems: Ingrown Toenails
The right way to clip toenails — straight across — is key to foot health. If you don’t cut them properly, the corners or sides of the nail can dig into skin and become ingrown. Other causes of ingrown toenails include shoe pressure, a fungus infection, and even poor foot structure. When you cut your toenails, use larger toenail clippers and avoid cutting nails to short, as this can also cause ingrown toenails or infection.

Foot Problems: Toenail Fungus
Toenail fungus can give nails an unattractive, deformed appearance. It can alter the nail’s color and spread to other nails, even fingernails. Avoiding toenail fungus is difficult, especially if you walk through wet areas where people tend to go barefoot, such as locker rooms and swimming pools. People with chronic conditions, such as diabetes or immune deficiency diseases like HIV, are especially vulnerable and may want to keep their shoes on.

Friday, December 16, 2011

Shin Pain While Walking

Q: I love walking, but when I walk at a fast pace my shins really start to hurt. What can I do to stop the pain?

A: First, make sure your walking shoes have good arch support, since shin splints often happen because of a fallen arch or flat feet. Also, try to avoid walking hills until you've walked on a flat surface for at least five minutes. This will warm up your shins so they don't become overstressed.

If you want to strengthen your shins, here's an easy towel exercise you can do! Sit in a chair, your feet bare, and place a rolled-up towel just in front of your toes. Grab the towel between your toes and your forefeet and unroll it, flexing the arches of your feet at the same time. Try to do this for 15 to 30 seconds every other day. It will help you keep up the good work and stay fit.

Thursday, December 15, 2011

Is Stress Raising My Blood Sugar?

Q: I have a really stressful job. I find that when I test my blood sugar at work or in the evening after work that my levels are markedly higher than on the days I don't work. I take my food to work with me, so my diet doesn't change from day to day. Is it the stress that is boosting my levels?

A: Is your physical activity level also the same during both times? If not, the difference may be simply because you are burning more calories during your off-work days. But if your diet and activities are similar during your on- and off-work days, it is possible that occupational stress is the cause of your higher sugar levels. Psychological stress from a demanding job or other life situations has been implicated in high glucose levels in otherwise healthy individuals. This is true especially among those who have limited social support or who have little authority to make changes at their job.

We are also learning that in people with diabetes, stress complicates glucose control. The mechanism for this is twofold. First, some individuals eat more while under stress, which then raises their sugar level. Second, during stressful times the body produces hormones as a survival mechanism to ensure that there is enough energy to respond to the particular stressor. These hormones facilitate the breakdown of stored fat and glycogen. In this process, glycogen is converted into glucose, increasing its concentration in the blood. These hormones also affect blood pressure, heart rate, and the immune system.

Stress reduction is one of the key elements of diabetes management. Unfortunately, there is no specific method that works for everyone. I recommend consulting your doctor or a psychologist to find what works for you.

Wednesday, December 14, 2011

Wardrobe Malfunctions: Are Your Clothes Causing You Pain?

From skinny jeans to sky-high stilettos, your clothing, shoes, and accessories may be a source of chronic pain that no amount of style will alleviate.

What's causing your chronic pain? Turns out, it could be your wardrobe.

A number of chronic pain issues can be traced to what you wear. The problem is most common in women — a whopping 88 percent wear shoes that are too small for them — but men can be fashion pain victims too. Among the high-style culprits are ultratight skinny jeans and mega pursesthat border on suitcase size. We've scoured the racks for some of the common clothing choices that cause chronic pain – and we've researched some painless alternatives.

Toe Pressure: High Heels and Pointy Shoes
Stilettos and other dramatic styles may be fashionable, but they are waging war on your feet on a daily basis, says Neil M. Scheffler, MD, a podiatrist at Sinai Hospital in Baltimore, Md. The result can ultimately be chronic pain. “High heels place the foot in a ‘toe-down’ position with the heel up, which puts a great deal of pressure on the front of the foot, mainly on the metatarsal bones,” he says. This creates short-term discomfort and can lead to long-term pain and other problems. “With continued wearing of high heels, the Achilles tendon shortens, creating an imbalance that can lead to foot deformities as well as postural symptoms.”

Flimsy Support: Flip-Flops and Flats
Considering the problem with high heels, you might think that wearing flip-flops or other flats would be the proper course of action for pain management, but these styles can cause pain in other ways. “Because flip-flops have no support for the foot, mechanical disorders are exaggerated,” says Dr. Scheffler. “Flip-flops are notorious for causing heel and arch pain called plantar fasciitis.” Instead, Scheffler suggests wearing running shoes. “I explain to my patients that to run 26-plus miles in a marathon, you need a great shoe,” he says. “Why not use this technology for everyday footwear?” Running shoes are supportive, give great cushioning, have adequate toe room, and are often available in varying widths, he adds.

Excess Baggage: Heavy Purses and Bags
Chiropracter Brett Winchester, an instructor at Logan College of Chiropractic in Chesterfield, Mo., has noticed a dangerous trend when it comes to women’s handbags and chronic pain. “With larger purses, many women are tempted to carry more items, which adds stress to the neck and shoulder areas,” he says. “We recommend a reasonably sized purse that can be draped across the shoulders and allows the arms to swing freely for walking.” For pain management or prevention, center the weight of the purse in the middle of your back or chest to balance your center of gravity.

Sciatica in Your Pocket: Men's Wallets
If you’re a man looking for easy pain treatment, simply take your wallet out of your back pocket whenever you are sitting, says Dr. Winchester. Sitting on your wallet creates a two-fold pain problem. “First, the wallet can put direct pressure on the sciatic nerve,” he says. “Second, it can create a pelvic unleveling, which can prompts imbalances throughout the body. Such problems can become prevalent among men who commute for long periods of time.”

Too Tight: Skinny Jeans
You may think you look good in stylish clothing choices like skinny jeans, miniskirts, and other tight clothing, but you might not like the long-term chronic pain that can result from wearing them. “There are reported cases of these jeans causing a nerve disorder called lateral femoral cutaneous nerve entrapment, though this would be considered rare,” says Winchester. “Other issues these jeans can create include the lack of hip extension. In human gait the hip is designed to have a certain amount of extension and flexion.” Skinny, tight jeans can hamper this motion, which can create pain problems in the lower back.

Unfit for the Job: Bras
Women can do themselves a favor when it comes to pain management or, better yet, prevention, by simply taking the time to find a bra that fits them well. Winchester says bras that fit poorly can create chronic pain problems in several ways. “Ill-fitting bras cause deep grooves in the shoulder area and can rub on the lower part of the rib cage,” he explains. “Most noticeably, an ill-fitting bra can also affect cosmetic appearance and everyday activities.” The pain management solution is simple: “Buying bras is like buying shoes,” says Winchester. “They must be tried on in the store first before purchasing. Specialty stores that only sell bras are usually great places to make an informed purchase.”

Monday, December 12, 2011

Vein Surgery For Younger-Looking Legs

Unsightly veins can make your legs look older and make you feel self-conscious, but leg vein surgery and other treatment options can help.

If you have varicose veins or spider veins in your legs, you’re not alone. It is estimated that more than half of American women and one-third of American men have leg vein problems.

These issues can make you feel insecure about exposing your legs, since they can make your legs appear unsightly and older. Fortunately, there are a number of treatments that can remove or improve the appearance of leg vein problems.

Treatment Options for Leg Vein Problems

In most cases, leg vein conditions are not dangerous, so most people choose to treat varicose and spider veins for cosmetic reasons. But in some cases leg vein problems need to be treated, possibly with vein surgery, because they can lead to blood clots, sores, skin ulcers, or painful irritation in the legs.

Whether your want to treat your leg veins for cosmetic or medical reasons, your treatment options include:

Sclerotherapy. Sclerotherapy is the most common treatment for leg vein problems. In this procedure, a doctor injects a solution into the vein that causes it to collapse; this stops the flow of blood and causes the vein to fade. Sclerotherapy can be performed without anesthesia in a doctor's office, and you can return to your normal activities immediately after the treatment. You may need multiple treatments to achieve desired results. Side effects of sclerotherapy may include pain, redness, sores, or bruising around the injection site; spots, brown lines, or tiny red blood vessels around the treated vein; and bulges of clotted blood in the treated vein. According to the American Society of Plastic Surgeons (ASPS), each session of sclerotherapy

Laser surgery. Laser surgery can be used to treat spider veins that are 3 millimeters in size or less. This procedure involves targeting lasers at spider veins so they will slowly fade and disappear. Laser vein surgery is non-invasive, and you will be able to return to your normal routine immediately. But it can take two to five treatments to completely remove spider veins, and the heat from the laser can be painful. Possible side effects include temporary redness or swelling around the treated area, temporary discoloration on skin that may last one to two months, and burns from the laser. According to the ASPS, laser vein surgery costs an average of $400 per session.

Endovenous leg vein treatment. Endovenous radiofrequency and laser treatment involves placing a small tube into a larger varicose vein and sending radiofrequency or laser energy into the vein, causing it to shrink. Like sclerotherapy and laser surgery, endovenous treatments can usually be performed in the doctor's office and you can return to your normal activities immediately. In some cases, endovenous treatment can lead to slight bruising. An endovenous treatment generally costs $2,000to $3,000 and may be covered by insurance if deemed medically necessary.

Vein surgery. In some cases of severe varicose veins, a surgery known as surgical ligation and stripping may be necessary. This procedure requires anesthesia and has to be performed in an operating room. Your surgeon will tie affected veins closed and completely remove them from your leg. The risks of vein surgery include reactions to anesthesia, bleeding, blood clots, wound infection, scarring, nerve damage, and pain that may last up to four weeks after surgery. Vein surgery is significantly more expensive than non-surgical treatments, but may be covered by medical insurance if your leg veins are affecting your health.

If you’re concerned about varicose or spider veins in your legs, talk with your doctor. He or she can take X-rays and ultrasound images of your veins to further diagnose your condition, and refer you to a doctor who specializes in vein diseases, if necessary.

Sunday, December 11, 2011

Night splint treatment of plantar fasciitis pain

Both the traditional adjustable night splint and a dorsal night splint improved plantar fasciitis pain in a retrospective study, with results trending in favor of the dorsal design, which provides less stretch but may improve patient compliance.

Plantar fasciitis is a common cause of subcalcaneal heel pain. It is a condition that affects about 10% of the population at some time during life and accounts for one million orthopedic outpatient visits annually.1,2 In approximately 85% of patients, the etiology is undetermined, but associations with obesity3 and limited ankle dorsiflexion of less than 10° have been reported as significant independent risk factors.4

Plantar fasciitis is typically characterized by pain and tenderness predominantly over the medial calcaneal tuberosity, which can ultimately limit physical activity. Symptoms are frequently reported to be worse in the morning as it is thought that the plantar fascia stiffens overnight, losing its ability to stretch optimally and eventually triggering pain.5 Unrelenting or nocturnal pain is an indication that the pain may be related to a different condition (e.g., tumor, infection, inflammatory arthropathy),6 while bilateral involvement should raise suspicions of a systemic disease.7

The treatment of plantar fasciitis aims at affecting the anatomical, biochemical, and environmental factors that may contribute to the development of the condition. Conservative treatment can be effective, as demonstrated in the literature, and is the initial treatment of choice.8, 9 Treatments should address any gastrocnemius-soleus complex tightness through stretching and an eccentric-based strengthening program.10 The associated inflammatory process should be a less important focus, as nonsteroidal anti-inflammatory drugs and steroid injections have failed to show long-term benefits.11 It is believed that night splints act to place the ankle in anatomical position such that nocturnal contractures of the gastrocnemius-soleus complex is reduced and further tension on the complex, which is thought to be unfavorable to plantar fascial healing, is avoided.12 This can be performed with a traditional adjustable night splint or more recently, with dorsal night splinting.

Previous studies have compared various methods of conservative treatment of plantar fasciitis against one another, but to our knowledge there is no study comparing the treatment of plantar fasciitis between two different types of night splints in the peer reviewed literature. In this retrospective study we sought to determine the clinical benefit of applying a dorsal night splint and to compare it to an adjustable night splint in treating plantar fasciitis.

Methods

Records of patients who were treated for plantar fasciitis with either dorsal night splints or adjustable night splints between September 2006 and August 2008 were retrospectively reviewed after obtaining IRB approval. The diagnosis of plantar fasciitis and determination of pre- and post-treatment scores on the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale were established through a consistent method of history, physical exam, and radiographs by the senior author during clinic visits with 170 patients during this time frame. All patients were randomized by entry into practice—patients received the dorsal night splint based on entry into the clinic during the first year and the traditional adjustable splint for entry during the second year of the study. From September 2006 to August 2007, all patients diagnosed with plantar fasciitis by the senior author were placed in a dorsal night splint, enrolled in physical therapy, and given silastic heel cups.

From September 2007 to August 2008, all patients diagnosed with plantar fasciitis by the senior author were placed in a traditional adjustable night splint, enrolled in physical therapy, and given silastic heel cups. All patients in both study groups were given the same prescription for formal and home-based eccentric Achilles exercises and stretching, as well as massage, iontophoresis, and ultrasound. No orthotics or corticosteroid injections were given.

Patients’ records were reviewed for the date of onset of splint treatment and the date symptoms resolved, the side on which the splint was used (right or left foot), age and gender of the patient, and the presence of a calcaneal stress fracture. Patients with a calcaneal fracture were excluded (41 patients), as were patients with metatarsal stress fractures and all other patients with other unrelated or concomitant foot diagnoses. Patients with partially locked records as established by university rules and regulations were also excluded (four patients).

The traditional adjustable night splint used in this study has adjustable flexion straps and adjusts from 10° to 90° of dorsiflexion (Figure 1a). The dorsal night splint has a rigid support on the dorsum of the foot and ankle (Figure 1b), but does not provide the same range of adjustable dorsiflexion as the traditional night splint, instead ranging from neutral to 5° of dorsiflexion. Although the dorsal night splint does not provide as much of a stretch as an adjustable device, the dorsal design is thought to be more comfortable, which could improve patient compliance.

Results

Of the 170 patient records reviewed, 125 were analyzed after excluding the patients with calcaneal stress fractures and partially locked records. The average patient age was 51.3 years. Of the 125 patients, 79 were male (63.2%) and 46 female (36.8%). Eighty-seven used adjustable night splints (69.6%) and 38 used dorsal night splints (30.4%). Two patients had metatarsal stress fractures (Table 1).

The average age of patients who used the traditional adjustable night splints was 49.5 years, while the average age of patients who used dorsal night splints was 55.6 years (p= 0.021, two-sample t-test). Of the patients who used dorsal night splints, 44.7% were male (n=17), and 55.3% were female (n=21). Of the patients who used traditional adjustable night splints, 33.3% were male (n=29), and 66.6% were female (n=58). Of the patients who used dorsal night splints, 47.4% were treated on the left foot (n=18), and 52.6% were treated on the right foot (n=20). Of the patients who used traditional adjustable night splints, 42.5% were treated on the left foot (n=37), and 57.5% were treated on the right foot (n=50). There were no statistically significant differences in gender or side between the dorsal night splint group and the adjustable night splint group (Table 2).

The overall average pre-treatment AOFAS hindfoot score was 77.3 out of a possible 100 points and average post-treatment AOFAS hindfoot score was 91.2 (average score change was 13.9). The average time for resolution of symptoms was 119.5 days (Table 3). The average increase in AOFAS score from initial treatment to post treatment was 12.5 when using an adjustable night splint compared with 17.1 when using a dorsal night splint. Controlling for age, this change was not found to be statistically significant (p= 0.146, ANOVA). The average time taken until symptoms resolved using an adjustable night splint was 118.6 days (median 84 days) compared with 108.3 days (median 49 days) in patients who used a dorsal night splint, a difference that was not statistically significant (p = 0.260, ANOVA model, log transformation on time to resolution).

Discussion

The plantar fascia is a thickened fibrous aponeurosis that originates from the medial and lateral tubercles of the calcaneus and runs forward into the proximal phalanges to form the longitudinal foot arch. The function of the plantar fascia is to provide static support of the longitudinal arch and dynamic shock absorption. Plantar fasciitis is considered a self-limited condition, with symptoms resolving in 80% to 90% of cases within 10 months.8 The literature-based natural history of plantar fasciitis serves as a historical “control” group to which this study’s splinting techniques are compared.

In most cases, plantar fasciitis will respond to multiple modalities of conservative measures.11 In one long term follow up study, investigators found that 80% of patients treated conservatively for plantar fasciitis had complete resolution of pain after four years.8 If it is left untreated, it may lead to further calcification of the plantar calcaneal tuberosity where the plantar fascia and intrinsic muscles are attached, which leads to a condition known as “heel spur syndrome.” This condition induces greater pain than plantar fasciitis and is difficult to treat.5 Common predisposing factors for plantar fasciitis include obesity, female gender, middle age and excessive pronation, which can lead to fascial damage and secondary gastrocnemius-soleus contracture as well as contracture of the intrinsic muscles, especially the flexor digitorum brevis. The primary goal of treatment should be to place the fascia at proper length to heal during both weightbearing and nonweightbearing activities.

In a previous study, night splints were cited as the best treatment by approximately one third of the patients with plantar fasciitis.11 Night splints usually are designed to keep a person’s ankle in a neutral or slightly dorsiflexed position overnight. Most individuals naturally sleep with the feet plantar-flexed. Bedding on the dorsal aspect of the foot further accentuates this position through the five to eight hours per night that an individual sleeps. This causes the plantar fascia to remain in a foreshortened position. Theoretically, night splints should resist secondary nighttime contraction of the gastrocnemius-soleus complex and intrinsic musculature, as well as gravitational forces, which act to place the fascia in a shortened position. This is accomplished by placing the foot at 90° to the ankle and applying mild dorsiflexion to the digits to utilize the pulley properties of the plantar fascia. Maintaining the proper length of the plantar fascia during the healing period prevents the fascia from healing in a shortened position, which could cause further pain while weightbearing.

Wapner and Sharkey recommended 5° of dorsiflexion in the night splint and reported improvement, based on physical examination in 11 of 14 patients (79%).12 The results of a prospective crossover study of 37 patients by Powell et al also support the efficacy of night splints, with 88% of their patients reporting improvement in symptoms after one month of treatment based scores on the AOFAS Ankle-Hindfoot Rating System and the Mayo Clinical Scoring System.2 In contrast, Probe et al found no statistically significant benefit in adding traditional night splinting to a standard nonsurgical protocol of anti-inflammatory medication and stretching in a prospective randomized study of 116 patients based on scores from the SF-36 (Short Form Health Survey). In our study there was an average AOFAS score change of 13.9 and an average time to resolution of pain of 119.5 days. We believe our data is in the range of what has been published. In a prospective evaluation of posterior (adjustable) night splinting of 33 patients, Batt et al noted an average time to resolution of pain of 87 days;8 Wapner and Sharkey reported resolution within four months.12

Our study shows a decreased time for resolution of symptoms in patients who used the dorsal night splints (median 49 days/ average 108.3 days) when compared with patients who used the adjustable night splints (median 84 days/ average 118.6 days). There was also a higher average increase in AOFAS scores in the patients who used dorsal night splints (17.1) compared with adjustable night splints (12.5).

Limitations of our study include the fact that a disproportionate percentage of patients fell into one treatment group, with 69.6% in the adjustable night splint treatment group and 30.4% in the dorsal night splint treatment group. This was a consequence of the randomization of patients entering the study per year. Another limitation is the inability to control for physical therapy compliance and exercise volume, though this is a standard challenge in most other relevant studies. Furthermore, the time patients actually spent in a splint overnight is unknown and could influence results. Although the results of this study were not significant, most prior studies of plantar fasciitis treatment do not have adequate power to detect a statistically significant treatment effect difference.14

Roos et al performed a prospective randomized trial comparing use of foot orthoses, foot orthoses and night splints, and night splints alone, concluding that foot orthoses and anterior night splints were effective for both short- and long term treatment of plantar fasciitis at 12 weeks and 52 weeks. The study did not reach statistical significance and called for further evaluation of treatment measures and direct comparisons of splint types.15 Our study reveals that there is a trend towards higher efficacy of dorsal night splints over adjustable night splints in the treatment of plantar fasciitis. Although the results of this study were not significant, we believe that follow up prospective randomized controlled studies with a larger cohort population may yield significant results in comparing outcome and efficacy of night splints.

By Selene G. Parekh, MD, MBA, Olubusola A. Brimmo, MD, Ryan May, BS, and Bret C. Peterson, MD.

Friday, December 9, 2011

Should I Be Concerned About Varicose Veins?

Q: I am 64 years old and have only recently started developing varicose veins in my legs. I'm using compression stockings, but they're uncomfortable during the warm months. What other options do I have to deal with them? Aside from the increased risk of a blood clot, do they pose any serious health risks? Will the varicose veins start to look worse as I get older?

— Tania-- Wichita, KS

A:

Varicose veins can be very unpleasant, particularly from a cosmetic point of view. These enlarged and tortuous veins usually show up in the legs; they are subject to high pressure when you’re upright and therefore likely to be uncomfortable and perhaps even painful while you're standing or walking. Varicose veins can also sometimes itch, and scratching them can cause ulcers. Ulcers that infect your veins can lead to blood clots — this is a condition known as superficial thrombophlebitis and is usually isolated to superficial veins. In rare cases, these blood clots can extend into deep veins, becoming a more serious problem. Still, varicose veins very rarely bring on serious complications. More than anything else, they are considered to be a cosmetic problem, which, unfortunately, can worsen as you grow older.

One of the options you might wish to consider to reduce the appearance of your varicose veins is surgical intervention. Vein stripping is one particular surgical treatment that can help. There are also newer, less-invasive treatments such as ultrasound-guided foam sclerotherapy, radiofrequency ablation, and endovenous laser treatment, each of which has its own pros and cons. Nonsurgical treatment options include elastic stockings, elevating the legs, and exercise.

Learn more WWW.CKPA.NET .

Thursday, December 8, 2011

Doctors amputate frostbitten feet of Alaska runner

ANCHORAGE, Alaska (AP) — An All-American distance runner who spent more than two days in freezing winter temperatures without winter gear has had his legs amputated just above the ankles.

Marko Cheseto, 28, is one of several Kenyan runners who competed for the University of Alaska Anchorage in cross-country and track. The amputations were reported Monday on the UAA Athletic Department website.

Cheseto was seen at about 7 p.m. in a UAA building on Nov. 6, a Sunday night, as two snow storms started to blanket the city. His roommates reported him missing the next morning. The disappearance prompted a citywide search.

Cheseto was found early the following Wednesday outside a hotel near the campus. He was wearing athletic shoes, a jacket and blue jeans but no hat or gloves. He was suffering from hypothermia and severe frostbite on his feet and hands.

The hotel manager told the Anchorage Daily News when Cheseto was found, paramedics could not remove the runner's shoes because they were frozen to his feet.

UAA officials said Cheseto's hands are expected to make a full recovery but his lower extremities were severely injured and required amputation. He is expected to remain hospitalized for recovery and rehabilitation, UAA officials said.

University of Alaska Anchorage police interviewed Cheseto after he was found and reported he had suffered a "personal crisis" when he disappeared. Authorities concluded he had spent the entire time outside.

In a statement on the athletic department website, Cheseto thanked volunteers and professionals who searched for him.

"As some may know, I've been going through a lot of personal issues," he said. "While I am still recovering — both physically and emotionally — I will do my very best to give back to the community that has helped me so much and to my home country, Kenya. I sincerely apologize for any problems that I may have caused."

Cheseto left the campus one day after accompanying the UAA cross-country team to the NCAA Division II West Region championships in Spokane, Wash.

Cheseto had won the West Region championship the two previous seasons. Cheseto had used his final season of cross-country eligibility but was expected to compete in spring track. He took last season off following the suicide of teammate William Ritekwiang, who also was from Kenya.

Cheseto was studying for a nursing degree at the school.

Athletic Director Steve Cobb said the university will continue to support Cheseto.

"We take our responsibility and commitment to the student-athletes entrusted to our care very seriously," he said on the athletic department website. "It was meaningful that our community was there for us in our time of need and we are sincerely appreciative of everyone's efforts."

Wednesday, December 7, 2011

How to Wear High Heels Without Pain

Discover the "healthy" way to wear heels. Plus, our favorite pairs for the holiday season.

The Best "Healthy" High Heels for the HolidaysThat pain that you feel at the end of a long night—no, it's not a hangover and it's not exhaustion. We're talking about something worse—the pain that's caused by a seemingly evil and malicious pair of high heels. But, believe it or not, not all high heels are created equal. In some cases, they can actually be healthier for your feet than flats. "Excess pronation is a condition that affects 75 percent of the population and has been related to many conditions, such as heel pain (otherwise known as plantar fasciitis), knee pain, and even lower-back pain," says podiatrist Phillip Vasyli.

In this case, doctors actually recommend wearing shoes with a slight heel, as opposed to our trusty flats. "The popular trend of ballet flats has caused us to see an increase in many of the aforementioned conditions due to a lack of overall support and flimsy shoe construction," Vasyli says.

Generally, there are a few things to look for when you're shopping for stilettos. First, make sure the heels are of moderate proportions, not the towering Lady GaGa variety. Save those for dinners out, where you'll be sitting for most of the evening.

Vasyli recommends opting for well-constructed "quality" shoes, especially those that have shock absorbing materials in the ball of the foot, and using an insert like Orthaheel, which he invented. He also suggests wearing your highest heels for only short periods at a time and giving them a little bit of closet time now and then."If you feel the need to wear higher-heeled shoes daily, then take a more comfortable shoe to get to and from work and wear the higher shoes while you're sitting at your desk," he adds.

Also, while you're having a ball, be conscious of the weight that's being distributed onto the ball of your foot. "The higher the heel, the more the shoe increases the arch height and also changes the 'arch position'," Vasyli says. He suggests looking for shoes that "contour" to your arch and distribute your weight over the entire foot, not just the ball of the foot.

By Jené Luciani

Friday, December 2, 2011

5 Lies You Shouldn't Tell Your Doctor

There isn't a lot your body can hide in one of those crinkly numbers. Maybe that's why so many women refuse to reveal much else at doctor visits. About a third of men and women in the United States admit to lying to their M.D.'s, according to a 2010 survey. But keeping secrets can be dangerous, especially if the information you're withholding leads to a wrong diagnosis. Besides, "a doctor's job is to advocate for your health, not judge," say Gary Fischer, M.D., a general internist at the University of Pittsburgh Medical Center. Here's why it's time to tell the whole truth -- and nothing but.

"I never smoke."

The real deal: Jean Thilmany has been lighting up a couple of times a month for the past 20 years. But because the 42-year-old Saint Paul resident doesn't consider herself a smoker, she never mentions it to her doctor. "I don't smoke often enough for it to affect my health," she says. Actually, if you puff even the occasional cigarette at happy hour, your doctor needs to know. Yes, cancer is a concern, but equally important, those smokes affect your circulation and increase your risk for blood clots.

"Nothing has changed since my last visit."

The real deal: Really? When your doctor asks "What's new?" she doesn't mean only medically. Whether you're in a tense relationship or fretting about work woes or money matters, chronic stress can trigger high blood pressure, migraines, tummy troubles and heart palpitations, Dr. Fischer says. "The stress hormone cortisol throws other hormones, like estrogen and progesterone, out of kilter," says Jerilynn Prior, M.D., director of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia. This does more than mess with your period: Estrogen helps prevent bone loss, and progesterone aids bone growth.

The good news: Although prolonged periods of stress can have serious health consequences, there is a lot you can do. Talk to your physician; she can suggest stress busters, like relaxation exercises and yoga. In some cases she may recommend that you speak to a mental health professional who can help you work through your problems.

"I'm not taking anything."

The real deal: More than 50 percent of Americans take supplements, according to the Centers for Disease Control and Prevention. The few natural remedies that you use may not seem noteworthy to you, but they are to your physicians. "A decade ago many women took Saint-John's-wort for PMS only to learn that it can make birth control pills less effective," says FITNESS advisory board member Mark Moyad, M.D., director of preventive and alternative medicine at the University of Michigan Medical Center. And that's not the only interaction your physician wants to watch out for. Using ginseng with antidepressants puts you at risk for serotonin syndrome, a potentially fatal condition that causes diarrhea, fever and seizures. Because fish oil can thin the blood, you should stop taking it a week before dental work or surgery and don't combine it with another blood thinner, like aspirin, without checking with your doctor. Too much vitamin D can cause kidney stones, while too much vitamin C can cause heartburn. So make a list of the pills you pop, including vitamins, supplements and meds (OTC and prescription), and bring it with you to your appointment.

"I feel fine."

The real deal: About one in eight women struggle with depression at some time, but recognizing that you need help isn't easy. Twice as many women as men are affected. In addition to having persistent feelings of sadness, guilt, hopelessness and irritability, depressed women may gain or lose weight. "Tell your physician about any significant changes in your mood, thinking or behavior that affect your ability to function at home, at work or with your friends," says David Fassler, M.D., clinical professor of psychiatry at the University of Vermont College of Medicine in Burlington. She'll probably rule out other potential causes, such as viruses, thyroid disorders and medication side effects, and then conduct a psychological evaluation herself or refer you to a mental health expert. The happy news is that there are many treatment options, including psychotherapy and antidepressants.

"I eat a healthy diet."

The real deal: After three days of swigging nothing but a concoction of lemon juice, maple syrup and cayenne pepper, Catherine Howe Bryant, 32, felt light-headed, lethargic and, not surprisingly, famished. "I dropped a few pounds, but I felt awful," admits the Winston-Salem resident. Still, Bryant does a liquid cleanse whenever she wants to "feel better" about her body. She's never told her doctor. What she and other women don't realize is that extreme diets can do real damage. "When your body doesn't get the protein it needs to generate new cells and tissue, it starts to burn muscle tissue, including the heart's cardiac muscle," says Arthur Frank, M.D., medical director of the George Washington University Weight Management Program in Washington, D.C. This can lead to heart palpitations, arrhythmias and many other cardiac problems. Putting yourself into starvation mode slows your metabolism in the short term and ultimately makes it difficult to maintain weight loss.

Whether you're trying to slim down for a beach vacay or training for a race, clue your doc in. She can help you devise a sensible plan and refer you to a nutritionist for a dietary tune-up that's safer than a detox or cleanse.

Thursday, December 1, 2011

Vitamin D: Who Should Take a Supplement

Vitamin D provides a wide range of health benefits. It is effective in preventing rickets and treating other bone diseases such as osteoporosis. According to the Mayo Clinic, getting enough vitamin D may prevent high blood pressure and protect against certain types of cancer. It may also promote weight loss for women. A growing body of research links heart health to sufficient vitamin D. Most recently, a large-scale study in the American Journal of Cardiology discovered that boosting vitamin D levels in heart patients who were deficient cut their risk of death by 60%, among other significant findings.

Getting enough vitamin D

It's estimated that 30-50% of Americans suffer from vitamin D deficiency. The human body produces vitamin D, which is actually a hormone, when exposed to sunlight. However, during the winter, it is impossible to get enough exposure anywhere north of San Francisco or Philadelphia. People in southern states who slather on sun block or who stay indoors most of the time may not be getting enough either. The same goes for people who are housebound due to illness or whose work keeps them inside all day. In addition to lack of sunshine, other conditions may increase likelihood of vitamin D deficiency:

Infants who are exclusively breastfed. Mother's milk may not provide sufficient levels. The American Academy of Pediatrics recommends a supplement of 400 IU per day.

Older adults. The elderly do not synthesize vitamin D as effectively as younger people and tend to spend more time indoors.

People with dark skin. The pigment melanin can reduce the body's ability to produce vitamin D from sunlight.

Obese people. Body fat alters the way vitamin D is released into the system.

Choosing a vitamin D supplement

If you are shopping for a supplement, research suggests that vitamin D3 is more effective than vitamin D2. Food sources rich in vitamin D include cod liver oil, fatty fish (such as mackerel), eggs, and fortified milk and orange juice.

There is some debate over how much vitamin D to take. The National Institutes of Health recommends 600 IU per day for adults but some experts say that taking a supplement that contains between 1000-2000 IU can be beneficial. Its important to stay within the appropriate range--there is a toxicity risk at over 10,000 IU. The best way to determine how much you might need is to have your physician administer a simple blood test and make a recommendation based on the current level in you system.