Although most people with Type II diabetes are on oral medications, some may need insulin to control their blood sugar levels.
By Marijke Vroomen-Durning, RN
Medically reviewed by Pat F. Bass III, MD, MPH
Type II diabetes, previously known as adult-onset or non-insulin-dependent diabetes, is becoming more common in North America. As more people are diagnosed with type 2 diabetes, more research is being done into better ways to manage the disease.
Type II Diabetes: Medications
Type II diabetes is usually treated with oral medications that stimulate insulin production in the pancreas. Insulin, used in type 1 diabetes, was generally only given in Type II diabetes as a last resort if the oral medications weren’t working.
Gerald Bernstein, MD, associate professor of medicine at Albert Einstein College of Medicine in Bronx, N.Y., and a past president of the American Diabetes Association, says that the idea of going on to insulin is often seen as a threat: “If you don’t lose weight, you’ll wind up on insulin.” But, over time, researchers and doctors are learning that it may be in a patient’s best interest to begin insulin treatment earlier for type 2 diabetes, rather than later.
It’s important to understand the goal of treating diabetes. The treatment of diabetes is, of course, meant to lower blood sugar levels, but this is the short-term goal. The long-term goal of diabetes treatment is to slow the progression of the disease and, therefore, delay or prevent complications.
Vincent Woo, MD, chair of the clinical and scientific section of the Canadian Diabetes Association, says “this is a big topic,” and refers to the association’s guidelines, which say:
• If after two to three months of lifestyle changes, blood sugar control hasn't improved, it’s time to start medications. This could include insulin in combination with oral medications.
• If blood sugar levels aren’t under control after a trial period of oral medications alone, insulin may be added if appropriate. Insulin is normally administered under the skin several times per day, either by injection or via an insulin pump. Several years ago an inhaled insulin was marketed in the United States, but it was discontinued due to poor sales.
Dr. Bernstein agrees: “The reality is that all of the new data and the goals of glucose control suggest that insulin would actually be better used if it were started very early in type 2 diabetes.” New guidelines “suggest that insulin should be the earliest medication intervention after the patient is taught lifestyle changes and is placed on metformin,” he says.
Type 2 Diabetes: Using Insulin for a Short Period
Many people with type II diabetes do quite well with oral medications and just need to be vigilant. Unfortunately, diabetes is a complicated illness that gets worse when your body is stressed. The stresses aren’t necessarily things like a serious illness or surgery — they could include stress over an infection or a good stress, like pregnancy. Regardless of the cause, in these situations you may need insulin to get you over the hump.
The idea here is you’re given insulin while your body heals itself from the stress and, if all goes well; the insulin may be reduced or eliminated once the stressor is gone and your body returns to its pre-stress self.
These insulin’s will be either short-acting or longer-acting insulins, or both, depending on what your body needs at that point. But, you should remember that this is most likely a temporary measure and that the hope — and aim — of the treatment is to get you back onto your usual diabetes management plan.
Living with diabetes can be frustrating, especially if you are trying your best to keep your blood sugar levels under control. While using insulin may not have been in your plan or vision of diabetes management, you should keep in mind your long-term goal of slowing down the disease process. And, if insulin is part of that plan, learning how to manage and use the insulin may be exactly what you need.
Showing posts with label surgery. Show all posts
Showing posts with label surgery. Show all posts
Saturday, September 25, 2010
Tuesday, September 7, 2010
Beyond Bunionectomy: The Role of Physical Therapy
More and more surgeons are embracing the idea that physical therapy after bunion surgery can improve range of motion and other functional outcomes. But some practitioners still aren’t sure it’s right for everyone.
Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.
Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.
“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”
In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.
Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.
“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”
At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.
Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.
Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.
“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”
So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.
Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).
Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.
“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.
Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.
“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.
A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.
“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”
Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.
At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.
Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.
“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”
Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.
“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”
Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.
“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”
Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.
Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.
“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”
The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.
“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”
Physical therapy following bunion surgery, Brown said, should extend well above the ankle.
“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”
Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.
“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”
A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.
“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”
He believes proper therapy and patient training can reduce the progression of bunion surgeries.
“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.
Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.
“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”
In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.
“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”
August 2010 by Linda Weber
Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.
Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.
“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”
In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.
Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.
“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”
At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.
Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.
Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.
“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”
So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.
Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).
Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.
“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.
Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.
“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.
A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.
“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”
Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.
At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.
Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.
“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”
Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.
“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”
Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.
“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”
Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.
Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.
“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”
The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.
“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”
Physical therapy following bunion surgery, Brown said, should extend well above the ankle.
“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”
Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.
“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”
A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.
“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”
He believes proper therapy and patient training can reduce the progression of bunion surgeries.
“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.
Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.
“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”
In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.
“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”
August 2010 by Linda Weber
Tuesday, August 24, 2010
Yao Ming is contemplating retirement
'Twas less than a week ago that the Houston Rockets introduced Brad Miller(notes) and his camouflage shorts as the newest member of their team. We applauded the great fit, and not just because of the abundant hunting opportunities. Not only would Miller be playing in a system that values his skills — passing, perimeter shooting, other things that start with "P" — but he'd also be stepping into a low-pressure situation where he could excel in limited minutes. It was all good, baby bay-bay.
However, it turns out we might be seeing a lot more of Brad Miller in the next few years. Because not only is Yao Ming(notes) unsure about how he will perform this coming season, he's also contemplating ending his career if his foot doesn't heal right. From the Associated Press:
In comments to Chinese state media Monday, Yao sounded far from optimistic about his future and also made a rare criticism of China's national basketball program.
"If the foot injury does not heal next season, I might choose to call it quits," he said. [...]
Yao, who has been in China to promote some of his charity events, all but ruled out playing in the 2012 London Olympics.
"The chance is very small," the 7-6 center was quoted as saying by the official Xinhua News Agency. "The foot injury will not allow me to play so many games anymore. Like I said before, I will quit the national team and the sport one day. It's what happens to every athlete."
Leave it to Yao Ming to be completely OK with his impending basketball mortality even though it's five years too early. It seems like just yesterday that Yao was sporting the pinstriped Rockets uniforms made famous by Matt Maloney, and now he's all but telling us he's almost done with the NBA. Somebody grab me some tissues.
Of course, there is a chance that Yao's foot will be fine this season. Zydrunas Ilgauskas(notes) went through a similar injury and surgery early in his career, and has played eight seasons since then. He was 23 when he broke his foot, which makes healing a lot easier than recovering from the same injury at 30.
I guess all we can do now is hope that Yao's foot turns out to be no big deal. Well, size 18 kicks are pretty large, but I meant "big" in a metaphorical sense. At the very least, the Rockets have the most enjoyable center ever signed for the next four years. It'd be tough to lose Yao, but those next three years would be filled with so many hearty laughs.
However, it turns out we might be seeing a lot more of Brad Miller in the next few years. Because not only is Yao Ming(notes) unsure about how he will perform this coming season, he's also contemplating ending his career if his foot doesn't heal right. From the Associated Press:
In comments to Chinese state media Monday, Yao sounded far from optimistic about his future and also made a rare criticism of China's national basketball program.
"If the foot injury does not heal next season, I might choose to call it quits," he said. [...]
Yao, who has been in China to promote some of his charity events, all but ruled out playing in the 2012 London Olympics.
"The chance is very small," the 7-6 center was quoted as saying by the official Xinhua News Agency. "The foot injury will not allow me to play so many games anymore. Like I said before, I will quit the national team and the sport one day. It's what happens to every athlete."
Leave it to Yao Ming to be completely OK with his impending basketball mortality even though it's five years too early. It seems like just yesterday that Yao was sporting the pinstriped Rockets uniforms made famous by Matt Maloney, and now he's all but telling us he's almost done with the NBA. Somebody grab me some tissues.
Of course, there is a chance that Yao's foot will be fine this season. Zydrunas Ilgauskas(notes) went through a similar injury and surgery early in his career, and has played eight seasons since then. He was 23 when he broke his foot, which makes healing a lot easier than recovering from the same injury at 30.
I guess all we can do now is hope that Yao's foot turns out to be no big deal. Well, size 18 kicks are pretty large, but I meant "big" in a metaphorical sense. At the very least, the Rockets have the most enjoyable center ever signed for the next four years. It'd be tough to lose Yao, but those next three years would be filled with so many hearty laughs.
Friday, August 13, 2010
Question: I have a large bump on the inside of my foot that seems to be getting larger, what is it, and can it be removed?
Answer: A bunion is a bony prominence, along the inside of the foot, at the base of the big toes. This “bump” represents a misalignment of the big toe joint. Bunions commonly occur on both feet, but on foot may be more severe than the other. They tend to be hereditary but can occur without a family history. They are not caused by poor shoe gear, but are often aggravated by the shoe. This deformity is cause by abnormal foot function. A foot that rolls in excessively (pronates excessively) allows abnormal stress to go through the big toe joint to cause the deformity. This is a progressive deformity. The deformity never gets better, only worse.
Conservative care consists of decreasing the pressure on the bony prominence by a wider or softer shoe or padding around the deformity. Sometimes good arch support of an orthotic will improve foot function enough to decrease the irritation of the deformity and slow down its progression. If conservative care is not successful, then surgical straightening is the treatment choice. Surgical treatment revolves around realigning the structural deformity. The bony prominence is removed and the joint is realigned. The type of procedure and the length of recovery are determined by the severity of the deformity.
In order for your surgeon to establish a diagnosis and determine the severity of the deformity, a health history, physical examination, and x-rays are necessary to evaluate the extent of your bunion deformity. Depending on your individual needs as well as your overall medical, condition, your surgeon will recommend the best treatment regiment for you.
Conservative care consists of decreasing the pressure on the bony prominence by a wider or softer shoe or padding around the deformity. Sometimes good arch support of an orthotic will improve foot function enough to decrease the irritation of the deformity and slow down its progression. If conservative care is not successful, then surgical straightening is the treatment choice. Surgical treatment revolves around realigning the structural deformity. The bony prominence is removed and the joint is realigned. The type of procedure and the length of recovery are determined by the severity of the deformity.
In order for your surgeon to establish a diagnosis and determine the severity of the deformity, a health history, physical examination, and x-rays are necessary to evaluate the extent of your bunion deformity. Depending on your individual needs as well as your overall medical, condition, your surgeon will recommend the best treatment regiment for you.
Friday, July 16, 2010
Surgical site infection risk in patients with diabetes
Surgical procedures are often unavoidable in patients with diabetes, and can even help reduce future risk of ulceration. But high postoperative infection rates in this patient population pose additional challenges to practitioners.
With 7.8% of the United States population (~23.6 million people) estimated to be diabetic, one can see how diabetes has become an increasing challenge for the medical community. It has been estimated that nearly a third of these patients are unaware of being diabetic. This prevalence will rise, as nearly 25% of adults over 60 are diabetic and there are increasing numbers being diagnosed in younger patients. Approximately 366 million people will have diabetes worldwide by the year 2030, most of these in developing countries. Foot disorders such as ulcers, infection, Charcot neuroarthropathy and peripheral arterial disease (PAD) are the most common causes of hospital admissions in diabetics. As diabetes mellitus is considered a lifelong condition, one can see the true impact on the healthcare system overall.
Peripheral neuropathy is one of the most common complications found in diabetics, prevalent in anywhere from 14-60% of the diabetic population. Peripheral neuropathy leads to sensory, motor and autonomic dysfunction, and this loss of protective sensation often causes these patients to fail to seek timely medical care for their conditions.
Foot surgery in patients with DM can be elective or preventative. Due to concerns with increased infection rates and slow healing of skin and bony structures in diabetics, elective surgery is performed with extreme caution. Prophylactic or preventative surgery is performed in those diabetics with pre-ulcerative areas, bony prominences and stable, non-infected ulcers. The purpose is to prevent ulcerations due to these bony prominences or to assist in healing of current ulcerations. Multiple types of surgeries can be performed based on the underlying bony deformity found, including hammertoe repair, bunion repair, metatarsal osteotomies, bone resections, Achilles tendon lengthenings for ulcers in the forefoot area and many more. Fracture repair is often required in diabetic patients. Those patients with Charcot foot deformity not treatable with bracing may require surgical intervention also.
It has been noted that diabetic patients without neuropathy can be treated with standard surgical technique and post-op care, but those who are neuropathic should have more fixation, be seen more often and remain non-weightbearing for approximately double the time period.
Peripheral arterial disease can also complicate the surgical site in diabetics, especially those with an insensate foot. Lack of blood flow to the surgical site not only affects the patient’s ability to heal the site quickly, but can also lead to an inability to fight off potential infection at the surgical site in the diabetic patient. Surgical site infections are infections that occur with 30 days of a surgical procedure, or within 1 year if an implant was inserted and is related to the surgery. One study found that by controlling factors such as hypothermia, blood glucose levels, removing hair from the surgical site and administering procedure-specific pre-operative antibiotics for an appropriate time frame, infection risk can be decreased.
One study showed a post-op infection rate of 6.7% in diabetic patients with neuropathy but no open wound undergoing forefoot surgery. A recent study was performed to examine wound infection rates involving 57,183 patients with ankle fractures undergoing repair. This study showed that non-diabetic patients had an infection rate of 1.4% after surgery. Diabetics without neuropathy or other comorbidities had a rate of 3.55% and diabetics with neuropathy or other comorbidities had an infection rate of 7.71%. Other reviews have found similar percentages, indicating that there is an obvious increased risk of infection in diabetics undergoing foot and ankle surgery. This implies that foot and ankle surgeons must have appropriate protocols in place to lessen these infection rates in their patients. First and foremost, comorbidities such as peripheral neuropathy and peripheral arterial disease must be diagnosed and managed prior to preventative surgery.
With 7.8% of the United States population (~23.6 million people) estimated to be diabetic, one can see how diabetes has become an increasing challenge for the medical community. It has been estimated that nearly a third of these patients are unaware of being diabetic. This prevalence will rise, as nearly 25% of adults over 60 are diabetic and there are increasing numbers being diagnosed in younger patients. Approximately 366 million people will have diabetes worldwide by the year 2030, most of these in developing countries. Foot disorders such as ulcers, infection, Charcot neuroarthropathy and peripheral arterial disease (PAD) are the most common causes of hospital admissions in diabetics. As diabetes mellitus is considered a lifelong condition, one can see the true impact on the healthcare system overall.
Peripheral neuropathy is one of the most common complications found in diabetics, prevalent in anywhere from 14-60% of the diabetic population. Peripheral neuropathy leads to sensory, motor and autonomic dysfunction, and this loss of protective sensation often causes these patients to fail to seek timely medical care for their conditions.
Foot surgery in patients with DM can be elective or preventative. Due to concerns with increased infection rates and slow healing of skin and bony structures in diabetics, elective surgery is performed with extreme caution. Prophylactic or preventative surgery is performed in those diabetics with pre-ulcerative areas, bony prominences and stable, non-infected ulcers. The purpose is to prevent ulcerations due to these bony prominences or to assist in healing of current ulcerations. Multiple types of surgeries can be performed based on the underlying bony deformity found, including hammertoe repair, bunion repair, metatarsal osteotomies, bone resections, Achilles tendon lengthenings for ulcers in the forefoot area and many more. Fracture repair is often required in diabetic patients. Those patients with Charcot foot deformity not treatable with bracing may require surgical intervention also.
It has been noted that diabetic patients without neuropathy can be treated with standard surgical technique and post-op care, but those who are neuropathic should have more fixation, be seen more often and remain non-weightbearing for approximately double the time period.
Peripheral arterial disease can also complicate the surgical site in diabetics, especially those with an insensate foot. Lack of blood flow to the surgical site not only affects the patient’s ability to heal the site quickly, but can also lead to an inability to fight off potential infection at the surgical site in the diabetic patient. Surgical site infections are infections that occur with 30 days of a surgical procedure, or within 1 year if an implant was inserted and is related to the surgery. One study found that by controlling factors such as hypothermia, blood glucose levels, removing hair from the surgical site and administering procedure-specific pre-operative antibiotics for an appropriate time frame, infection risk can be decreased.
One study showed a post-op infection rate of 6.7% in diabetic patients with neuropathy but no open wound undergoing forefoot surgery. A recent study was performed to examine wound infection rates involving 57,183 patients with ankle fractures undergoing repair. This study showed that non-diabetic patients had an infection rate of 1.4% after surgery. Diabetics without neuropathy or other comorbidities had a rate of 3.55% and diabetics with neuropathy or other comorbidities had an infection rate of 7.71%. Other reviews have found similar percentages, indicating that there is an obvious increased risk of infection in diabetics undergoing foot and ankle surgery. This implies that foot and ankle surgeons must have appropriate protocols in place to lessen these infection rates in their patients. First and foremost, comorbidities such as peripheral neuropathy and peripheral arterial disease must be diagnosed and managed prior to preventative surgery.
Monday, March 1, 2010
Foot Pain.…Make it STOP!!
Patients often ask, “How much pain will I have after surgery?” This is a very difficult question to answer because everyone experiences pain differently. This also makes testing someone for pain difficult. Everyone experiences pain at different levels and have different thresholds for tolerating pain. Pain is often difficult to locate. When our bodies experience a pain, it sends the signal through our brain through nerve fibers. Small nerve fibers called delta fibers send 90% of the pain signals to the brain to specific locations in the cortex of the brain. Testing these fibers shows us where the pain is coming from. Small nerve fiber testing is a painless test that can show where the pain is coming from in about 20 minutes. An EMG tests for nerve damage. Pain occurs before the nerve is damaged. By testing the small nerve fibers, it locates accurately with 95% sensitivity where the pain is before there is permanent damage. This leads to earlier and more effective treatment. If you are experiencing pain that is not responding to traditional treatment, consult with your physician to see if you are a candidate for small nerve fiber testing.
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