INFANT BRACHIAL PLEXUS INJURIES

The brachial plexus is a network (bundle) of nerves in the shoulder and under the arm. The network is composed of the nerves that carry signals from the spinal cord to the shoulder, arm, hand, and fingers. These signals transmit information between the brain, the spinal cord, and the arm and hand and are required for typical movement and feeling (sensation). If nerves in the upper part of the brachial plexus bundle are damaged, the injury is called Erb’s (or Erb-Duchenne) Palsy. If the nerves in the lower part of the brachial plexus are damaged, the injury is called Klumpke’s (or Dejerine-Klumpke) Palsy. In some instances, all the nerves may be damaged, resulting in "global" palsy.

Injuries to the brachial plexus result in movement and sensation difficulties in the arm, which may be mild or severe, and temporary or prolonged. Brachial plexus injury occurs in approximately 1.5 of every 1,000 infants born; the rate of injury is lower in smaller infants (under 6 pounds) and increases as the size of the infant increases, especially in babies who weigh 9 pounds or more.

What is a Brachial Plexus Injury?

The brachial plexus is a bundle of nerves that runs from the neck through the shoulder to the arm. Although injury can happen anytime, most brachial plexus injuries occur during birth when the infant's shoulder becomes wedged in the birth canal. This event, called shoulder dystocia, can stretch the brachial plexus, damaging the nerves. The delivery becomes an emergency situation, and additional maneuvers are required to deliver the infant. Injury also may occur without shoulder dystocia if the labor is long, the infant is large, the mother develops gestational diabetes, the delivery requires external assistance (such as forceps), or if a breech birth (buttocks- or feet-first rather than head-first) occurs.

Possible Causes

Erb's or Klumpke's Palsies result from 4 types of brachial plexus injuries:

• Neuropraxia occurs when 1 or more of the nerves are stretched and damaged, but not torn. It is the most common type of injury to the nerves of the brachial plexus, and may heal spontaneously.
• Neuroma results from a torn nerve that heals, but scar tissue develops. The scar tissue puts pressure on the injured nerve and prevents signals from being transmitted between nerves and muscles. Neuroma injuries require treatment to heal.
• Rupture describes a torn nerve, but the tear is not at the site where the nerve attaches to the spine. Surgery will be required, and the muscles may continue to weaken if physical therapy treatment does not occur following surgery.
• Avulsion is the most severe type of injury, in which the nerve is torn from the spine. The size and growth of the arm or hand may be affected, and damage may be present for life.

Signs and Symptoms

The signs and symptoms of brachial plexus injury vary, depending upon which nerves are damaged and the extent of the damage. Major damage may result in a limp or paralyzed arm. The arm muscles are weak and lack feeling or sensation.

In Erb's Palsy, the signs may be a stiff arm that is rotated inward with the wrist fully bent and fingers extended. This position is often called the "waiter's tip" because it resembles a food server holding the hand discreetly for a tip.

If other nerves are damaged, as in Klumpke's Palsy, the posture of the arm will be different. Sometimes the fingers and hand can move even when the arm has limited movement. The amount of pain that is present also is dependent upon the extent of the nerve damage.

How Is It Diagnosed?

Brachial plexus injuries are often apparent at birth because the infant's arm is limp or unusually stiff. Diagnosis of the injury requires a careful neurological examination by a specialist to determine which nerves have been affected, and the severity of the injury. Usually, the examination will include physical observation of the arm as well as some special tests, such as an electromyogram (EMG) that reveals the extent of muscle damage caused by the nerve injury. A nerve conduction study (NCS) may be used to determine how far signals are transmitted along the nerves. Other scans may be required to assess the damage to the nerves.

Some children's hospitals offer a team approach in diagnosing and treating children with brachial plexus injuries. The specialists on the team might include physicians, orthopedic surgeons, and physical therapists. Surgery may be necessary if the nerve damage is too extensive for recovery with therapy alone. Physical therapy will likely be a part of the treatment plan, whether or not the child has surgery. Sensory re-education may be included if the brain forgets how the arm and hand should function during the time the nerve is regrowing or healing. Seeking treatment as early as possible, and seeking care by experts in brachial plexus injury can make a big difference in helping a child gain full use of their arm.

How Can a Physical Therapist Help?

A physical therapist is an important family treatment partner for any child diagnosed with a brachial plexus injury. Physical therapy should begin as soon as possible after diagnosis or surgery, and before joint or muscle tightness has developed. Physical therapists will:

• Identify muscle weakness and work with each child to keep muscles flexible and strong.
• Help reduce or prevent muscle or joint contractures (tightening) and deformities.
• Encourage movement and function.

Even when surgery is not required, therapy may need to continue for weeks and months as the nerves grow again or recover from damage. Children with Erb's Palsy will usually recover by 6 months of age, but other palsies may require longer treatment. Each treatment plan is designed to meet the child's needs using a family-centered approach to care.

Evaluation. Your child's physical therapist will perform an evaluation that includes a detailed birth and developmental history. Your child’s physical therapist will perform specific tests to determine arm function, such as getting the child to bring the hands together, grasp a toy, or use the arm for support or for crawling. The physical therapist will test arm sensation to determine whether some or all feeling has been lost, and educate the family about protecting the child from injuries when the child may not be able to feel pain. Physical therapists know the importance of addressing the child’s needs with a team approach, review all health care assessments, and send the child for further evaluation, if needed.

Treatment. Physical therapists work with children with brachial plexus injury to prevent or reduce joint contractures, maintain or improve muscle strength, adapt toys or activities to promote movement and play, and increase daily activities to encourage participation—first in the family, and later, in the community. Treatments may include:

• Education on holding, carrying, and playing with the baby. Your physical therapist will make suggestions for positioning, so that your baby's arm will not be left hanging when the baby is being held or carried. Your physical therapist will provide ideas for positioning the baby on the back or stomach for play without injury to the arm.
• Prevention of injury. Your physical therapist will explain the possible injuries that could occur without the baby crying, since the baby cannot perceive pain if sensation is limited in the arm.
• Passive and active stretching. Your physical therapist will assist you and your child in performing gentle stretches to increase joint flexibility (range of motion), and prevent or delay contractures (tightening) in the arm.
• Improving strength. Your physical therapist will teach you and your child exercises and play activities to maintain or increase arm strength. Your physical therapist will identify games and fun tasks that promote strength without asking the baby to work too hard. As your child improves and grows, your physical therapist will identify new games and activities that will continue to strengthen the arm and hand.
• Use of modalities. Your physical therapist might use a variety of intervention techniques (modalities) to improve muscle function and movement. Electrical stimulation can be applied to gently simulate the nerve signal to the muscle and keep the muscle tissue functional. Flexible tape can be applied over specific muscle areas to ease muscle contraction. Constraint-induced movement therapy (CIMT) may be applied to the nonaffected arm to encourage use of the affected arm. Repetitive training of the affected arm is encouraged, using age-appropriate tasks, such as finger painting, building a tower, or picking up and eating small bites of food. Your physical therapist will collaborate with other health professionals to recommend the best treatment techniques for your child.
• Improving developmental skills. Your physical therapist will help your child learn to master motor skills, like putting the child’s weight on the injured arm, sitting up with arm support, and crawling. Your physical therapist will provide an individualized plan of care that is appropriate based on your child’s needs.
• Fostering physical fitness. Your physical therapist will help you determine the exercises, diet, and community involvement that will promote good health throughout childhood. Your physical therapist will continue to work with you and your child to determine any adaptations that may be needed, so that your child can participate fully in family life and in society.

Therapy may be provided in the home or at another location, such as a hospital, community center, school, or a physical therapy outpatient clinic. Depending upon the severity of the brachial plexus injury, the child's needs may continue and vary greatly as the child ages. Your physical therapist will work with other health care professionals, eg, occupational therapists and physicians, to address all your child's needs as treatment priorities shift.

OBESITY ACCOUNTS FOR WHAT PERCENTAGE OF US ADULT DEATHS

At a time when more Americans are overweight than ever before, a study published in the American Journal of Public Health suggests that obesity is more deadly than previously estimated.

The study, which examined data from 1986 to 2006, when Americans were comparatively lean, determined that as many as 18% of deaths of individuals aged 40- to 85 are linked to obesity.

As NBC News reported ("Heavy burden: obesity may be even deadlier than thought" - August 15, 2013), many factors increase a person's likelihood of weight problems, from income to level of education. And people who are obese are more likely to have other unhealthy habits, such as smoking and poor diets.

"People who are overweight or obese are far more likely than thinner people to have heart disease, cancer, or diabetes, and to have strokes or heart attacks," NBC reported. "Usually, but not always, fatter people are less fit than thinner people, and exercise can clearly protect you from death and disease."

As experts in human motion, physical therapists at CHAMPION can design fitness programs to help you exercise safely. Give us a call for questions, or to set up an evaluation!

IS IT REALLY NECESSARY FOR SURGERY FOLLOWING A MENISCUS TEAR?

Could 1 of the most popular surgical procedures in the United States be unnecessary many of the approximately 700,000 times it is performed each year?

A study published in the New England Journal of Medicine suggests that might be the case for arthroscopic surgery to repair a torn meniscus—particularly if the tear is a result of wear and aging, as opposed to a traumatic event.

As the New York Times reported ("Common Knee Surgery Does Very Little for Some, Study Suggests" - December 25, 2013), a Finnish study of 146 patients between the ages of 35 and 65 found that those who had arthroscopic surgery had no better level of satisfaction 1 year later than had others in the study who had undergone a mock surgical procedure.

"Those who do research have been gradually showing that this popular operation is not of very much value," Dr David Felson told the Times.

What exactly does that mean? Well, it means that there's essentially a chance that the outcomes of a surgical repair are not significantly greater than that of physical therapy, meaning you can achieve close to the same outcome at a much cheaper cost. Does this concept apply to everyone? No, it absolutely does not. This study is one of a few that are starting to go public that only apply to those in generally good health, not other knee conditions, and no outstanding circumstances - meaning they are low risk patients who wish to get back to moderately stressful (on the body) activities, at the most. High level athletes, young athletes, and professional athletes are not considered in this category, as well as elderly, individuals with other degenerative conditions of the knee, and those with multiple injuries of the knee (like a meniscus tear and ACL tear, or something along those lines.) 

Talk to your physical therapist today, or come see an orthopedic physical therapist at CHAMPION  about whether surgery is a good option for you!  

DISCOID MENISCUS #MaybeShe'sBornWithIt?

A discoid meniscus is an abnormally shaped meniscus (cartilage that cushions the bones of the knee) present in 1% to 3% of people born in the United States. The condition is the result of abnormal formation of the meniscus during development in the womb. While some people may be unaware of their discoid meniscus and never experience symptoms related to it, they live at a higher risk of injury than those born with a normal meniscus. A discoid meniscus is commonly detected in childhood or adolescence, and often requires surgical intervention. Physical therapists provide treatment prior to and following surgery, and for conditions not requiring surgery.

What is Discoid Meniscus?

Our knees contain 2 cushions between our thigh bone (femur) and shin bone (tibia), made of cartilage called meniscus. The meniscus is normally crescent-shaped. Its role is to provide stability to the knee joint and absorb forces when we stand and move. Both menisci are attached to the shin bone (tibia) by the meniscofemoral ligament.

A discoid meniscus is present at birth. It occurs when the cartilage does not properly develop, resulting in a thicker disc- or oval-shaped meniscus. The defect most often occurs in the meniscus on the outer (lateral) part of the knee joint. Approximately 20% of individuals diagnosed with a discoid meniscus have it in both knees.

There are 3 types of discoid menisci. The classifications are:

• Incomplete Discoid Meniscus. The shape of the meniscus is a bit wider and thicker than a normal meniscus.
• Complete Discoid Meniscus. The shape of the meniscus is significantly wider than a normal meniscus, covering the shin bone (tibia).
• Wrisberg-Ligament Meniscus. The normally present meniscofemoral ligament is absent.

Their abnormal shape and thickness make discoid menisci more prone to injury and tearing. The meniscus tissue is often not capable of healing itself due to its limited blood supply, which is required for tissue healing.

Meniscal injuries most commonly occur in activities that require sudden stopping, pivoting, and "cutting," such as in sports. Pain may also be present, sometimes without a specific injury to, or a tear in, the discoid meniscus.

In some cases, arthroscopic surgery may be required to reshape the abnormal meniscus to make it as normal as possible.

How Does it Feel?

With a discoid meniscus or torn discoid meniscus, you may experience:

• Pain in your knee, most often on the outer (lateral) side of the leg.
• Sharp pain with running, jumping, cutting, or deep squatting.
• Swelling in the knee.
• Tenderness on the outer side, or less commonly on the inner side, of the knee.
• Catching or locking of the knee while walking or squatting.
• Loss of knee motion, particularly getting "stuck," while fully bending or straightening the knee.
• Loss of strength in the quadriceps (thigh) muscle.
• Discomfort with daily activities, like walking up and down stairs.

How Is It Diagnosed?

Diagnosis of a discoid meniscus begins with a thorough medical history and physical examination. Your physical therapist will assess different measures of the knee area, such as motion, strength, flexibility, tenderness, and swelling. Your physical therapist will perform several tests specific to the knee joint, and may ask you to briefly demonstrate the activities or positions that cause your pain, such as walking, squatting, and stepping up or down stairs.

If your physical therapist suspects there may be an injury inside the knee joint, such as a discoid meniscus, the therapist will likely recommend a referral to an orthopedic physician for diagnostic imaging, such as ultrasound, x-ray, or MRI. An MRI, which looks at bones, muscles, and cartilage, is the best imaging source to identify a discoid meniscus and a tear in the meniscus.

How Can a Physical Therapist Help?

When you have been diagnosed with a discoid meniscus, your physical therapist will work with you to develop a plan to help achieve your specific goals. If surgery is needed, your physical therapist will work with you after surgery. To do so, your physical therapist will select treatment strategies in any or all of the following areas:

Range of Motion. An injury or surgery to the knee joint causes the joint to be irritated, often resulting in swelling and stiffness, resulting in loss of normal motion. While it is important to regain your normal knee motion, it is also important to allow your injury to heal, without placing excessive stress on the healing joint. Your physical therapist will assess your motion, design gentle exercises to help you regain normal range of motion, and establish a plan that will balance joint protection with motion restoration.

Strength Training. Your physical therapist will teach you exercises to strengthen the muscles around the knee, so that each muscle is able to properly perform its job, and stresses are eased, so the knee joint is properly protected.

Manual Therapy.Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move your knee cap (patella) or patellar tendon and surrounding muscles to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. 

Pain Management. Many pain-relief strategies may be implemented; the most beneficial with knee pain is to apply ice to the area, and decrease or eliminate specific activities for a certain length of time. Your physical therapist will help to identify specific movements or activities that continue to aggravate your knee joint, and will design an individual treatment plan for you, beginning with a period of rest, and gradually adding a return to certain activities as appropriate.

Functional Training.Physical therapists are experts at training athletes to function at their best. Your physical therapist will assess your movements, and teach you to adjust them to relieve any extra stress in your knee.

Education. Your physical therapist will work with you to identify and change any external factors causing your pain, such as exercise selection, footwear, or the amount of exercises you complete. Your physical therapist will develop a personal exercise program to help you return to your desired activities.

Can this Injury or Condition be Prevented?

A discoid meniscus is present at birth and, therefore, cannot be prevented. Maintaining appropriate lower-extremity mobility and muscular strength are the best methods for preventing any type of knee injury. Unfortunately, the structure of some individuals’ menisci can increase the risk of sustaining an injury. It is imperative to be aware of any knee pain that you experience, particularly with squatting, running, or cutting, as these are signs of a potential knee injury. Identifying and addressing these injuries early is helpful in their treatment.

Real Life Experiences

Ashleigh is a 15-year-old girl who has been playing soccer since she was in the first grade. She plays with her high school team during the week, and competes in tournaments with her club team on the weekends. Last weekend, while she was running and cutting in her soccer game, she felt a sharp pain in her right knee. She was able to finish playing, but after the game, she told her dad her knee was hurting. She said it had begun getting sore during one of the practices that week, but she didn’t want to tell her coach because she was worried she would not be allowed to continue to play. Now she said she felt like her knee was swollen. Her dad immediately called their local physical therapist.

Ashleigh's physical therapist performed a comprehensive health history and examination. The physical examination revealed that Ashleigh’s knee was tender, swollen, and that she had lost leg motion and strength. Because Ashleigh’s knee was so tender, her physical therapist referred her to an orthopedic surgeon. Her MRI results showed that Ashleigh had a discoid meniscus in her right knee that required surgery.

Ashleigh underwent an outpatient arthroscopic surgery, which required 2 small incision holes in the front of her knee. She was able to return home the same day. After her surgery, Ashleigh returned to physical therapy. Ashleigh used crutches for about 2 weeks after her surgery, until her leg was strong enough to walk without support. Together, Ashleigh and her physical therapist, father, and coach developed a treatment plan to help get her back on the soccer field. The treatment process began with exercises to regain motion and strength.

After about 2 months, when her knee was less tender and she had met some of the goals set in physical therapy, Ashleigh began light running, in preparation for her return to soccer. Throughout her rehabilitation, Ashleigh and her physical therapist worked together to improve the ways she moved, including her sqatting, running, and jumping form, in order to decrease the chance of her developing another knee injury. Along with her physical therapist, coach, and parents, Ashleigh developed a gradual reintegration plan for her return to soccer.

A month later, Ashleigh was back playing soccer! In order to minimize her risk of further knee problems, she continued to perform the daily exercises her physical therapist had prescribed. She also changed her routine to allow for adequate warm-up time before and after each practice. At the end of the season, thanks to Ashleigh’s goal scoring, her team won the high-school state championship!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

• A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
• A physical therapist who is a board-certified specialist, or has completed a residency in orthopedic or sports physical therapy, as the therapist will have advanced knowledge, experience, and skills that apply to an athletic population.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

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

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping athletes with knee pain.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.

Further Reading

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

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

Sun Y, Jiang Q. Review of discoid meniscus. Orthorp Surg. 2011;3(4):219–223. Article Summary on PubMed.

Davidson D, Letts M, Glasgow R. Discoid meniscus in children: treatment and outcome. Can J Surg. 2003;46(5):350–358. Free Article.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Allison Mumbleau, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.

HAPPY NEW YEAR!

The happiest of New Years to all of Johnson and Jackson County. 
WE THINK you should make your goals to HELP YOURSELF by HELPING YOUR BODY! 

Each January, Americans rush back to the gym determined to burn off holiday season calories and work toward New Year's resolutions to get into shape. Unfortunately, various studies indicate that more than half of those who join a gym or fitness club will drop out within 3-6 months.

One common reason is injury.

Below are resources developed by physical therapists that can help you avoid injury and reach your fitness goals any time of year.

http://www.moveforwardpt.com/PatientResources/VideoLibrary/detail/safe-exercise-starter-plan

The Rotator Cuff Tear (RTC)

A rotator cuff tear is a common cause of pain and disability among adults. In 2008, close to 2 million people in the United States went to their doctors because of a rotator cuff problem. 

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Normal Anatomy of the Shoulder

Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

This illustration more clearly shows the four muscles and their tendons that form the rotator cuff and stabilize the shoulder joint.

Reproduced with permission from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears:

• Partial Tear: This type of tear damages the soft tissue, but does not completely sever it;
• Full-Thickness Tear: This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon;

A rotator cuff tear most often occurs within the tendon.

Cause

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater risk for a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
• Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
• Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms

The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

A rotator cuff injury can make it painful to lift your arm out to the side.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

Doctor Examination

Medical History and Physical Examination

Your doctor will test your range of motion by having you move your arm in different directions.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

After discussing your symptoms and medical history, your doctor will examine your shoulder. He or she will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder, your doctor will have you move your arm in several different directions. He or she will also test your arm strength.

Your doctor will check for other problems with your shoulder joint. He or she may also examine your neck to make sure that the pain is not coming from a "pinched nerve," and to rule out other conditions, such as arthritis.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

• X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.
• Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how "old" or "new" a tear is because it can show the quality of the rotator cuff muscles.
  
  Treatment

If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.

Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.

There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend nonsurgical management of rotator cuff tears.

Nonsurgical Treatment

In about 50% of patients, nonsurgical treatment relieves pain and improves function in the shoulder. Shoulder strength, however, will not improve as much without surgery. 

Nonsurgical treatment options may include:

• Rest: Your doctor may suggest rest and and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.
• Activity modification: Avoid activities that cause shoulder pain.
• Non-steroidal anti-inflammatory medication: Drugs like ibuprofen and naproxen reduce pain and swelling.
• Strengthening exercises and physical therapy: Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
• Steroid injection: If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine.

A cortisone injection may relieve painful symptoms.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:

• Infection
• Permanent stiffness
• Anesthesia complications
• Sometimes lengthy recovery time

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

• Your symptoms have lasted 6 to 12 months
• You have a large tear (more than 3 cm)
• You have significant weakness and loss of function in your shoulder
• Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

What if your doctor recommended no surgery?

Come see us at Champion Physical Therapy - regardless of what healing stage you are in, we will do our best to improve your daily functionality and quality of life. Hope Hillyard, DPT, Owner, specializes in sports and degenerative-related injuries, including the Rotator Cuff Tear. We do recommend that you seek physical therapy as soon as possible following your decision with your doctor to avoid surgery - the quicker, the better!

Appointments available now

SPRING ATHLETES - TAKE CARE OF THOSE HAMSTRINGS

Hamstring Muscle Injuries

Hamstring muscle injuries — such as a "pulled hamstring" — occur frequently in athletes. They are especially common in athletes who participate in sports that require sprinting, such as track, soccer, and basketball.

A pulled hamstring or strain is an injury to one or more of the muscles at the back of the thigh. Most hamstring injuries respond well to simple, nonsurgical treatments.

Normal Hamstring Anatomy

The hamstring muscles run down the back of the thigh. There are three hamstring muscles:

• Semitendinosus
• Semimembranosus
• Biceps femoris

They start at the bottom of the pelvis at a place called the ischial tuberosity. They cross the knee joint and end at the lower leg. Hamstring muscle fibers join with the tough, connective tissue of the hamstring tendons near the points where the tendons attach to bones.

The hamstring muscle group helps you extend your leg straight back and bend your knee.

Description

A severe hamstring injury where the tendon has been torn from the bone.

A hamstring strain can be a pull, a partial tear, or a complete tear.

Muscle strains are graded according to their severity. A grade 1 strain is mild and usually heals readily; a grade 3 strain is a complete tear of the muscle that may take months to heal.

Most hamstring injuries occur in the thick, central part of the muscle or where the muscle fibers join tendon fibers.

In the most severe hamstring injuries, the tendon tears completely away from the bone. It may even pull a piece of bone away with it. This is called an avulsion injury.

Cause

Muscle Overload

Muscle overload is the main cause of hamstring muscle strain. This can happen when the muscle is stretched beyond its capacity or challenged with a sudden load.

Hamstring muscle strains often occur when the muscle lengthens as it contracts, or shortens. Although it sounds contradictory, this happens when you extend a muscle while it is weighted, or loaded. This is called an "eccentric contraction."

During sprinting, the hamstring muscles contract eccentrically as the back leg is straightened and the toes are used to push off and move forward. The hamstring muscles are not only lengthened at this point in the stride, but they are also loaded — with body weight as well as the force required for forward motion.

Like strains, hamstring tendon avulsions are also caused by large, sudden loads. During sprinting, the hamstring muscles are lengthened and loaded as the back leg pushes off to propel the runner forward.

Risk Factors

Several factors can make it more likely you will have a muscle strain, including:

Muscle tightness. Tight muscles are vulnerable to strain. Athletes should follow a year-round program of daily stretching exercises.

Muscle imbalance. When one muscle group is much stronger than its opposing muscle group, the imbalance can lead to a strain. This frequently happens with the hamstring muscles. The quadriceps muscles at the front of the thigh are usually more powerful. During high-speed activities, the hamstring may become fatigued faster than the quadriceps. This fatigue can lead to a strain.

Poor conditioning. If your muscles are weak, they are less able to cope with the stress of exercise and are more likely to be injured.

Muscle fatigue. Fatigue reduces the energy-absorbing capabilities of muscle, making them more susceptible to injury.

Choice of activity. Anyone can experience hamstring strain, but those especially at risk are:

• Athletes who participate in sports like football, soccer, basketball
• Runners or sprinters
• Dancers
• Older athletes whose exercise program is primarily walking
• Adolescent athletes who are still growing

Hamstring strains occur more often in adolescents because bones and muscles do not grow at the same rate. During a growth spurt, a child's bones may grow faster than the muscles. The growing bone pulls the muscle tight. A sudden jump, stretch, or impact can tear the muscle away from its connection to the bone.

Symptoms

If you strain your hamstring while sprinting in full stride, you will notice a sudden, sharp pain in the back of your thigh. It will cause you to come to a quick stop, and either hop on your good leg or fall.

Additional symptoms may include:

• Swelling during the first few hours after injury
• Bruising or discoloration of the back of your leg below the knee over the first few days
• Weakness in your hamstring that can persist for weeks

Doctor Examination

Patient History and Physical Examination

In this severe tear of the hamstring tendon away from the bone, the muscle has balled up at the back of the thigh.

Reproduced from Frank RN, Walton DM, Erickson B, Nho SJ, Bush-Joseph CA, Verma NN: Acute proximal hamstring rupture: surgical technique. Orthopaedic Knowledge Online Journal 2014. Accessed July 2015.

People with hamstring strains often see a doctor because of a sudden pain in the back of the thigh that occurred when exercising.

During the physical examination, your doctor will ask about the injury and check your thigh for tenderness or bruising. He or she will palpate, or press, the back of your thigh to see if there is pain, weakness, swelling, or a more severe muscle injury.

Imaging Tests

Imaging tests that may help your doctor confirm your diagnosis include:

X-rays. An X-ray can show your doctor whether you have a hamstring tendon avulsion. This is when the injured tendon has pulled away a small piece of bone.

Magnetic Resonance Imaging (MRI). This study can create better images of soft tissues like the hamstring muscles. It can help your doctor determine the degree of your injury.

Treatment

Treatment of hamstring strains will vary depending on the type of injury you have, its severity, and your own needs and expectations.

The goal of any treatment — nonsurgical or surgical — is to help you return to all the activities you enjoy. Following your doctor's treatment plan will restore your abilities faster, and help you prevent further problems in the future.

Nonsurgical Treatment

Most hamstring strains heal very well with simple, nonsurgical treatment.

RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

• Rest. Take a break from the activity that caused the strain. Your doctor may recommend that you use crutches to avoid putting weight on your leg.
• Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.
• Compression. To prevent additional swelling and blood loss, wear an elastic compression bandage.
• Elevation. To reduce swelling, recline and put your leg up higher than your heart while resting.

Immobilization. Your doctor may recommend you wear a knee splint for a brief time. This will keep your leg in a neutral position to help it heal.

Physical therapy. Once the initial pain and swelling has settled down, physical therapy can begin. Specific exercises can restore range of motion and strength.

A therapy program focuses first on flexibility. Gentle stretches will improve your range of motion. As healing progresses, strengthening exercises will gradually be added to your program. Your doctor will discuss with you when it is safe to return to sports activity.

Surgical Treatment

Surgery is most often performed for tendon avulsion injuries, where the tendon has pulled completely away from the bone. Tears from the pelvis (proximal tendon avulsions) are more common than tears from the shinbone (distal tendon avulsions).

Surgery may also be needed to repair a complete tear within the muscle.

Procedure. To repair a tendon avulsion, your surgeon must pull the hamstring muscle back into place and remove any scar tissue. Then the tendon is reattached to the bone using large stitches or staples.

A complete tear within the muscle is sewn back together using stitches.

Rehabilitation. After surgery, you will need to keep weight off of your leg to protect the repair. In addition to using crutches, you may need a brace that keeps your hamstring in a relaxed position. How long you will need these aids will depend on the type of injury you have.

Your physical therapy program will begin with gentle stretches to improve flexibility and range of motion. Strengthening exercises will gradually be added to your plan.

Rehabilitation for a proximal hamstring reattachment typically takes at least 6 months, due to the severity of the injury. Distal hamstring reattachments require approximately 3 months of rehabilitation before returning to athletic activities - so come see us at Champion Performance and Physical Therapy! Your doctor and physical therapist will tell you when it is safe to return to sports.

Recovery

Most people who injure their hamstrings will recover full function after completing a rehabilitation plan. Early treatment with a plan that includes the RICE protocol and physical therapy has been shown to result in better function and quicker return to sports.

To prevent reinjuring your hamstring, be sure to follow your doctor's treatment plan. Return to sports only after your doctor has given you the go-ahead. Reinjuring your hamstring increases your risk of permanent damage. This can result in a chronic condition.

New Developments

Platelet-rich plasma (PRP) is currently being investigated for its effectiveness in speeding the healing of hamstring muscle injuries. PRP is a preparation developed from a patient's own blood. It contains a high concentration of proteins called growth factors that are very important in the healing of injuries.

A few treatment centers across the country are incorporating PRP injections into the nonsurgical treatment regimen for some hamstring muscle injuries. However, this method is still under investigation and more research is necessary to prove PRP's effectiveness.

PREVENTING BACK PAIN AT HOME AND AT WORK

Almost everyone will experience back pain at some point in their lives. Back pain varies from one person to the next. It can range from mild to severe, and can be acute or chronic, depending on the cause.

Preventing all back pain may not be possible. We cannot avoid the normal wear and tear on our spines that goes along with aging. There are, however, things we can do to lessen the impact of low back problems and adjust aspects of our daily routine to better prevent acute injuries from occurring. 

Having a healthy lifestyle is the first way to prevent back pain. 

• Exercise

Combine exercise, like walking or swimming, with specific core-strengthening exercises to keep the muscles in your back and abdomen strong and flexible.

• Weight

Maintain a healthy weight. Being overweight puts added pressure on your spine and lower back.  Quick weight gain without adjusting your daily exercise regime will usually cause problems in the low back, as the muscles require time to strengthen as your weight increases (body builders, pregnancy, etc.)

• Avoid Smoking

Both the smoke and the nicotine cause your bones, and more specifically, your spine to age faster than normal.  Smoking is a known catalyst of osteoporosis, which is will cause weakening of the vertebrae. 

• Proper Posture

Good posture is important to avoiding low back problems. How you stand, sit, and lift things has an increasing effect on your spine health.

• Drink Plenty of Water

Water is required for healthy function in every cell of the human body.  The spine, like all other joints, requires lubricant to allow pain-free movement. Drinking enough water each day can increase your body's natural lubricant production. 

Guidelines for Proper Lifting

• Plan ahead what you want to do and do not be in a hurry.
• Position yourself close to the object you want to lift.
• Separate your feet shoulder-width apart to give yourself a solid base of support.
• Bend at the knees.
• Tighten your stomach muscles.
• Lift with your leg muscles as you stand up.
• If an object is too heavy or is an awkward shape, do not try to lift it by yourself. Get help. 

Picking Up a Light Object

To lift a very light object from the floor, such as a piece of paper, lean over the object, slightly bend one knee and extend the other leg behind you. Hold on to a nearby chair or table for support as you reach down to the object, as necessary.

Picking Up a Heavy Object

Whether you are lifting a heavy laundry basket or a heavy box in your garage, remember to get close to the object, bend at the knees, and lift with your leg muscles. Do not bend at your waist.

When lifting luggage, stand alongside of the luggage, bend at your knees, grasp the handle and straighten up.  Do your best to keep your stomach tight while lifting the object.  This anatomical act of checks-and-balances will allow your core to split the opposing force between both sides of the body, and therefore, lessening the stress on the back, alone.  The checks-and-balances system includes the quadriceps and hamstrings, the biceps and triceps; or in other words, muscles that pull the body in the opposite direction from the other. 

Holding An Object

While you are holding the object, keep your knees slightly bent to maintain your balance. If you have to move the object to one side, avoid twisting your body or leaning backward. Point your toes in the direction you want to move and pivot in that direction. Keep the object close to you when moving, and again, keeping your stomach tight will lessen the stress on the low back and naturally force you to keep from leaning backward. 

Placing an Object on a Shelf

If you must place an object on a shelf, move as close as possible to the shelf. Spread your feet in a wide stance, positioning one foot in front of the other to give you a solid base of support. Do not lean forward and do not fully extend your arms while holding the object in your hands.

If the shelf is chest high, move close to the shelf and place your feet apart and one foot forward. Lift the object chest high, keep your elbows at your side and position your hands so you can push the object up and on to the shelf. Remember to tighten your stomach muscles before lifting.

Supporting Your Back While Sitting

When sitting, keep your back in a normal, slightly arched position. Make sure your chair supports your lower back. Keep your head and shoulders erect. Make sure your working surface is at the proper height so you don't have to lean forward. Once an hour, if possible, stand, and stretch. Place your hands on your lower back and gently arch backward.

Move Often

Allow yourself plenty of opportunities to move and stretch.  The recommended break time for students is 5 minutes for every 30 minutes studying, or 10 minutes for every 60 minutes.  It's proven to improve cognitive function and memory, as well as relieve tension in the muscles of the body. Think about it - how many times have you been "in the zone" writing a letter or typing an email, and when you press that send button, you feel your shoulders, neck, and back relax?  That tension over time will cause tight muscles.  When the muscles are tight, they pull on the bones.  When they pull on the bones so much, they can move the bones slightly out of place - but slightly is enough to feel it. Some companies are now allowing employees to inquire about a standing desk - one that can raise if you'd prefer to stand for part of your day. Make inquiries with your HR department if this interests you!

Need Help Adjusting?

 If you suffer from acute or chronic back pain, talk to your doctor about the possibility of starting physical therapy with us at Champion Performance and Physical Therapy. If some of these qualities sound oh-too-familiar and think you could use some overall strengthening exercises for your core to simply improve your quality of life, you are welcome to contact us and we'll see if you are eligible to come in we can see if you qualify to come in without a prescription from your doctor for a simple evaluation and exercise plan. 

Source: http://orthoinfo.aaos.org/topic.cfm?topic=A00175

WHAT TO EXPECT FOLLOWING A KNEE REPLACEMENT

Activities After Knee Replacement

After having a knee replacement, you may expect your lifestyle to be a lot like it was before surgery— but without the pain. In many ways, you are right, but returning to your everyday activities takes time. Being an active participant in the healing process can help you get there sooner and ensure a more successful outcome.

Even though you will be able to resume most activities, you may have to avoid doing things that place excessive stress on your "new" knee, such as participating in high-impact sports like jogging. The suggestions here will help you enjoy your new knee while you safely resume your daily activities.

Hospital Discharge

Your hospital stay will typically last from 1 to 4 days, depending on the speed of your recovery. Before you are discharged from the hospital, you will need to accomplish several goals, such as:

• Getting in and out of bed by yourself.
• Having acceptable pain control.
• Being able to eat, drink, and use the bathroom.
• Walking with an assistive device (a cane, walker, or crutches) on a level surface and being able to climb up and down two or three stairs.
• Being able to perform the prescribed home exercises.
• Understanding any knee precautions you may have been given to prevent injury and ensure proper healing.

If you are not able to accomplish these goals, it may be unsafe for you to go directly home after discharge. If this is the case, you may be temporarily transferred to a rehabilitation or skilled nursing center.

When you are discharged, your healthcare team will provide you with information to support your recovery at home. Although the complication rate after total knee replacement is low, when complications occur they can prolong or limit full recovery. Hospital staff will discuss possible complications, and review with you the warning signs of an infection or a blood clot.

Warning Signs of Infection

• Persistent fever (higher than 100 degrees)
• Shaking chills
• Increasing redness, tenderness or swelling of your wound
• Drainage of your wound
• Increasing pain with both activity and rest

Warning Signs of a Blood Clot

• Pain in your leg or calf unrelated to your incision
• Tenderness or redness above or below your knee
• Increasing swelling of your calf, ankle or foot
• Increased stiffness of the calf and hard-to-the-touch when palpated

In very rare cases, a blood clot may travel to your lungs and become life-threatening. Signs that a blood clot has traveled to your lungs include:

• Shortness of breath
• Sudden onset of chest pain
• Localized chest pain with coughing

Notify your doctor if you develop any of the above signs.

Recovery at Home

You will need some help at home for several days to several weeks after discharge. Before your surgery, arrange for a friend, family member or caregiver to provide help at home.

Preparing Your Home

The following tips can make your homecoming more comfortable, and can be addressed before your surgery:

• Rearrange furniture so you can maneuver with a cane, walker, or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
• Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
• Get a good chair—one that is firm with a higher-than-average seat and has a footstool for intermittent leg elevation.
• Install a shower chair, gripping bar, and raised toilet seat in the bathroom.
• Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending over too far.

Place items that you use frequently within easy reach.

Wound Care

During your recovery at home, follow these guidelines to take care of your wound and prevent infection:

• Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as necessary. Ask for instructions on how to change the dressing before you leave the hospital.
• Follow your doctor's instructions on how long to wait before you shower or bathe.
• Notify your doctor immediately if the wound appears red or begins to drain. This could be a sign of infection.

Swelling

Mild to moderate swelling is normal for the first 3 to 6 months after surgery. To reduce swelling, elevate your leg slightly and apply ice. Wearing compression stockings may also help reduce swelling. Notify your doctor if you experience new or severe swelling, since this may be the warning sign of a blood clot.

Medication

Take all medications as directed by your doctor, and within your own limits. Home medications may include narcotic and non-narcotic pain pills, oral or injectable blood thinners, stool softeners, and anti-nausea medications.  Use caution when taking medications that may affect your vision, balance, or stability, as they may affect your ability to walk or drive.

Be sure to talk to your doctor about all your medications—even over-the-counter drugs, supplements and vitamins. Your doctor will tell you which over-the-counter medicines are safe to take while using prescription pain medication.

It is especially important to prevent any bacterial infections from developing in your artificial joint. Your doctor may advise you to take antibiotics whenever there is the increased possibility of a bacterial infection, such as when you have dental work performed. Be sure to talk to your doctor before you have any dental work done and notify your dentist that you have had a knee replacement. You may also wish to carry a medical alert card so that, if an emergency arises, medical personnel will know that you have an artificial joint.

Diet

By the time you go home from the hospital, you should be eating a normal diet. Your doctor may recommend that you take iron and vitamin supplements. You may also be advised to avoid supplements that include vitamin K and foods rich in vitamin K if you taking certain blood thinner medications, such as warfarin (Coumadin). Foods rich in vitamin K include broccoli, cauliflower, brussel sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions.

Continue to drink plenty of fluids, but try to limit coffee intake and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.

Resuming Normal Activities

Once you get home, you should stay active. The key is to not do too much, too soon. While you can expect some good days and some bad days, you should notice a gradual improvement over time. Generally, the following guidelines will apply:

Driving

In most cases, it is safe to resume driving when you are no longer taking narcotic pain medication, and when your strength and reflexes have returned to a more normal state. Your doctor will help you determine when it is safe to resume driving.

Sexual Activity

Please consult your doctor about how soon you can safely resume sexual activity. Depending on your condition, you may be able to resume sexual activity within several weeks after surgery.

Sleeping Positions

After you are no longer using any ambulatory aides, you can safely sleep on your back, on either side, or on your stomach.  During the earliest stages of healing, however, your physician will instruct you through approved sleeping positions. 

Return to Work

Depending on the type of activities you do on the job and the speed of your recovery, it may be several weeks before you are able to return to work. Your doctor and physical therapist will advise you when it is safe to resume your normal work activities.

Sports and Exercise

Here at Champion Performance and Physical Therapy, we will instruct you through progressive stretching and strengthening exercises so as to help you return to performing all daily activities in a timely fashion.  Stationary biking is a great way to maintain muscle tone and allow some flexibility in the knee until your physical therapist and orthopedic surgeon approve swimming and other types of exercise and cardio. When riding stationary bicycles, try to achieve the maximum degree of bending and straightening possible.   Please consult us at Champion Performance and Physical Therapy prior to beginning any exercises listed above on your own.

After a few months,  your doctor and physical therapist will likely give you the go-ahead to return to many of the sports activities you enjoyed before your knee replacement.  

• Walk as much as you would like, but remember that walking is no substitute for the exercises prescribed by your doctor and physical therapist.
• Swimming is an excellent low-impact activity after a total knee replacement; you can begin as soon as the sutures have been removed and the wound is healed - seek approval from your physical therapist prior to swimming.
• In general, lower impact fitness activities such as golfing, bicycling, and light tennis will help increase the longevity of your knee and are preferable over high-impact activities such as jogging, racquetball and skiing.

Air Travel

Pressure changes and immobility may cause your knee joint to swell, especially if it is just healing. Ask your doctor before you travel on an airplane. When going through security, be aware that the sensitivity of metal detectors varies and your artificial joint may cause an alarm. Tell the screener about your artificial joint before going through the metal detector. You may also wish to carry a medical alert card to show to the airport screener.

For more questions - ask our physical therapists here at Champion Performance and Physical Therapy! 

Please note, every person and body is different and rehabilitation may vary from person to person - this information does not replace medical advice from a licensed physician.  This published information is strictly for educational purpose.