Archive for April, 2008

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So, move to our final case. The bottom line here is that osteoarthritis is not necessarily a disease of older people. There are ways to modify it coming up. There are other ways to treat it that mimic more surgical procedures and may be preferable to use those instead of the surgical procedures.
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Our last case – back to younger people – by that I mean a 22-year-old graduate student who had knee pain several weeks into the new semester. This was described as anterior knee pain, worst with prolonged sitting, climbing or descending stairs. She had occasional sense of catching, locking and giving way. Physical exam showed slight lateral movement in the patella at the end of an active extension. This is what some would call a J-sign. Instead of the patella coming and tracking all the way in the middle of the trochlear groove, as it gets to the top it actually slides over to the sides. As if you have an upside-down J written on your knee. This is a finding that is not found in normal subjects. Patellofemoral crepitus was present. She had minimal medial translocation of her patella possible. It was hard to move it from side to side. And she had peripatellar tenderness. Her x-rays were normal, including A-P and skyline views. So this was a woman with anterior knee pain with some definite patellofemoral tracking problems who I thought needed attention to her altered biomechanics. Sleepwell herbal xanax with special discounts.
In spite of our best efforts, we are running out of time for our case so we’ll try to move through this one quickly. Because of her pronounced patellar tracking problems, and also lower extremity weakness in this person, we decided to try exercise and also to try patellar taping for her to see if it reduced her pain. In fact, when we taped the patella medially in this case, in clinic, we found that we reduced her pain by 50% for normal activities. So that made us think that patellar taping would be a good adjunct to the rest of the therapy. Patellar taping is a bit controversial. There is a growing body of research and literature on it now and most clinicians will use it if it seems to work on their patient. It does reduce lateral movement of the patella during exercise, although the clinical assessment of the patella hasn’t been shown to be extremely reliable, we know that patellar tracking or lateral displacement does occur because it’s very reliably measured on x-ray. Patellar tracking, as we said before, is not a consistent predictor of pain but done properly it has been shown to reduce pain with exercise and stepping by at least 90% and is a good adjunct. Viagra cialis levitra online
This is what patellar taping looks like. Usually the patella is taped medially. It’s done in clinic. We do to allow effective strengthening of the quadriceps without continuing to irritate tissues and get effusion, which inhibit the VMO. People can also be taught to do their own taping outside of clinic. We use taping not just taping but to strengthen exercises. Another example, here she is not going to sit in the chair. The chair is just behind her in case she decides she needs to use it quickly. So this is functional strengthening. Very often use side stair stepping. What you see here is very good posture. The hips are level as they go up and down. They are using the knee. We’d use taping in that. We have found that foot orthoses can change patellar alignment and since she has that problem we are also going to use a foot orthosis with her. You can see here, without foot orthosis and good shoes. So again, minimal attention at the foot can often produce dramatic results at the knee. Her exercise program is one that you generally wish a young person to adopt and maintain for their lifetime. Some stretching. We are also going to teach her some patellar mobilization that she can do on her own at home, because her patella did seem to be tight. We are going to teach her quadriceps stretching exercises. This is a lot more effective and more comfortable and people don’t get hamstring cramps when they stretch their quadriceps like this.
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We expect her to do better and to develop life-long habit of exercise and fitness. So sometimes coming to the healthcare professional for a problem can be an opportunity to help people develop some good habits that will prevent problems later.

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This is title irrigation in practice. There’s really not much to it. Anesthetizing the joint and the skin and putting in a 14-gauge needle that’s hooked up to a device that lets you run fluid through it, a liter, and about 60 cc aliquots. In the early 90’s we tested this prospectively in 15 different centers and these are the outcome measures. The dark lines are people who underwent irrigation, the light lines are the people who had ongoing medical management, close attention only. And there’s a significant trend towards pain relief after these various activities at 12 weeks of follow-up. Trying to expand on the lavage effect, analysis of the lavage effect, and also look at what arthroscopy tells us in early knee OA. Less than a year of symptoms, less than grade II on x-ray, but satisfying ACR criteria. There were some surprises in this group. One of them was that a number of patients, practically one-third or more in UCLA, had findings like this. This is cartilage above and this is synovium and what’s embedded here – we think – are crystals. Now patients with crystals were excluded from the study and yet even with normal synovial fluids and normal x-rays it is not showing any calcium deposits. We do see quite a bit of crystals in these patients with OA knees. It may be why they did better. At the close we had trouble showing a difference between whether they got 3 liters of lavage or just enough lavage to clear out the joint, which is less than 250 cc. Although in both groups there was a reduction in pain. It was a bit more of a reduction in the 3 liter lavage group, but all the patients who had crystals had much greater improvement than those who did not.
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The French have been at this for a long time and consider it part of their standard practice in knee OA. This is French lavage in practice. They use two entry points and they do it in a closed procedure. You may recall earlier this year seeing the results of their prospective study where they compared either placebo injection, joint lavage with placebo, cortisone or joint lavage with cortisone. What we see here first off is that anything done at the beginning, right away, plummets the pain scores. The puncture is still therapeutic. But then retaining that fact is much more likely in patients who underwent lavage with a cortisone injection. What’s missing here and what’s coming from Indiana very shortly is a comparison of joint lavage versus a sham lavage.
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There are other things we can do to the knee, of course. For the past year we’ve had this stuff, although this is from a veterinary flyer. This is hyaluronate. High viscosity material that comprises synovial fluid that’s purified from rooster combs and can be injected repeatedly into knees with some effect. There have been a number of trials. This is again thanks to Kerwin, showing that in general there are two things this complicated graph says. First off, it confirms what Miller saw 40 years ago. That if you keep injecting a knee – now, with hyaluronate you have to inject the knee either three or five times in succession once a week – but if you keep injecting the knee, regardless of what you do, you reduce the pain score. Because on this graph are solid lines and dotted lines and the solid lines are hyaluronates and the dotted lines are placebo, and all of those things reduce pain scores. But in general the trend is – and it’s usually significant – is that even with that phenomenon you get more pain relief after their hyaluronate injection than after the saline injection.
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With this 33-year-old man, I’m sure he’s happy to know that we have a cure for his disease. But seriously, I think that the data that is beginning to accumulate about glucosamine and chondroitin sulfate do warrant its use, particularly in young folks who have what really amounts to osteoarthritis and want to do something that might modify the long-term outcomes. It’s safe, it’s not very expensive, and this is what we recommended to our fellow. He is going to hold off on the hyaluronate and on the repeat joint lavage. But he does need more attention from a physical therapist. Actually, he went for the hyaluronate for his knees, he would take that. But he also went on glucosamine. So he had his knee joint effusion reduced and went back and I encouraged him to continue the therapy program that was prescribed to him. Because what he has to do over the long term is do whatever he can to modify the various processes that he has going on. Canadian viagra online

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There have been, in different forms, some prospective studies examining the effect of arthroscopy in osteoarthritis, the knee. In 1991 a couple of groups in Nottingham took advantage – there were different referral patterns in the two orthopedists in town. Some went and always got arthroscopy and some went and always got physiotherapy. So over a couple of years looked at … they ended up with 39 patients undergoing lavage and 24 undergoing physiotherapy and at the end of 6 and 12 months of follow-up there was a trend. And it reached some significance that the lavage people had a bit more pain relief. Cialis professional at Canadian pharmacy. A smaller study looking at patients who underwent arthroscopic debridement versus arthroscopic lavage actually found not only no difference between the two, but no benefit really in either group after a short term follow-up. A larger, very ambitious study done years ago in Chicago by Bing Chang and Bill Arnold and others looked prospectively as arthroscopic debridement versus title irrigation; title irrigation being a wash out of the knee with a liter of fluid put through a large port cannula. After 12 months of follow-up in their study, which comprised 18 in the surgery group and 14 in the titled irrigation group, there was really no difference between the two in all various outcome measures.
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So that was perhaps countered a bit by this study from Hubbard, although his group was a different type and his procedure was different. These are people with normal x-rays on whom he saw some cartilage disruption and then took his basket forceps and chopped out the loose cartilage. This is different from the usual arthroscopic debridement in osteoarthritis when there is a quite a bit of work on things like disrupted menisci. If you had a disrupted meniscus in his study, you weren’t included in the final analysis. Over the course of about five years – which was his follow-up – there was a trend that the folks who got this chopped out bit with their otherwise normal knees did a little bit better. I’m not sure that supports the use of arthroscopy in the kind of patients we consider to have osteoarthritis.
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Finally, a small study that was listed as a pilot study to be continued – unfortunately, we haven’t seen data since ’96 – the Houston VA looked at groups – 10 patients total. Three underwent arthroscopic debridement, 2 underwent arthroscopic lavage and 5 were taken to the operating room, put to sleep and at the other end, after their leg was draped, had the three arthroscopic portals made not quite to the capsule and noises made as if arthroscopic surgery was being done. Well, at the time of follow-up there were no major differences between any of the groups regardless of what was done. So, I’m not sure what this is telling us about arthroscopy. I think overall, what it is telling us is that if there anything about arthroscopy that may help it may be the arthroscopic lavage. Now this is an observation that goes back 60-70 years. You know that in osteoarthritic synovial fluids there is junk there that the lab doesn’t tell you about. But these are small pieces of cartilage that have come loose from the joint. This is what happens if you centrifuge that down and stain it. These are hyalin cartilage that has come loose from the degenerating joint surface. Those probably helped to promote some of the focal inflammation that may cause some pain in knee osteoarthritis. Removing them one way or another can relieve pain in a number of different postulated ways. Removing those particles may help limit the synovitis that they produce. You also may be removing crystals. There are some temporary effects of lavage that may help, like pooling and dilution of degradative compounds. Not many OA joints have adhesions, or fibrosis but you do stretch the joint during lavage. And of course -especially with that Houston VA study – we can’t discount a placebo effect of doing a somewhat major procedure on someone with knee complaints. Generic cialis 20 mg

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I want to show you a quick example here of doing a quadriceps setting exercise but doing it in the functional position, so the person is standing and they are getting the motor learning they need to contract the quadriceps at the proper time and gait. We did our best, we did all we could, however after four weeks of doing his exercises there was still pain and swelling, minimal strength gains and no change in his sense of stability. So I referred him back to my favorite rheumatologist.
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Disappointed patient post arthroscopy is something else going on. Unfortunately it is not an uncommon reason for an occasional visit to a rheumatologist. This 33-year-old man does have some issues. Certainly there are other more common causes of post arthroscopy persistent troubles. More serious ones at least, concern about infection, concern about bleeding. We are not going to address those here. We are going to look and try to answer the question of what else might be going on. One of the first thing to do is to review the arthroscopic data if available. The report on this man was that what he actually had was a partial medial meniscectomy of his posterior horn, along with chondroplasty and there was mention by the orthopedist of focal grade III changes in the medial tibiofemoral compartment. This means disruption of cartilage almost down to bone, quite fibrillated but no exposed bone. And the physical findings were indicating that he had arthritis in his knee, had a slight warmth, some wall effusion, medial joint line tenderness and medial tibiofemoral crepitus. Although his plain films didn’t show osteoarthritis, taking him into the most sensitive x-ray view, that is a skiers view where they bend about 45 degrees bearing weight, showed narrowing of the medial joint space. So what this man had is not this. This might have worked out better after an arthroscopy. This is a traumatic flat tear of the medial meniscus and during arthroscopy that is resected to a stable edge and they usually do quite a bit better. His was probably more like this. This is degenerative tear of the posterior horn of the medial meniscus, a very common finding in a painful osteoarthritic knee. Whether it causes pain or not, whether or not it should be removed, is still rather controversial. Although the trend is towards leaving all of this alone. There is also disruption here at the cartilage on either side and what this is, is this is probably the first thing to degenerate in response to altered biomechanics that eventually produce osteoarthritis.
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The use of arthroscopy in osteoarthritis is still pretty common. It is perceived as a minimally invasive procedure, certainly compared to other operations. And yet the data that supports its use is actually not very good. What often prompts the arthroscopy is a study such as this. This is an MRI done on somebody with osteoarthritis and knee pain. The report comes back where you have a tear on the posterior horn of the meniscus. Meniscal tear equals need for surgery, correct? Well this particular MRI is not one of my patients. It’s actually from an older paper by Felix Fernandez. It was written in nearby in Wayne State who looked at the knees by MRI of patients with OA which included a lot of asymptomatic knees. What he found was that many of the findings that we might be considering pathologic on the MRI are in fact very common and not associated with pain. Meniscal tears are extremely common in these asymptomatic knees. About the only difference is whether or not there is an effusion, although that was present in the asymptomatic knees as well. So basically, the recommendation for surgery on an MRI may be in error. Certainly in people with osteoarthritis. Generic pharmacy.

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This is just an idea of why having a pronated foot can be such a problem to the knee, and I think we should look at this as maybe why women have more knee OA than men. Floor contact forces go here, body weight forces go here. You can see here that there is a discrepancy between floor contact and body weight coming down. More body weight, a greater Q-angle, more genu varus at the knee. You are going to increase this distance here and as the talus comes down you will get more stresses on the knee. So this person particularly we really need to support the foot and try to keep that from happening. Our plan is actually to put her on a home program that was reported by O’Reilley and colleagues, which I’ll show you here in a minute. But we also need to really work on stretching her plantar flexors. What you are seeing here is the regular plantar flexor stretch but using a little rolled up towel to make sure that they get supination in the foot when they stretch their plantar flexors. Stretching over a pronated foot not only is not particularly effective but it really stretches the plantar fascia and people can end up with an awful lot of foot and heel pain.
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The in-home exercise program reported by O’Reilley used a totally home-based exercise program with only four visits for instruction and they also found significant improvements in pain, physical function, Walmax score, SF-36 and anxiety and depression. The reason I show you this slide is that this woman is in this category here, at the highest risk for age-adjusted death rates and that comes from Blair’s earlier work where they showed that people with low fitness and who were sedentary have twice the death rate potential of people who are only moderately fit. And this is just the difference between people who are doing nothing and people who are doing something. The something that we will recommend for her and try to get her involved in is a physical activity for health, which is a recommendation from the Surgeon General in his report on physical activity. It’s not exercise, it’s not scary, it’s just being more active on most days of the week at a moderate level, so you can still talk to your friends and sing a song or whatever you do. Buy Human Growth Hormone. The new information there for those of you who aren’t familiar with this is that people can accumulate 30 minutes of exercise during the day in as little as 10-minute bouts and get the same health effects as people who do 30 minutes continuously. For many people with lower extremity pain and arthritis, getting to 10 minutes of continuous activity is a good goal and is all they need to be able to do at one time to achieve those health benefits of moving from the low to the moderate category. We will expect to see her later and try to get her into some arthritis foundation and group programs. I think my bottom line as a therapist on this case is that in a patient with knee OA conservative management is not rest and inactivity.
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We are also trying to present to you today, not always is the doctor first, but in the order that people with knee pain generally enter our lives and who they see first. In this case we have a 33-year-old fellow who is a golfer. He underwent arthroscopy about six weeks ago for unexplained knee pain and swelling. We don’t know exactly what they found. He says he was briefly shown some quad strengthening exercises that he doesn’t do very well, but he has taken to riding a stationary bike and lifting some weights because he wants to stay active and be ready for golf season again. He still has pain. It’s worse with use. Intermittent swelling and a periodic feeling that it’s going to give way. He self-referred himself to the therapist, wanting exercise and wondering about a brace. And this is the way he looked. I hope you can see this on the right knee, there is quite a difference in his ability to contract the quadriceps as compared to his left and it’s his right knee that hurts. I just want to reinforce the idea that pain inhibits quadriceps activity very dramatically. So although he tried hard to be able to contract both quadriceps and do his exercises, he physically was not able to do that. We put him on some dynamic exercise, and the reason we did is based on this finding by James and colleagues in Australia which actually showed that dynamic exercise, such as walking, cycling, actually improved synovial circulation in knees that have a fusion. As you can see here, the traditional isometric of straight leg raising or just staying in flexion actually decreases synovial blood flow. So we like to keep him moving, think his bike is good. Herbal xanax.

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Orgasm Difficulties

There are women who are unable to achieve orgasm despite being sufficiently aroused to have sex. This condition is known Female Orgasmic Disorder (FOD)

Women differ from men in that orgasm is a learned, not automatic, response. About five to ten percent of women never have an orgasm through any type of sexual activity – a condition called Kamagra pharmacy. Canadian Kamagra is most often the result of sexual inexperience, performance anxiety, or past experiences, such as sexual trauma or a strict and prudish upbringing creating inhibitions about sex and sexual pleasure.

There are women who do enjoy sexual activity in spite of reaching orgasm only occasionally or even never. However, for such women, sexual relationships would be far more pleasurable and fulfilling if they could reach orgasm on most occasions of sexual activity.

Treatments

On-going research suggests that any type of medication that increases blood flow to the sexual organs will help to treat sexual disorders in women by increasing physical stimulation in the area. Herbal formulations of gels or creams like Female Sexual Tonic or supplements that enhance blood circulation, such as Female Sexual Oil, have shown promising results.

Trials have been conducted with Viagra on the basis that this drug increases blood flow to the genital areas. However, the scientific community is still waiting for firm evidence to be published that this drug can work on women. A small study published earlier found no positive impact of Viagra on postmenopausal women.

For the moment, doctors concentrate, where possible, on eliminating medications that might have a negative effect on sexual performance. They also review contraceptive methods to ascertain whether this is a factor. Women who suffer from vaginal dryness may be advised to use lubricants or sexual stimulant creams during intercourse. Some doctors recommend that women use Kegel exercises, which help to develop the muscles around the outer portion of the vagina that are involved in pleasurable sensations.

In many cases, masturbation with vibrators has shown remarkable success in overcoming both arousal dysfunction and orgasmic disorder in women. This is because very often the clitoris and vagina have simply not learnt how to respond to stimulation. In such situations vibrator masturbation can successfully train the sex organs to respond to sexual stimulation.

The renowned sex therapist and educator, Helen Singer Kaplan, M.D., Ph.D., suggested the use of vibrators in the treatment of non-orgasmic females. She advised that for those women who have never had an orgasm (primary absolute orgasmic dysfunction), should manual masturbation not be sufficient to reach orgasm, then a vibrator is indicated.

Psychological counseling can also play an important part in treating women with sexual problems, as can coaching in sexual foreplay and stimulation techniques.

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The symptoms of female sexual dysfunction can include lack of desire for sexual intercourse, an inability to enjoy sex, inadequate response to sexual stimulation, insufficient vaginal lubrication, or repeated failure to reach orgasm.

Inadequate response to sexual stimulation and difficulty or inability to reach orgasm is a common but complex problem in women. It is a problem that can have many different causes. Surveys indicate that 40 to 45% of all women suffer from some form of sexual dysfunction. This might be caused by illness or by lack of physical response from the sex organs, but may also be linked to psychological factors.

The female equivalent of male impotence or erectile dysfunction is known as Female Sexual Arousal Disorder (FSAD).

When men and women are sexually stimulated and become aroused, there is an enhanced flow of blood into their sexual organs and their genitals become engorged with blood. In females, this normally should result in:
Enlargement of the clitoris and surrounding tissues (comparable to a male penis erection)
Secretion of vaginal lubrication
Relaxation and widening of the vaginal opening to facilitate insertion of a penis for intercourse.
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FSAD patients have the desire to have sex but their genital area fails to respond in the normal way, making sex painful or impossible.

Underlying Medical Condition

FSAD can result from various underlying medical conditions including:

• high blood pressure

• diabetes

• irritations, infections and growths in the vaginal area

• reactions to contraceptive devices.

Medications used to treat high blood pressure, peptic ulcers, depression or anxiety and cancer may also cause problems. Another factor is the physical, hormonal and emotional changes that occur during or after pregnancy or while breast feeding.
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FSAD is also frequently linked to psychological factors, which may include:

• Relationship issues with the male partner

• Depression

• Poor self-esteem

• Sexual abuse or incest

• Feelings of shame or guilt about sex

• Fear of pregnancy

• Stress and fatigue

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Now for this particular person, we aspirated and injected her knees and also injected her pes anserine bursa but still said there were some issues which she should address with a physical therapist.
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Our biomechanical findings in this person were much like some of the others that we have seen. Bilateral knee and plantar flexor weakness in this case as well as lack of ankle dorsiflexion. She has bunions as well. She also has more pronounced calcaneal valgus on weight-bearing and does have pronounced pronation. Her body mass index is over 30, which we know puts her well in the range of being obese. What we plan to do is address the foot posture and lack of dorsiflexion that contribute to her knee pain and bunions. She has problems with lower extremity alignment and strength that produces and unstable knee and poor shock absorption, which contributes to joint stress and damage, we speculate. She is sedentary, deconditioned, overweight, possibly depressed judging from her posture and her affect, and at high risk for secondary illnesses related to inactivity. Our goal is to reduce her knee pain, protect her joints, improve function and get her involved in daily physical activity. We are going to look at customized orthotics for this person rather than just off-the-shelf because of her weight and also because she more pronounced biomechanical problems there, and also try to get her fitted in athletic shoes that have a continuous rocker-type sole, which require less extension at the metatarsal joints and will allow her to move with less pain and less stress on that area. Also shoes that have adequate depth and room for her forefoot so she doesn’t continue to get pressure on her bunions.
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Here’s some examples of what we call semi-rigid orthoses and you can see here these all have an example of not only having some kind of control of the rear foot but also to support the medial longitudinal arch. They are worn easily in extra depth shoes. You can see here an example of what happens. What you can see here is the same person with a semi-rigid orthotic that has been customized for them and does support their medial longitudinal arch. So you can look very easily and see what happens when you change and control the foot, what happens at the knee. This is an example of a rigid foot orthoses which is not being used in arthritis as much but we are trying some trials of it at our institution now. It doesn’t give at all. It’s heavy, tough plastic, and what you see in there that people talk about as being the golf balls they have to walk on, are actually inserts that are firm and fit up right under the sustenaculum talus to actually mechanically support that bone so it doesn’t drop during weight-bearing. To wear orthotics like these is quite … people need a lot of support for the break-in period and they certainly need shoes like this to be able to accommodate them. I wanted to show you the shoe on the right, the white one, the Good Guy. That gives you an idea of a rocker-bottom sole that’s available commercially. The heels are often notched and the toes are up a little bit and it makes it easy for the person to progress over their forefoot, so they can be very comfortable and not expensive
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