As the realm of orthopedic medicine has continued to expand over the years, surgeries have become more and more commonplace. Among those surgeries, some of the most frequently performed operations are joint replacements. Joint replacement is a surgical procedure in which either some or all parts of a joint are removed and replaced with a prosthesis, an artificial body part. Many joints in the body can be replaced, including the hip, knee, ankle, shoulder, elbow, wrist, and thumb. The most commonly performed joint replacements are hips, known as a Total Hip Arthroplasty (THA), and knees, known as a Total Knee Arthroplasty (TKA). Typically, these surgeries are performed on older patients with severe arthritis but are also performed after severe trauma in elderly patients, such as a fall. Joint replacements are designed to replicate movements of a normal joint so that people can return to normal, healthy lifestyles.
Physical Therapy (PT) is often an integral part of the recovery process for patients that have undergone a joint replacement. PT often starts very early in the patient’s recovery, and can even begin on the day of the surgery, in the case of a TKA or THA. Patients often spend a couple of days in the hospital, where they undergo PT before they are sent home. Once the patient returns home, they are usually treated by a Home Health PT until they are strong enough and mobile enough to leave their home. When a patient is no longer homebound, they are typically referred to an outpatient PT clinic by their surgeon. In outpatient PT, the patient should expect to perform a number of exercises to help strengthen the muscles around the replaced joint and throughout the affected extremity. As the patient progresses, the exercises will increase in intensity accordingly. The PT will also be stretching the patient to help the patient attain full range of motion in their replaced joint. The goal of outpatient PT is to help a patient return to their desired level of functional and recreational activity.
Before surgery, patients should not discontinue exercise. In fact, patients tend to recover more quickly following a joint replacement if they are active with exercise leading up to their surgery. Some strategies for pre-surgery exercise for knee and hip arthritis include low-impact cardiovascular activities, such as biking and swimming, and low load, high repetition exercises focused on strengthening the quadriceps and hip musculature. These surgeries regularly require at least a few months to a full year for a full recovery. Joint replacements have evolved to the point where they are now routine surgeries for many orthopedic surgeons. Currently, the outcomes after these surgeries are quite good, but there remain risks as with any surgery. If a patient is looking for any further guidance, they should not hesitate to consult with their surgeon or their physical therapist.
In my time as a pediatric occupational therapist, I’ve come to learn that fun is everything. My success rate in getting therapeutic benefit out of an activity is directly correlated to how fun I make it. If I am a kid- will I sit still and complete 10 reps with an arm weight? No. Will I complete a challenge on the rock wall to climb to the top? Absolutely. It’s our job every day to make therapeutic activity the most fun thing on earth, and when it comes to feeding therapy, it’s no different.
Each of us has a very unique sensory system with different thresholds of what our body considers a “safe” amount of input. It’s biologically advantageous for us to go into protective mode in response to a toxic smell (we leave the area), a loud noise in the house late at night (our heart beats fast ready for “fight or flight”), or a taste of spoiled milk (we gag and spit it out instantly). However, input not normally offensive for the average person can be very insulting to someone with a low sensory threshold. This is where our picky eaters come in.
Feeding is one of the only activities in which we use all of our senses at once. If I’m a child with an oversensitive sensory system, food has the potential to look, sound, smell, feel, or taste offensive. Imagine- if the touch of different textures, or the smell, or even the sight of it enters my overresponsive sensory system- my body might respond to a chicken nugget like yours would spoiled milk; Gagging, spitting out, refusing to interact with it. Even if I was willing to put it in my mouth, coordinating all of my motor actions to sit up, feed myself, and manipulate the food is a lot to handle. Not to mention if I had reflux after every meal, I would be even less excited about dinner time. The behavioral responses you may see are responses such as refusal, crying, or running away. But if you were a child and you had a medical issue, sensory issue, or difficulty with motor coordination every time you were presented with foods, wouldn’t you have high anxiety surrounding food and resist it too?
So how do we help our picky eaters? Eating is not an instinctive behavior beyond the very early weeks of our lives. Learning to eat takes many, many steps. We have to teach our children to eat. But before we do that, we have to make food fun. We have to PLAY. Herein lies the most important part of feeding therapy, the best piece of advice I have to offer; if you want to teach your picky eater to eat, we must decrease the anxiety around food and mealtimes first.
I put the chicken nugget on my head. Uh oh, it’s about to fall, here it goes! Ahhhhhh! Crashhh! Instantly, according to this two year old I am the most fun person in the world with the source of the joke being the food they won’t eat. But they’ll play with it. They’ll put the chicken nugget on my head, touching it, feeling it, getting crumbs on their fingers, smelling it, waiting for it to fall. They’ll squish it to see what it’s going to do in their mouth; they’ll learn all about it. But more importantly, they will laugh, play, and enjoy themselves. And suddenly, this food isn’t so scary. Feeding therapy is a slow progression but it absolutely has to revolve around play. We need to explore, play, get messy, and learn about our food before we can ever eat it. Only when we are comfortable and our body has gotten desensitized to the novelty or to the threatening texture will we ever gain any ground in starting to expand our diet.
So, that is why as an OT, I have had a chicken nugget: in a ball tower; in the bed of a toy truck; in a toy dinosaur’s mouth; on a fire truck’s ladder; in a dog’s food bowl; in a racecar; on top of a block tower; and- on my head. And I wouldn’t have it any other way.
In New Orleans, we love our food! But during the holidays we all have a tendency to over indulge. Take a break from traditional, calorie rich, fatty holiday foods with healthier alternatives. We’re not suggesting you forgo the Christmas gumbo. But what about substituting one of your traditional dishes or a replace a meal that surrounds the holidays with something healthy and delicious?
2 cups prepared quinoa (preferably cooked in gluten-free chicken stock)
1 large sweet potato, diced into cubes
1-1/2 cups onion, diced
1 cup celery, diced
1 bay leaf
3 cloves garlic, diced
1 teaspoon fresh rosemary, chopped
1 teaspoon fresh thyme, chopped
1/2 teaspoon fresh sage, chopped
1 large apple, cored and diced
1 cup raisins or craisins
1/2 cup chopped toasted pecans or walnuts
3 tablespoons apple cider vinegar
1 tablespoon fresh parsley, chopped
1 teaspoon cumin
Salt and pepper
Preheat oven to 375 degrees F. Toss sweet potato cubes with olive oil and a pinch of kosher salt and place in a roasting pan. Roast sweet potato cubes in the oven about 30 minutes, or until the sweet potatoes are cooked through and browning. Remove from oven and set aside.
Coat a large frying pan with olive oil and begin heating over medium heat. Add onion, celery and bay leaf to the pan and sauté until soft and translucent, about 10 minutes.
Add garlic, rosemary, thyme and sage (along with a pinch of salt) to the pan with the onions and celery and continue cooking, stirring often, another 3 minutes.
Add quinoa to a large bowl. Add roasted sweet potato cubes to the quinoa. Add the onion, celery, garlic herb mixture to the quinoa (discard the bay leaf) and stir together well.
In the same pan you cooked the onion, celery garlic mixture, over medium-high heat, add the diced apple and cook about 2-3 minutes, stirring often. Add cooked diced apple to the quinoa.
Add craisins/raisins, nuts, apple cider vinegar, parsley and cumin to the quinoa and stir well. Salt and pepper to taste
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As the end of the year approaches, beckoning us all to holiday parties and gift giving, we don’t often think about maximizing our health insurance benefits. But the truth is, this is a perfect time of year to do just that. Since most folks have “calendar year policies”, their deductibles and Out of Pocket (OOP) expenses will reset on January 1. So, if you have been putting off your appointments or need an evaluation, now is the perfect time to schedule to make sure you are getting the full benefit of this year’s health insurance benefits. Ready to book your appointment? Call us at 504-828-7696 (adult appointments) or 504-866-6990 (appointments for children).
For many years, newspaper editors would contact me in December about writing an article about “Holiday Blues”. I would generate my usual list of suspects, and then add a few new features to make it fresh. Though annual events, the holidays in particular lead to a variety of special issues. This year I will take a more optimistic perspective, calling it Holiday Challenges, rather than the more tradition title.
I am going to summarize a number of issues that can create both visible and invisible impact. The reason to discuss them is to give individuals more clarity, since labeling factors can make things more manageable. So, what makes the holidays so potentially problematic?
Let’s start with the extra demands. We know that stress reactions occur when individuals have to adapt quickly to multiple tasks within small windows of time. Home demands can include wanting to cook special meals, bake cookies, or prepare for parties or guests. Increased time with family can be mixed blessings. While good to see family we haven’t seen for a time, too much “togetherness” can lead to irritability, or raise long-standing hurts. Those who have school-age children may feel pressure to satisfy their kids’ “wish lists”, or the parents may just feel guilty that they could not afford everything they would have wanted to offer. Those with teenagers may experience their children’s emotional distance as they separate psychologically, or they may sense their teenager’s boredom or rebellion.
Some people cannot travel to see friends or family, either because of poor physical health or limited finances. Hallmark cards surround us with lovely scenes, families around the table, warmth of the fire. These images are tantalizing and hopeful, but the reality often does not measure up to these idyllic descriptions. The holidays can be unusually difficult for those who are single, separated, divorced, or widowed. The loss during the year of any close family or friends can be acutely noticed; for example, people are often overheard saying, “this is my first Christmas without him (her)”; also, those that have sold their homes, or downsized, or experienced job loss will be strongly affected by this time of year.
I know a number of people who are exhausted from attending all their gatherings. They may eat or drink too much, stay out too late, and generally tax their overall energy levels. Remember, good events can be as stressful as “bad” events in terms of having to adapt and utilize effort. Of course, individual vary in what each experiences as stressful. If one tends to perfectionism, the holidays may have higher impact.
Some more invisible stressors can be experienced by those who are not Christian, or those who are not religious at all. It can feel alienating to be surrounded by holiday music for the four weeks from Thanksgiving, not to mention everyone saying “Merry Christmas”, if one is feeling on the periphery. The wisest thing is probably to join in the spirit, and appreciate the sentiment, but not all individuals have the capacity to do that.
Let’s not overlook work issues. There are some service providers who have much greater demands at this time of year. Postal workers, policemen, airport personnel, and shopkeepers are just a few who have increased workloads. Employers may have year-end statements to complete, performance evaluations to render, and additional orders to fill, while still attending to family demands at home.
There are potential stressors from a variety of sources around the holidays. It is obviously a time of considerable joy and reflection for so many. It is perhaps easy to overlook the compounding effects of both external and internal factors that can lead to fatigue, feeling off-balance, or moodiness. With increased awareness, hopefully you are able to be somewhat selective in your efforts, acknowledge changes in your life with optimism, and experience the warmth and generosity of spirit that the season offers. May you have meaningful, satisfying days!
We are obviously biologically programmed to respond quickly to danger. Threats can be to our physical well-being, yet also to our psychological and emotional status. Being asked to come to the boss’ office can trigger an anxious thought of demotions or firing, whether this has any basis in fact. Individuals often confuse the possibility of an event with the probability of an event – a crucial difference. While a plane you are on could theoretically crash, the odds of that happening are essentially zero. We wish for absolute security where there is none. Interestingly, gamblers and phobics have similar distortions of probability, but in different directions. While gamblers ignore how small their actual chances are of winning, thereby forging ahead to place their bets anyway, phobics hugely escalate the chances of something bad happening, and therefore avoid situations completely despite little risk.
An important feature of a fear response is that the body activates instantly when it perceives danger, whether is it a real danger or not. Also, while our bodies have an immediate on switch, they do not have an immediate off switch. This discrepancy causes a variety of problems. For some individuals, the physiological symptoms of arousal that come with fears can be frightening themselves, thereby creating an escalating loop. This is often associated with an anxiety attacks that persist.
Let’s explore some further examples of situations when individuals may become fearful unnecessarily. There is ride at Universal Studios theme park called “Back to the Future”, which is based upon the movie of the same name. On this ride, people sit in Delorean “cars” which is atop a pedestal programmed expertly to tilt in synchrony with a movie. The Deloreans have the illusion of blasting off, flying through windows, over lava flows, dodging fierce animals, and a variety of exhilarating (or terrifying) challenges. There are some individuals who react with fear, as if they are on a roller coaster that is hurtling them to possible harm or death. The reality however is that if they take their eyes off the movie screen, and turn their heads, they will see other “cars” tilting in rhythm to the movie. There is noactual danger of harm. There is a similar effect at Epcot Center’s ride, “Soaring”, which gives the illusion of flying over mountains and lakes, while individuals are never more than three feet off the ground.
Children on haunted house rides may be frightened when they are unable to discern true danger from being startled by plastic or mechanized figures. It is always interesting to see at what age children move from a real fear response, to feeling somewhat safer, and ultimately not being activated by the ride designers’ attempts to scare them.
Let’s say that on Halloween, someone points a gun at you. You may forget the date, and be quite terrified, yet the “gun” may be made of plastic, or even of chocolate. He even may break off a piece of it to share with you! You were never in danger from this gun, but the idea of a gun. We want to be self-protective and prudent, yet we also must have some discrimination function that allows us to separate real danger from illusion, and true threat from exceedingly low risk. This can admittedly be a challenge. Too unresponsive, and we might suffer unnecessarily by our failure to assess. Too reactive, and we fight battles that are irrelevant or non-existent. The overreactive pattern has the added burden of activating our bodies, and keeping them in a state of physiological arousal that has negative health consequences itself.
Sometimes we use “security blankets” to help us, such as lucky charms, and superstitious rituals. These may not offer any real added protection, but they may provide some comfort if the individual has the belief that they keep them safe. In the children’s movie, “Dumbo”, the elephant ultimately learns to fly by opening his enormous ears and holding his “magic” feather. He repeatedly performs his unique skill in a circus, wowing the audience in the process. One day however, after jumping off the high platform, he loses his feather, and begins a downward spiral towards the ground. Simultaneously, his coach, a mouse on his trunk, is screaming at him, “It’s NOT the feather!” Charming and instructive.
We are all learning to hold more positive beliefs and devise improved coping skills, knowing that having those perspectives lead to exploring our environment more confidently. To return to the ride at Universal Studios, to reduce the fear in that situation, an individual has only to know that it is a movie, or perhaps take their eyes off the screen to gain relief. In a parallel way, we often have “movies” going in our heads that may have been created by assumptions, creativity, or historical associations. I am fond of the quote, “The world expands or constricts in proportion to one’s courage”. Approaching rather than avoiding new situations allows for greater learning, the development of new skills, and deepening of our capabilities. That sounds encouraging, though I’m scared I won’t remember that!
We all like a certain amount of stability and predictability in our lives, yet too much certainty and routine lead to boredom. We all crave and need some novelty in our lives to spark our interest and wake us up. Would you prefer to watch a sports game Live, or on tape knowing the final score already?
I am a part-time professional musician. When less experienced, I needed to know exactly what we were playing, the chords, the sequence, as well as the musicians. Over time, I came to appreciate changes in speed, solos, and even to play gigs Live with musicians I just met. Improvisation became sought after and delightful, and now moving away from the original music pattern is the most fun of all, and usually leads to our best material. Where are you going? To freedom and creativity. Moving away from the usual can lead to anxiety, fear of chaos, and panic over the idea that you’ll be permanently lost, yet what if where you are now going for the first time leads to your new favorite location? Creativity requires that we include new material, or at least to put things together in fresh ways.
I recall working with a music teacher who loved Bach and Mozart, but was uncomfortable with jazz. He preferred the mathematical certainty of the classical cadence with limited key changes. His music preference reflected his avoidance to take chances and explore. As we worked together on overcoming his discomfort with novelty, he began to expand his musical taste, and could begin to appreciate jazz, and even enjoy it. It opened up his interpersonal style as well, and was more able to speak freely to others.
When my daughter was in her early teens, we were on a road trip where we had prepaid to stay at several Bed and Breakfast Inns, staying only two or three nights in each. She absolutely loved the first Inn, developed a sweet relationship with the owner, and didn’t want to leave when it was time to depart. Three days later, at the third Inn, they had unusual animals, and she declared that it was her favorite place. I reminded her that if had been entirely up to her, we never would have left the first Inn! It brings up a useful point. What factors lead us to decide to stay longer or leave, not only vacation spots, but also jobs, or even moving to another country? People leave countries due to war, famine, persecution, failing economy, hoping for a better life (even if the current one is satisfactory), adventure, and curiousity. What determines when an individual makes a decision to take the risk of someplace new? Certainly relevant are ones mood, timing, and context.
Sometimes detours are forced upon us. We have to leave what is comfortable or expected. Other times, we have a choice whether to remain with the usual, or shift. If we want to take risks, we want them to be moderate risks, with decent odds of a good outcome,yet sometimes we have to risk it all and be death-defying! As individuals, we have different capacity to tolerate uncertainty. Comedians have to risk the audience groaning or not responding at all, otherwise they could never be on stage. Salesmen have to tolerate hearing “no” from the majority of their potential customers (I recall a salesmen telling me that he hoped to be rejected by 90 people this month, because speaking to 100 people would lead to 10 sales). So, we have avoiders and dare-devils, with all that is in between.
Many have wrestled with job changes, both forced and chosen. I was counseling people who had lost jobs during a large company’s downsizing, and there was understandable apprehension about the future. Looking at surveys of other people who had lost their jobs, interestingly and reassuringly, one-third were earning the same at their next job, one-third were making more, and only one-third were making less. So, two thirds were making as much or more once they left their current job! Some would never have left on their own, but benefitted from being let go.
There is an experiment that tests problem solving in babies who crawl. Researchers put a clear plastic wall of only a few feet in length between a crawling baby and something shiny and attractive on the other side of the room. When the babies attempted to go to the item, they were frustrated by the inability to get there because of the wall. It was interesting to see which babies stayed there upset, versus those who ultimately learned that they could reach the desired item by crawling a few feet to the left or right to get around the wall. Note that in this case, the so-called “detour” was the only way to get to the object. Sadly, as adults we also are prone to feeling stuck when the direct path is blocked, and also do not see that “as the crow flies” is sometimes unavailable or impossible. I recall a charming, yet meaningful cartoon. The driver is on a pot-holed, curved, dirt road asking for directions from a man standing beside the car. Off in the distance, there is a straight, well-lit road with guard rails, yet the standing man says to the driver, “Take the dirt road, the other is a mirage”!
Think about the idea that “The path I almost missed was the best choice I ever made”. Strange isn’t it? I almost didn’t try that new flavor, almost didn’t get past my anxiety to ask my future wife her name, almost didn’t leave my last job for a better one, almost didn’t buy a Honda when I always had bought a Chevy, almost didn’t try writing a new song, almost didn’t try to play a new solo of a familiar tune, almost didn’t go to a new vacation spot because we had always gone to the beach, almost wasn’t faced with traveling a new direction because there was an accident ahead. Glad for the changes, and glad for the detours! Which “detours” have you taken, and which ones might you now try?
Harold Steinitz, PhD.
Crane Rehab Center
Research suggests that the better we understand the cause of our pain the better we are able to manage it. As a physical therapist I never underestimate my patients' ability to understand their underlying pathology. But what about understanding the nature of pain itself?
Over the past 15 years there has been a tremendous amount of research on the pathophysiology of pain. We now know,for example, that pain is 100% produced in the brain. This is all pain, whether it be sharp, dull, mild or severe. This also includes pain which is short in duration called acute pain or pain that is persistent or has lasted for months called chronic pain.
Acute pain is the result tissue damage such as a back strain or ankle sprain. Generally, this can be managed with anti-inflammatories, active rest and a gradual increase in activity.
Chronic pain, however, is different. Most tissue damage has healed in 3 to 6 months, so chronic pain is less about tissue damage and more about the sensitivity of the nervous system. This makes it a little more difficult to treat.
According to the International Association for the study of pain, "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". The key concepts in this definition of pain are that pain has an emotional component and that pain is "experienced".
Anyone who has chronic pain has experienced this emotional component of pain. What is not so clear it is where does all this pain come from? As I mentioned before, all pain is produced in the brain. Any input into the brain can affect our perception of pain. This includes our past pain experiences, our emotional state, our life experiences, our genetics, our general health and our brain's processing systems. Chronic painful conditions are usually the results of an injury going untreated, under treated or undiagnosed. Nerve reactions and responses are heightened such that normal mechanical stimulus such as a touch on the skin is perceived as very painful. It is as if the volume on our pain system has been turned all the way up and doesn't know how to turn itself back down.
Physical therapy treatment for chronic pain needs to address several issues. First of all it is important to address primary location of the pain and any areas connected to the areas of pain. Secondly, because the way the brain processes pain is different in chronic pain "brain treatments" such as guided imagery, visualization and Mirror therapy can be very helpful. Thirdly, patients with chronic pain need to be educated regarding the pathophysiology behind their symptoms. Taking some of the "mystery" out of their pain perception can ease anxiety, decrease sympathetic input and decrease a fear of movement.
In addition to physical therapy treatments other treatments include medication, cognitive behavioral therapy, relaxation, biofeedback and stress management.
Mo Crane, PT
Malcolm Gladwell has written an article in the New Yorker, “How David Beats Goliath”, that focuses on how the underdog can often win, for example, citing surprising war engagements and unlikely sports victories. Perhaps we could call this solely “brains over brawn”, yet this is only part of the story. He makes the point that effort can trump superior skill. It brought to mind my first experience playing soccer when a freshman in high school. We had a very inexperienced team, and a new coach who admitted that he knew little about soccer. Since he couldn’t teach us much about the game itself, he focused most of our attention on building endurance. He told us we weren’t going to lose any games because the opponents had more stamina than we did. Amazingly, we had a very good season.
There are countless examples of seemingly inferior teams defeating stronger foes, by calling upon unusual tactics or sheer determination. Motivation can lead to individuals and groups to rise above their norm, creating chemistry and disorienting the opposition. Opponents who are use to succeeding easily can become flustered when their usual methods are thwarted. At that point, they may begin to doubt their capacity, and press too hard. It is what occurs when “momentum” shifts. Gladwell also highlights that it is the willingness to be creative, and not to meet the opponents using their preferred strategy, that can ultimately succeed, since “when underdogs choose not to play by Goliath’s rules, they win”. He describes how David had to call upon his own skills with the slingshot, rather than accept a doomed battle fought with strength and military training.
Before large artillery and planes, warfare was fought at close quarters, typically with the combatants having the largest number of soldiers winning. Clearly then, fighting a battle with each side losing one for one is not a useful format for the smaller army. It is why the Minutemen defeated the highly trained Redcoats, who had learned to form straight lines. They had little response to the guerilla tactics. It is one of the reasons that both the French and American forces lost in Indochina/Vietnam – the enemy used “hit and run” tactics, and neither of the Western countries grasped that the Chinese/Vietnamese would wait a thousand years to win, a timeframe that no occupying country could tolerate.
In his book, “Home Team”, Coach Sean Payton of the Saints describes his strategy in the Superbowl against the Indianapolis Colts. He knew that quarterback Peyton Manning was masterful at picking teams apart, so he focused on ways to limit the number of plays that Manning would have available. His gamble to begin the second half with an onside kick which the Saints recovered was brilliant, and part of his overall plan to keep the ball out of Manning’s capable hands. By the time the Colts righted themselves, the Saints were ahead, forcing Manning to press to win the game. Those who watched, witnessed the Saints interception which sealed the victory. Payton cites his mentor Bill Parcells as saying that “the real credit comes when you arrive at a disadvantage – and you still win”. He analyzed opponents strengths and liabilities, and could devise a game plan which exploited the weaknesses. I like his phrase, “fresh analysis beat conventional thinking every time. No preconceived notions.”
Edinbergh, Scotland has a wonderful fort high up on the rocks overlooking the city with a sheer drop on one side. The fort was always well defended from the obvious front, however the eventual occupiers performed the seemingly impossible task of finding a way to scale the mountain side. Similarly, the Conquistadors subdued the entire Aztec nation with only 300 men by riding into the Aztec city like conquerors who were already victorious. The Spanish soldiers did have horses and steel weapons, however they would have been clearly overwhelmed had the Aztecs not been so disoriented and frightened.
In summary, if seemingly underpowered or overmatched, an individual or group must either be willing to generate more energy and effort, thereby outdoing the motivation of the opposition, or they must be able to implement a creative strategy, and certainly not engage in the preferred method of their opponent. So, to answer the original question, I guess it is best to work “smarter and harder”, but certainly at least one of the two. Good to know!
Jayson DeLeaumount, DPT