House Call, MD

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

As a kid, my friends and I always got together to play tackle football.  None of us weighed over 100 pounds and, as such, we threw our bodies at one another like Adam Sandler in The Waterboy. We didn’t think twice about going head first into someone on the opposing team.  Little did we know, throwing our bodies around like this could potentially be extremely damaging.  This general disregard could have caused a plethora of injuries, the most common of which (caused by Goldberg-esque spear shots) being neck injuries.  Neck injuries are a serious concern in the NFL.  Millions of dollars are poured into research looking at the long-term effects of head injuries, specifically concussions.  This past week, Indianapolis Colts’ quarterback and Saturday Night Live star, Peyton Manning, underwent neck surgery to relieve symptoms of a pinched nerve that he has been suffering from for the past four years.  Despite the enormous media coverage his surgery received, the exact type of surgery he underwent was not disclosed…luckily we have a pretty good idea of what went down (one of the few perks of medical training).  This article will dive head first into the injury, from the anatomy of the nerves (called spinal nerves… ingenious!) to symptoms associated with a pinched nerve and the surgeries and physical therapy commonly used treat them.

Stat Fact: As of February 1^st, 2010 more than 250 current and former athletes have volunteered to donate their brains to research the effects of repeated head trauma.

Spinal Nerve Anatomy

The cervical spine has seven bones called vertebrae.  Each vertebra contains a vertebral disc that acts as the “air bag” or cushion between adjacent vertebra.  Each of these vertebrae is associated with a spinal nerve root that exits the spine between the vertebrae.  Once the nerve exists, it travels a distinct path relaying sensation and providing motor control to specific regions of the body.  The nerves are the electrical system of the body.  One of their functions involves sending information to muscles causing activation and contraction.  The nerves in the cervical spine provide information to various areas of the neck and arms.  Pinched nerves are caused by a variety of anatomical adaptations to stress.  With the majority of pinched nerves, the gel-like disc between the vertebrae loses it’s elasticity and is compressed, decreasing the amount of space between vertebrae and subsequently causing compression of the nerve.  Another common cause of pinched nerves is from a bulged disc; in this pathology the gel-like center of the intervertebral disc bulges through the tough outer layer.  This bulging region then presses on the nerve root decreasing conductance of the nerves and causing excruciating pain.

Stat Fact: Vertebral discs begin to lose their size and absorption capacity by the third decade of life.

Signs and Symptoms

Pinched nerves present in a variety of ways, most of which involve pain and discomfort…not a good thing for any athlete, let alone a 10-time pro bowl quarterback.  Despite the fact that the “pinching” of the nerve occurs just outside the spinal cord, most signs and symptoms occur in the area that the nerve innervates (i.e. the region of the body to which the nerve supplies electrical connections).  As stated, most of the nerves in the cervical region of the spinal cord distribute sensation to the arms and neck.  Common symptoms of a pinched nerve include:

• Numbness and decreased sensation in the area supplied by the nerve

• Sharp or burning pain radiating over the region supplied by the nerve

• Symptoms become more severe with coughing or sneezing

• Muscle weakness or twitching in the affected area

• Feeling that the area involved has “fallen asleep”

These symptoms can be felt on one or both sides of the body.  Medical doctors or physical therapist can confirm these symptoms with a variety of tests:

• Reflexes: Reflexes are typically decreased in patients with a pinched nerve

• Nerve Conduction Study: This involves the application of an electrode to the farthest point of a potentially compressed nerve followed by a mild electrical pulse (don’t worry…not Frankenstein style) to a point higher up the nerve.  The study is testing the speed with which that impulse is carried down the nerve.  Slowed conduction speeds can indicate that the nerve is being compressed at some point along the path.

• Electromyography: This test measures the electrical activity produced by a muscle.  This test is performed by placing a needle (which sounds scarier than it really is…think acupuncture needle not horse tranquilizer) into the muscle and record the electrical discharge made by the muscle during movement.

• Magnetic Resonance Imaging: This technique uses a magnetic field and radio waves to produce an image of the affected area and look for a region of nerve compression.

These tests, as well as the patient’s symptoms, will provide the doctor (either a physical therapist or an MD) with a better idea of the severity of the injury and the ideal treatment course.  The more we know, the more we can help you…thus all the tests (they really aren’t as fun for as to perform as you think).

Stat Fact: 70% of cervical radiculopathies (a.k.a. the pain and loss of function caused by pinched nerve) occur at the 7^th cervical vertebrae (indicated by the white arrow in the x-ray shown). This nerve innervates the triceps (We don’t play football anymore but we’re pretty sure the triceps are important…yes, our sources have just confirmed they are).

Treatment Options

Surgery

Most surgeries for a pinched nerve are part of the “otomy” family: foraminotomy, laminotomy, hip-hopotomy (OK, one of those is fake.  Any guesses?) The suffix “-otomy” is Latin for “partial removal” and “-ectomy” is total removal (for example, a cholecystectomy is the removal of the gall bladder). If I had to guess, I would say Mr. Manning had an “-otomy”, considering that the press releases proclaim it was minor surgery.  Nowadays, these types of surgeries are minimally invasive endoscopic surgeries (meaning that they are performed through small incisions with a video camera and tiny instruments). In Peyton Manning’s case, we do not know which form of surgery he received but it is most likely a foraminotomy or laminotomy:

• Foraminotomy:  This outpatient surgical procedure is used to widen the foramen (the round opening that exists between the two vertebra) by removing small pieces of the vertebrae to relieve the pressure being placed on the nerve.

• Laminotomy: This surgery can be performed in the outpatient setting as well and is used to clear space on the spinal cord.  This surgery relieves pressure placed on the nerve by removing part of the lamina of the vertebra (the portion of the vertebra seen in the picture above and below the intervertebral foramen) creating more space for the nerve to pass through.

Another typical surgery to relieve pressure is a discectomy.  A discetomy is performed when a bulging disc is the cause of the nerve compression.  The procedure involves the removal of the intervertebral disc that is putting pressure on the spinal nerves (you can see in the picture to the left that the inner gel-like part of the disc has ruptured through the tough outer ring of the disc and is now pressing on the nerve root…and a pinched nerve is born).  Total removal of an intervertebral disc increases the likelihood of degeneration since it takes away the cushion between the vertebrae at that level.  Newer minimally invasive procedures have been developed to decompress the bulging disc without removing the whole disc itself (easier to do AND you may be able to salvage your intervertebral disc).

Physical Therapy

In therapy, enhancing the strength of the muscles that hold the head upright is essential.  Most pinched nerves and bulging intervertebral discs are caused by poor posture for extended periods of time.  Hunched behind the center, the quarterback keeps their neck extended (to keep their eyes on the defense rather than the center’s robust butt) decreasing the space between the vertebrae.  Repeated bouts of poor posture may have lead to Manning’s pinched nerve…that or repeated bone-crushing blows from 300 pound linebackers moving at lightening fast speeds.  Our guess: The latter.  Since Manning was able to play with the injury for 4 years, it is likely that it was not an acute injury (enter the mental image of Manning being speared by Goldberg), but rather a progressive injury.  With these types of injuries, consistent neutral neck posture is mandatory (Good luck staring at the center’s booty, Peyton).  Increasing strength and flexibility will alleviate pain and prevent reoccurrence of the injury.  The goal of strengthening exercises is to increase strength in the front and back of the neck.  Recommended neck-strengthening exercises can be seen in our previous article, Pain in the Neck.

Conclusion:

Even though you’re not a 6′5”, 230 pound, 10-time Pro Bowl quarterback, you may still end up with the same neck problems if you do not address them now.  Proper posture, strength and flexibility of the neck and shoulders are key to preventing pinched nerves.  Keep this in mind next time you spend 8 hours sitting at a desk in front of a computer…nobody wants to end up as another Office Space neck pain statistic.  Help us help you.

Questions? E-mail John: mullen@myhousecallmd.com

by Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

We, at House Call, MD, are big fans of the “snuggle.”  There are few people on this planet who will not benefit in some way from a hug, massage or simple back rub.  A recent New York Times article suggests that we may be on to something (1).  While outright snuggling may create interesting and awkward scenes in the workplace, recent studies are showing that positive interactions involving touch may increase in human performance.

Before we dive into the details of the research on this topic and the science behind them, let’s start with some simple logic: If touch makes us “feel better” and “feeling better” makes us work harder, then it follows that positive or cooperative touch can improve performance.  Seems fairly reasonable to us.  Now on to the science behind the theory.

First, we must show that touching someone is a means of communicating—right?   Some of the most compelling studies regarding the role of touch in communicating emotion are currently being performed at UC Berkeley.  The most recent study sought to show that a wide array of emotions could be conveyed between two complete strangers using only touch.  What is interesting to us is how they conducted their study…

Imagine you are a freshman in college taking a Psychology course and, as part of your grade, you are required to participate in a study currently taking place on campus.  As part of the study you are taken to a small room and blindfolded (and yes, this does sound like the opening scene of a cheesy horror film, but stick with us).  After a minute, an individual enters the room, slaps your wrist, and walks out.  You are then given a list of emotions and asked to identify the emotion the other person was trying to convey to you.  You circle your answer (What would you answer, by the way?), re-blindfold yourself and wait for the next assault.  An individual walks in for the second time, hugs you, and leaves.  You are given the same list of emotions to choose from…etc.

The experiment showed that touch, independent of words, sounds or facial expressions, functions as a distinct means of communicating emotion.  The emotions that were successfully communicated in this study include: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.  Pretty impressive, right?

You may still be thinking “OK, so how is snuggling supposed to make me perform better?”  This is where the fun comes in.  Michael Kraus of UC Berkeley conducted a study examining the role of “tactile communication” (a.k.a. touching) and its effects on the performance of NBA players (2).  The study hypothesized that players who touched fellow teammates more often throughout a game would be more successful on the court.  They believed that the same would be true for entire teams as well (i.e. the more high-fives and butt pats, the better the team would play).  They watched each individual player in the NBA for an early season game and tallied the number of times the player touched a teammate. “These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.”  Can you imagine a bunch of scientists sitting around a television tallying “chest bumps”?  Welcome to the wacky world of UC Berkeley.  After assigning each player a score based on the number of touches throughout the game, the researchers quantified each player’s performance throughout the season in terms of points scored, rebounds gained, successful passes completed, and a number of other parameters that make a player valuable.  The researchers found that the more a player touched his teammates in that early season game, the more successful the player was that season. Teams that had the highest number of positive touches between players were also the most successful teams in the NBA!

According to the study, the Boston Celtics and the Los Angeles Lakers were at the top of the list of the touchiest teams, while the Sacramento Kings and Charlotte Bobcats were the least touchy teams in the league (1).  And the league’s most touchy-feely player?  Kevin Garnett of the Celtics (see photo of picture-worthy hug at left).  While the study showed a correlation between touching and performance, they did not prove that touching causes improved performance.

This observation has been studied in other settings as well.  Tiffany Field, one of the more prolific touch researchers, studied women with prenatal depression.  In the study, they compared participants whose partners gave them a regular massage to a control group in which the subjects got didily-squat (isn’t that sad?).  Guess what they found? Yep, those receiving regular rub-downs reported both a decrease in pain as well as improved relationships with their partners (3).  The same group of researchers studied autistic children and showed that touch therapy (which consisted of 15 minutes of physical contact two times per week for four weeks) was associated with less touch aversion, off-task behavior and stereotypic behavior and improved attention, behavior regulation, social behavior and initiating behavior (4).  Put simply, autistic kids were able to more easily control their behavior (this is one of the biggest challenges of the disease).

What is the science behind these observations?

Lets look at two hormones the body produces in relation to touch: oxytocin and cortisol.

Oxytocin

Oxytocin is the ultimate snuggle hormone.  It is best known for its action in pregnant women and is particularly responsible for milk “let-down” (a.k.a. allowing the milk made in the mammary glands of the breast to move to a “holding chamber” so that when the baby sucks on the nipple, milk is actually released).  Interestingly enough, the very act of suckling causes an increase in release of oxytocin by the pituitary gland (we have no political position regarding that statement.  Use this newfound knowledge at your own risk).  It is a self-perpetuating cycle to make sure babies get the food they need!  In terms of pregnancy, oxytocin also prepares the cervix for the birthing process (“Pitocin”, as oxytocin is called in this setting, is used as a topical gel to move things along and get the baby out faster).

Oxytocin is not only found in pregnant women…no need to feel left out, gentlemen.  Both men and women release oxytocin in relation to touch.  Studies have even found an increase in its release with warm contact on the skin.   Increases in oxytocin levels have been correlated with an increase in trusting behavior and decrease in fear.  It has also shown to be associated with generosity, empathy and even sexual arousal.   All of these emotions contribute to the formation of a bond between individuals.

Cortisol

On the opposite end of the spectrum, cortisol is commonly referred to as the “stress hormone.”  It raises blood pressure, spikes your blood sugar and suppresses the immune system among other things.   The body naturally increases its levels of this hormone in times of stress and anxiety (Remember “fight or flight” from high school biology?  This is a related chemical reaction).  Interestingly, one of the actions of oxytocin is the inhibition of cortisol.  One would think that a peak in cortisol levels in situations like an NBA game would help with performance.   The research, however, shows that it may actually be beneficial to have some level of suppression of cortisol in this scenario.

Therefore, when an NBA player high-fives his fellow teammate, he is triggering a biochemical signal in his teammate’s mind and body that says, “You can trust me.”  Perhaps it is this sense of security that allows players to push themselves physically and out-perform their rivals.  So next time you are on the spot, whether it be before shooting the game-winning free throw or as you sit down to take that final exam, giving the person next to you a motivating high-five will make a lot more sense.  It may be the “secret-weapon” you have been looking for.

Questions? E-mail Kelly: erickson@myhousecallmd.com

References:

1. Carey, B. Evidence That Little Touches Do Mean So Much.  The New York Times.  February 22, 2010.

2. Kraus, M, Huang, C,  and Keltner, D. Running Head: Touch, Cooperation and Performance.

3. Field T, Figueiredo B, Hernandez-Reif M, Diego M, Deeds O, Ascencio A.  Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. J Bodyw Mov Ther. 2008 Apr;12(2):146-50. Epub 2007 Oct 2.

4. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., Dowling, M. Brief Report: Autistic Children’s Attentiveness and Responsivity Improve After Touch Therapy. Journal of Autism and Developmental Disorders.   Volume 27(3), June 1997, pp 333-338

by Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

With record-breaking storms keeping many Americans trapped indoors this winter, it is hard to imagine that summer will ever come.  Daydreaming about your spring getaway or summer vacation to Europe may be your only respite from the cold.  But when you consider vacation, especially one that takes you multiple time zones away from home, one of the major drawbacks is coping with the even harsher reality of “jet lag”.  Whether it requires you to sleep when you arrive at your destination rather than enjoying immediate exploration or demands that you take yet another day off from work once you return home, jet lag is undeniably inconvenient.  Here we will explain the causes of jet lag and how to best prevent it from hindering your well-deserved adventures.

What is jet lag?

According to a recently published article in The New England Journal of Medicine, jet lag is a “recognized sleep disorder that results from crossing time zones too rapidly for the circadian clock to keep pace.”  It is a constellation of symptoms that can include insomnia, daytime sleepiness, fatigue, poor physical performance, cognitive impairment and gastrointestinal changes.  What the scientists meant to say was that you are going to feel lousy.   Jet lag is most commonly experienced after crossing at least 5 or 6 time zones (the East Coast-West Coast trip doesn’t apply here!).  Jet lag is most commonly confused with “travel fatigue”, which is the unfortunate result of the combination of sleep deprivation, stress caused by traveling, diet changes, etc.  While travel fatigue can be easily treated with a little rest and T.L.C., jetlag is a horse of a different color.

How does this “jet lag” nonsense happen?

The body’s circadian clock is located in the suprachiasmatic nucleus (SCN) of the hypothalamus (imagine a point directly between your eyes and two inches towards the back of your head…eureka, you’ve found it!).  It communicates with the retina, allowing it to sense light and dark.  Based upon our regularly predictable cycle of waking and sleeping, the SCN promotes alertness or sleepiness in sync with our daily routine by regulating the secretion of melatonin from the pineal gland.  The system works such that light inhibits the secretion of melatonin.  Therefore, melatonin has often been referred to as the “dark hormone”, because it is only secreted when there is no stimulation by external light (aka nighttime).  The problem with this system is that our circadian clock does not adapt quickly to changes in the cycle (i.e. flying half-way around the world in single day).  Therefore, in the same way that “motion sickness” is the result of desynchronization between visual and spatial stimuli in the setting of movement (didn’t know that, did you?), jet lag is the body’s response to the imbalance between a predicted sleep-wake cycle and a change in external light and dark stimuli.

How to Beat It:

1.  Re-sync your clock. This is accomplished with 2 strategies.

• Timing of Light Exposure: Based on what we now know about the circadian clock, we now understand how light can be used as a powerful tool to “trick” the circadian clock and therefore advance or delay it.  Although it may seem logical to think that sleep itself resets the clock, it is actually exposure to light and dark that is most effective.  What does this mean?  Studies have shown that light exposure should be used as follows after travel. Eastward travel: Upon arrival seek exposure to bright light in the morning.  This will help delay your circadian clock.  Westward travel: Seek exposure to bright light in the evening, which will help advance your circadian clock.

• Taking Melatonin:  Because light inhibits melatonin secretion, recommendations for melatonin are the opposite of those for light exposure.  When melatonin is taken in the evening, it resets the body clock to an earlier time and when taken in the morning, it causes the clock to be set to a later time.  Guidelines for melatonin use are, once again, broken down depending upon the direction of travel.  Eastward travel: Take 0.5mg-3mg at bedtime to shift your circadian clock to an earlier time and help you fall asleep.  Westward travel: Take 0.5mg during the second half of the night to shift circadian clock to later time and allow you to continue to sleep.  When traveling westward, the most common sleep disturbance is difficulty staying asleep.  Therefore, melatonin should be taken after awaking in the middle of the night in your new time zone.

2. Plan out your ZZZZZ’s. When planning a trip, you buy your airlines tickets in advance, purchase your travel books and research all of the best sites to visit.  Why not spend a few extra hours sleeping before you leave to help ease the jetlag when you arrive?  More sleep plus less jet lag sounds like a good deal to us.  In general, this means shifting the timing of your sleep 1-2 hours earlier for a few days before eastward travel and 1-2 hours later for a few days before westward travel.

3. Medication. When all else fails, manage your symptoms with some good old-fashion meds.

• Downers (aka sleeping pills):  Studies have shown that 10mg zolpidem at bedtime helps patients get a good night’s rest after long-distance travel and helps to reduce the symptoms of jet lag.  It’s best if you give the medication a test-run before you leave to ensure that you do not have any unwanted side effects while in the safety of your home country (amnesia and confusion…not so fun in a new city where you don’t speak the language).

• Uppers: Caffeine, while generally discouraged for those attempting to overcome jetlag, can be used in small doses early in the day to increase daytime alertness and decrease sleepiness.  Small doses for those of you who missed that part the first time.

The Take Home Message: Jet lag sucks (as the scientists so eloquently explained) but can be mitigated with some planning, preemptive measures before you leave home, and a little proactive management once you’re on the ground in your exotic location of choice (our advice: print out this article so you can remember all these tips when it’s go time).  There’s no reason to feel like poop during your valuable travel time.  Vacation, here we come.  Now get packing!

Questions?  E-mail the author: Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

References:

1.  Sack, Robert L.  Jet Lag.  The New England Journal of Medicine 2010; 362:440-7.

2.  Herxheimer, A., Sanders, M., Mahowald, M., Sokol, H.N., Jet Lag. UpToDate, 2010.

3.  Herxheimer, A, Petrie, KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev 2002; :CD001520.

4.  Jamieson, AO, Zammit, GK, Rosenberg, RS, et al. Zolpidem reduces the sleep disturbance of jet lag. Sleep Med 2001; 2:423.

5.  Morris HH, 3rd, Estes, ML. Traveler’s amnesia. Transient global amnesia secondary to triazolam. JAMA 1987; 258:945.

by G. John Mullen, DPT 2011

With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return.  The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle.  The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday.  As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination.  Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.

Stat Fact: Ankle sprains in men and women whose average age was 23 had an injury rate of 10 per 1,000 hours of sports participation.

What is an ankle sprain?

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments.  These injuries are caused by running, jumping, landing on an uneven surface or awkwardly planting your foot (or tackling a quarterback in the NLF in Freeney’s case).  The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot.  You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them.  This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined).  There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments.  In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.

The signs and symptoms of a sprained ankle are similar to most musculoskeletal injuries:

• Pain and swelling

• Bruising

• Difficulty walking

• Stiffness

Stat Fact: Sprains of the lateral ankle make up 85% of all ankle sprains.

Acute Ankle Sprain:

Now that you know some basic facts about the ankle, we will discuss what to do if you have just sprained your ankle playing a pick-up game of basketball or Louisville Chugger.  Most ankle sprains are Grade I (i.e. relatively benign) and will begin to feel better within a few days.  To help speed up the healing process, most physicians, physical therapist and medicine men will tell you to R.I.C.E. your ankle.

• Rest: For 24-48 hours after an injury, rest your ankle and allow it proper time to heal.  During this time sit back, relax, watch The Office and discontinue any physical activity.

• Ice: Icing can be used to decrease swelling of the injured ankle.  Ice should be used for approximately 20 minutes (about the same length as an office episode…) at a time and should be used intermittently throughout the day (about 6 times).  Make sure the injury site does not go numb when icing the injury.  When the injury becomes numb, tissue can be damaged and more harm can be done!  The type of cooling method is irrelevant, but make sure the ice pack, pack of frozen corn or cold pack covers the inflamed area. Additionally, make sure not to leave the ice on for longer than 20 minutes.  The ice is used to reduce the swelling in the area.  When ice is left on for longer than 20 minutes, the body begins to think that it is freezing and increases the amount of blood to the area to warm it up (thus increasing the swelling!).   The take home: 20 minute on, 20 minutes off!

• Compression: An ACE bandage works best, but any type of garment can be used to compress the injury site.  Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done.  Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).

• Elevate: This is simple, keep your ankle higher than your heart…lying down is key here (for those of you trying to maintain the kung fu position with one leg in the air) and remember to keep your ankle elevated with a pillow while you sleep.

If the ankle swelling does not subside after a few days (~7 days) or if the ankle is preventing you from everyday activites, it may be necessary to see the physician or physical therapist and it is likely you have suffered a Grade II or III sprain…our hearts go out to you.

Chronic Ankle Instability/Functional Ankle Instability

Now that you’ve sprained your ankle and the pain and inflammation has gone by the wayside, you may be interested in preventing future ankle sprains. If you are a bit of a couch potato (not recommended by physicians) it is likely the sprain was a freak accident and is unlikely to occur again.  On the other hand, if you are an active individual, the ankle is likely to be reaggrevated by future activities.   The good news is that future ankle injury can be prevented by non-surgical options including ankle braces (orthosis), strengthening and improving balance.

1. Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity.  This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly.  If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).

2. Balance: Balance exercises include: single leg standing, single leg squats, single leg calf raises, etc. Any of these single leg activities helps improve your balance while strengthening your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging.  A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles.  Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.

3. Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual.  Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball.   One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock.  I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock, and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left.   Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle).   Movements in all these planes of direction will greatly strengthen your ankle and improve your balance.  These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult.  A little TV time makes them infinitely more enjoyable.

Stat Fact: Basketball players with a history of ankle sprains were nearly five times as likely to sustain another ankle injury.

If these non-invasive interventions do not help the ankle instability, surgery may be considered.  Ankle surgery is done only in the most severe cases of ankle instability and would have to be recommended to you by an experienced orthopedic surgeon.

Ankle instability and sprains can hamper one’s recreational football and basketball career, but implementing these three main sources of rehabilitation (bracing, balance, and strengthening) can get you back in action sooner and keep you there longer.  Rehabilitation programs vary greatly from injury to injury and if you have chronic ankle instability it is recommended to see your physician or physical therapist to implement an individualized plan to help strengthen your ankle and get you back to 100%.  Let’s hope Dwight Freeney is doing his ankle exercises (enter his long walks on the beach) and keeping that ankle elevated (for the Colts’ sake that is!).

References:

Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. Review.

Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review.  Sports Med. 2008;38(7):553-63.

by Sarah Gilman-Short, MD 2010

Writing this article has been an interesting journey. A few weeks ago I turned on the radio to hear some pundit screaming, “this is just the first step with this health care reform – first they’re taking away our mammograms, then they’re going to start rationing everything![1]” I wanted to call in, but instead I prepared myself to shoot off a fiery retort extolling the new guidelines and explaining the importance of evidence-based medicine, public health, and risk-benefit analyses. However, after looking at all sides of the issue, I see that things are much more complicated than I had previously thought and my position is much less clear (who’s fair and balanced now, Fox News?).

So now, with the utmost humility and effort, I bring you a primer on the complicated relationship between doctors and numbers, using the recent change in the recommended guidelines for breast cancer screening as an example. And there may be a little rant about health care reform for good measure, but I’ll try to tone down the politics as best I can.

Personally, I’ve always distrusted numbers; they’re shifty and unfriendly creatures. In the third grade, I literally shook with fear before every timed arithmetic test. However, medical school has forced me to confront my numerophobia, and, although I still do not like the little buggers, I have come to deeply respect their utility in my profession. I see myself as an artist and humanist foremost, and I fully believe in the power of individualized care drawing heavily on a strong relationship between the doctor and patient. However, if doctors didn’t care about hard evidence and science, we’d still be running around “blood letting” everyone with a fever.  This is one of the biggest challenges of medicine – we have to merge the evidence we’ve been given (which can be somewhat dodgy itself) with our own intuition and first-hand experience in order to make the right decision for the unique patient in front of us. Sometimes the numbers are right and sometimes they’re wrong, but usually those evil numbers win.[2]

This brings me to the new breast cancer guidelines. If you haven’t yet experienced the treat of being hollered at by a media pundit (and I do recommend it; quite exhilarating during your morning commute) I’ll give you a quick explanation. The United States Preventive Services Task Force (USPSTF[3]) is an independent board of “experts in health prevention and primary care” who have taken on the formidable task of pooling all the evidence from multiple clinical trials regarding a particular subject. They mix all the studies together in a huge pot, add some eye of newt and rat’s tail, mutter a few incantations, and then poof[4]…an evidence rating is set, a guideline is published, and all the primary care physicians in the country collectively gasp together, recognizing that they’ve been doing everything totally wrong their whole career. This happens, oh, about once every few months, and has included everything from abdominal aortic aneurysm screening to youth violence counseling.[5]

The concept of an “evidence rating,” although somewhat boring, merits discussion. Theoretically, the strength of evidence behind every decision that doctors make can be distilled down to by the USPSTF to a single letter. There are tons of really good studies that unequivocally say that cigarette smoking is very bad for your health;[6] therefore, counseling patients to stop smoking is grade A, or strongly recommended. Grade B means that there is “at least fair” evidence to support the service.  Grade C means that the USPSTF makes no recommendation for or against the service and D means that the service is either ineffective or actually hurts patients (thus the USPSTF recommends against it). There is one more distinction – called “I Statement” – which means that there is insufficient evidence to make any kind of decision whatsoever. In theory, the letter is determined by a weighing the risks of a particular service against the strength of evidence for the benefits of the service. Telling your patients to stop smoking is not risky and it can have a huge benefit for people; hence Grade A[7].

So what happened with breast cancer screening? The smart USPSTF people set the sights of their mystical computer programs on breast cancer screening. And they came up with the following results:

1. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years (Grade B Recommendation).

2. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms (Grade C Recommendation).

3. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (I Statement).

4. The USPSTF recommends against teaching breast self-examination (Grade D Recommendation).

5. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older (Grade I Statement).

6. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer (Grade I Statement)[8].

Now let’s try it in English. If the USPSTF were a normal person standing in front of you, it would say: “If you’re a woman between 50 and 75 years old, there’s pretty good evidence that you should get a mammogram every two years. Even though there seems to be a significant amount of evidence, I don’t really know if it’s a good idea to get a mammogram if you’re between 40 and 49 years old, so I’m going to leave that up to you and your doctor. And there definitely isn’t enough evidence at all to say if you should have one after age 75. As for your self-breast exams, they’re either totally ineffectual or harmful, so you probably shouldn’t do them. There isn’t enough evidence to prove if your doctor’s clinical breast exam is useful. Lastly, there isn’t enough evidence to prove that special studies like digital mammograms or MRIs of the breast help more than they hurt people.”

I don’t know about you, but if the USPSTF were my doctor, I would be writing some really angry Yelp reviews. The USPSTF doesn’t know anything about me, doesn’t care about me and all of this talk about evidence and proof doesn’t mean anything to my or Teresa Heinz’s[9] tatas. At the same time, the USPSTF is not sexist or intrinsically evil. The USPSTF, with all its unfriendliness, doesn’t care about money. It only cares about large-scale risks and benefits – which, in the case of breast cancer, involve unnecessary biopsies, further imaging, and psychological stress weighed against the possibility of a life-saving early intervention. I think that, even though you have to do 556 mammograms to diagnose 1 case of invasive breast cancer in women 40-49 years old, it’s still worth it[10]. Conveniently, the American College of Obstetricians and Gynecologists as well as the American Cancer Society[11] agree with me.

This brings us back to the struggle between the individual and the public good, which has been at the root of the health care debate. In this case, I chose to ignore evidence (albeit wishy-washy) and to potentially ignore economics to come out in favor of the one woman out of 556 who benefits from getting a mammogram between the ages of 40-49.  Wouldn’t you?  At the same time, I’m not completely satisfied with this decision. As I said before, the USPSTF doesn’t take cost into consideration, and I think that cost-effectiveness should always be taken into account when deciding whether or not to perform a test. Despite the way we’ve historically practiced medicine in this country, our money and resources are not infinite. It feels ugly to merge economics with medicine, but the truth is that we, as a nation, have become very good at providing incredibly expensive health care of questionable quality to the “haves” while neglecting the “have not’s,” bankrupting the American people along the way.  America’s pathetic rankings on the full spectrum of health indicators reflect this discrepancy (for example, we rank 33^rd in the world for infant mortality…behind Brunei, Cyprus, and New Caledonia.  We’ve included a lovely picture of Brunei for those considering relocation).[12] We all might have to make some individual sacrifices to provide the greatest good for our society as a whole. We’re working on it, but we still have a long way to go.[13]

References

[1] I can’t find the particular pundit now, but here’s a good example of what people have been saying in the same vein.

[2] For a fabulous, in-depth discussion about this, please check out this article.

[3] Say that phrase three times fast.  About the U.S. Preventive Services Task Force

[4] The real and much less interesting version involves a series of ugly calculations that I shudder to think of.

[5] U.S Preventive Services Task Force Recommendations

[6] It really is! Seriously, don’t do it!!!

[7] It also helps to repeat the message. So this is meant for you. Don’t do it.

[8] USPSTF Breast Cancer Screening Recommendations

[9] Teresa Heinz’s take on the new breast cancer screening recommendations

[10] American College of Obstetricians & Gynecologists’ Screening Recommendations for Cervical Cancer

[11] American Cancer Society Responds to Changes to USPSTF Mammography Guidelines

[12] Population Reference Bureau, World Infant Mortality Rates, 2008

[13] The New York Times on the Senate Health Care Reform Bill

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