HEALTH CARE REFORM – A perspective

June 30, 2010 By

According to the Centers for Medicare and Medicaid Services, the Affordable Care Act that was passed by Congress and signed by President Obama will provide Medicare recipients better health care and ensure accountability so people — not insurance companies — will have greater control over their own care.

Present benefits will not change, yet necessary improvements to the system are vital if we are to keep the Medicare system strong and solvent. Changes are reported to occur in the form of cost savings and benefits, with a focus on quality of care.

Open enrollment this fall will provide people with a choice between the original Medicare plan and a new Medicare Advantage program. There will be no change in eligibility. Benefits will include more affordable prescription drugs. Those who enter the Part D “donut hole” will receive a one time $250 rebate check if they are not already receiving Medicare Extra Help, with checks issued monthly throughout the year as beneficiaries enter the coverage gap. If the coverage gap is reached, recipients will receive a 50% discount next year when buying Part D covered brand name prescription drugs. And, additional savings will be received over the following 10 year period until the coverage gap is closed in 2020.

Free services to include annual examinations, colorectal cancer screening and mammography will be provided. This has not been the case to date. Future plans lean toward patients being able to choose the physician they want to see, not the physician they have been assigned to. Additional financial support will be provided to community health centers, allowing them to serve an additional 20 million new patients.

New resources through the Elder Justice Act will work toward preventing and combating elder abuse and neglect in nursing homes. A voluntary insurance program known as CLASS will help pay for home care and long-term support.

Insurance companies will not be allowed to deny coverage because of pre-existing conditions for children beginning in September 2010 and for adults in 2014. And, insurance companies will not be allowed to establish financial lifetime limits on coverage beginning this September. Also beginning in September there will be an expansion of limits for young people to remain on their parents’ insurance plans until they reach the age of 26.

There is no question that annual Medicare spending will continue to increase as it has in the past; however, because of programs enacted that will address fraud and abuse, spending will occur at a slower pace than it has in the past.

In eight years senior citizens can expect to save up to $200 a year in annual premiums and an additional $200 a year in co-insurance costs than they might have paid prior to enactment of the new law. Those individuals earning $85,000 ($170,000 for married couples) can be expected to pay higher premiums than on lower income earners.

I’m not naïve enough to thing everything will be perfect. There will be kinks and obstacles, mountains to climb and bridges to cross. The Government may stub its collective toes along the way. But, it’s a start and I for one can give my endorsement to President Obama and his attempt to help the nation become a stronger one, both financially and from a health perspective.

A. Miller
Medical Assistant, Ret.

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Scoliosis

May 31, 2010 By

Most of you are familiar with the term scoliosis. You are aware that it involves some type of curving of the spine; although most people are not familiar with the reasons why someone develops it and what can be done to treat it. As a chiropractor it is very common for someone to enter my office with some degree of a spinal curvature. In fact, it is rare to see a truly straight spine. That is one reason that back pain is such a common malady. Scoliosis can be present in adults as well as children even though most scolioses present in adults most likely began when they were adolescents. In order to understand what a scoliosis is lets first take a look at what a normal spine should look like.

A “normal” spine when viewed from the front or from behind should appear straight up and down. When viewed from the side there should be three apparent curves. There should be a curve towards the front of the body in the neck or cervical region, this is a lordotic curve; a curve towards the back of the body in the middle back or thoracic region, a kyphotic curve; and a curve towards the front in the lower back or lumbar region, again a lordotic curve. It is the alteration of the straight up and down posture of the spine that constitutes a scoliosis; that is when the resultant curve is greater than ten degrees.

Most curvatures, greater than 80% of the time, are of unknown causes or idiopathic. Sometimes trauma, tumors, neurologic disorders or birth anomalies affecting the shape of the bones of the spine may be the underlying cause. In a lot of cases the cause may be as simple as having one leg congenitally shorter than the other, which can also happen post-leg fracture or by having inequalities of the feet. Most people who have scoliosis have curves less than twenty degrees which are not usually of any great clinical significance other than they can contribute to back pain. These are not of any great concern as long as they are stable and not progressing. These curves do have the ability to progress rapidly, especially in children and adolescents, and particularly in young girls who have not yet had their first menses. They therefore need to be monitored closely early on in those situations.

Scolioses are generally found on spinal screenings which are commonly done in the school systems. Parents may notice that their child has one shoulder or hip higher than the other or that one pants leg needs to be hemmed a bit higher. Also, there may be a noticeable “hump” on one side of the spine while a child is bent over at the waist. Sometimes the curves may be very subtle and may be missed during a mass screening as is done in the schools so I always encourage my patients to bring their children in so that I can screen them also. If a curvature is found x-rays are generally performed to assess the degree and extent of the curve and to see if the cause of it can be determined. Occasionally a MRI of the spine may be necessary to rule out any pathology that may be instigating the problem.

Scoliosis can affect the patient’s quality of life by restricting movements, causing pain and restricting lung and heart function. In some cases there can even be psychological scarring as the curves can be disfiguring affecting the patient’s self-esteem.

Treatment for scoliosis primarily depends on the degree of the curvature. When a curve is mild, generally less than 25 degrees, the patient is monitored with periodic screenings and x-rays to insure that the curve is not progressing. As long as the curve does not appear to be progressing no treatment is needed unless the patient is experiencing pain. If the curve does progress to between 25 to 45 degrees then the patient may be a candidate for bracing. Bracing can help stop the progression of a curve but won’t reverse it. If the curve progresses to beyond 45 degrees then surgery is generally performed which usually entails the implantation of a metal rod to stabilize the curvature.

As a chiropractor, my role in the treatment of scoliosis, involves the early detection and treatment of the subsequent pain that my be present as a result of the condition. Spinal manipulation has not been shown to be effective for stopping or reducing scoliosis but it can help restore some of the mobility that is lost due to the abnormal positions that are assumed by the vertebrae and thus help in relieving some of the pain that the patient may have. Another role that I can play is in determining if the scoliosis is present due to a leg length deficiency or inequalities in the feet. I have seen this many times over the years in my practice. These conditions can usually be addressed with orthotics or by simply adding height inside the shoe of the short leg. Another recommendation I make is to do stretching and mobility exercises which is best addressed by joining a yoga class.

The key to scoliosis is the early detection of such. It is a condition that can be potentially life threatening if it is progressive and left unchecked. Luckily, most scolioses are not of the progressive type and never need any intervention. If you should have any concerns you should discuss them with your chiropractor or primary care physician.

Dr. David D. Godwin
Chiropractic Physician
Salisbury, NC
704-633-9335
www.salisburychiropractic.us

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Low back pain

May 24, 2010 By

Low back pain (LBP) affects almost all adults at some point in their lives. Moreover, back pain among adolescents is on the rise. There is a tremendous cost, both financially and personally with chronic back pain. 2.5% of all medical expenditures are spent on LBP. Individuals with LBP have medical expenditures 60% higher than those without.

A common question may be what is my diagnosis? Is it lumbar sprain, lumbago, sciatica, stenosis, herniated disc etc? Medical research demonstrates that in only about 15% of all cases of LBP there is a specific pathoanatomical diagnosis. When an MRI is performed on pain free individuals there are a large percentage with bulging discs 55-80%, herniated discs 25-35%. At age 35 there is a 40% chance you will have visible arthritis on an X-Ray before your symptoms begin. At age 70, the likelihood is 100%. Therefore, these tests typically do not guide treatment for LBP.

There is an obvious value for imaging studies if there is a suspected fracture, cancer or unusual or prolonged symptoms that have failed to respond to conservative treatment. In the case of simple mechanical LBP, Geer Physical Therapy uses a detailed history and a movement based exam to help classify your symptoms. We then match your movement impairments and functional limitations with specific treatments. This approach has been shown to be favorable vs. conventional treatment.

Feel free to contact me if you have any questions regarding our approach to LBP.

Mike Mangini PT OCS CMP
Geer Physical Therapy
99 S Canaan Rd
Canaan CT 06018
860-824-3820
mmangini@geercares.org

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Mercury fillings

May 17, 2010 By

AN INTERVIEW WITH DR. LIVINGSTONE, THE HOLISTIC DENTIST
(First appeared in Natural Nutmeg, January 2008, reprinted with permission by Dr. Thomas Livingstone)

Q: What are some concerns regarding mercury fillings?
A: First, mercury fillings are not stable and react to hot or cold temperatures. So, every time you drink something hot, the filling will expand and every time you drink something cold, the filling will contract. This can eventually crack the enamel of the tooth. In addition, when you drink a hot beverage, mercury can vaporize and this material is ingested. The body changes mercury from a non-toxic to a toxic substance in the cellular membrane to eliminate it from the body.

Q: How can one determine if they have mercury toxicity from their fillings?
A: Some people process mercury effectively and others don’t process it well at all. Hair, urine and blood analysis can be checked for toxicity. If mercury is passed through the urine and not stored in the hair, then we know that individual can process mercury. If we find mercury in a hair sample, then we know they are not eliminating it.

Q. Should individuals with mercury fillings have them removed?
A. That is up to the individual, but in my opinion mercury doesn’t belong in the human body. It may depend on how many mercury fillings they have, however. If a mercury filling needs to be replaced because of deterioration, it should be replaced with another material.

Q: What other materials are options for dentists to use besides mercury fillings?
A: There are numerous bonded materials that dentists can use to fill cavities. However, they are harder to work with, about 20-40% more expensive and typically insurance does not cover these types of materials. One type is crushed quartz and an epoxy binder which is the same color as your teeth and doesn’t expand or contract or release toxins into the body.

Q: What are the symptoms of mercury toxicity?
A. Some of the symptoms include a metallic taste in your mouth, bad taste after eating, lethargy, frequent headaches, and fever. However, be aware that there are probably 50 or 60 symptoms that a person may exhibit.

ON THE SUBJECT OF PERIODONTAL DISEASE

Q: Is it normal for your gums to bleed while flossing or brushing your teeth?
A: No, this is not normal and it typically signals gum disease. This can result in loss of bone support around your teeth and the formation of pus pockets. It may also be a cause of bad breath.

Q: What can I do to stop my gums from bleeding?
A: Some initial things to do would be to use a baking soda type toothpaste and/or rinse with a warm salt-water solution. The salt content will kill any bacteria by changing the pH of the mouth. Have your dentist check for healthy gum attachment to your jaw. There should be no more than 2-3 mm pockets; otherwise the bone may be dissolving from around the teeth. The next step would be a cleaning under the gum with a special solution that your dentist would perform. Your dentist will flush the pockets, remove any tartar and bacteria and the gums should tighten up.

Q: Is this a hereditary problem?
A: It can be genetic. However, sometimes it happens in smokers or other individuals who are prone to a fast buildup of tartar.

Q: What else can be done to prevent this from happening?
A: Some individuals can benefit from taking certain supplements as described below:
Vitamin C. 4-6 g/day (but cut back if develop diarrhea)
Coenzyme Q10: 30 mg dose, open the capsule and sprinkle half in mouth and rub
on gums. Take the rest internally.
Vitamin E: 400 IU/day
Garlic: 6-8 capsules/day
Flossing is essential and one can benefit from having more frequent cleanings performed by your dentist. If you have tartar buildup, you might benefit from getting your teeth cleaned every 3-4 months.

Dr. Thomas Livingstone
Canaan Gentle Dental Care
Canaan, CT 06018
(860) 824-0751

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Ingrown Nail

April 26, 2010 By

Perhaps the most common condition seen in a podiatrist’s office is the ingrown toenail. In my practice, I have noticed this to occur most commonly in younger men but certainly there is a wide distribution of patient’s suffering from this condition. It is not as common to see this in the elderly.

Recalling that Androcles pulled a thorn from the lion’s paw illustrates how something as small as a thorn has the ability to incapacitate even the strongest and toughest. And while not quite a podiatrist and not quite an ingrown nail, the story’s point is made.

At the base of a nail are the cells that form the eventual nail. The toenail has a width just as your toe, itself, has margins in which the nail should grow. In many cases, the cause of ingrown nails is directly related to the manner in which the nail is cut. As the nail is cut, many patients are overly aggressive and cut the nail on an angle that allows the distal margin of the toe to fold in slightly. When the nail grows out, it bumps into the nail fold which becomes inflamed and uncomfortable. Of course trauma and some irregularities of the cellular configuration are not uncommon causes that contribute to this condition.

At this point I would like to make the distinction between an ingrowing nail and an ingrown nail. An in ingrowing nail, connoting an action in progress, is a sub-acute but sore area of the toe where the nail is pressing on the skin fold. The toe hurts more when pressure is applied but otherwise, doesn’t feel too bad unless something hits it. There is redness and localized tenderness all associated with inflammation. In contrast, an ingrown nail is one in which the nail has broken the soft tissue of the skin fold and is often accompanied by drainage, warmth, increased pain, with or without pressure and a localized and sometimes systemic infection.

When presented with the mildly tender ingrowing nail, it is often easy enough to cut the nail back just proximal to the point of tenderness, being sure to round the edges of the remaining nail edge. Most often, there is near complete relief after the nail section has been removed. I often recommend warm saline soaks and the application of vasoline or Neosporin in the groove that remained.

Generally speaking, an ingrown nail is too tender to remove without the benefit of a local anesthetic. Once the toe is numb, a vertical section of the nail is removed whereby enough of the underlying wound is free of pressure and the full wound margins are visible. It is important that the wound has enough time to heal before the new nail grows back over it. Again, warm, saline soaks are recommended and a light dressing is applied as needed.

The place for antibiotics with these wounds should be on per patient basis. Many patients have been placed on drugs before I ever see them. They relate improvement while on the medication but recurrence after they have stopped. The key here is not the antibiotics but the removal of the offending nail. The nail, itself, acts as portal of entry for bacteria directly into the wound. Until the nail is removed, the wound is prone to reinfection.

When there is recurrence of an ingrown nail, a permanent procedure to selectively eliminate the margin of the offending nail can be performed in the office. It is performed under a local anesthetic and only requires about 15 minutes. The post-operative course is relatively short and the success rate approaches 100%.

As common as the ingrown nail is, avoidance of it seems relatively simple. You must use the appropriate instruments, avoid vertical cutting of the nail and round all nail edges.

Andrew E Schwartz, D.P.M.
51 Hospital Hill Road
Sharon, CT 06069
860 364 5944

88 Elm Street
Winsted, CT 06098
860 379 3100

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Gardening for your health

April 12, 2010 By

Gardening can be a fun and rewarding hobby. Sadly, it can be hard on the body. With spring, there is an incredible amount of yard work that can also be repetitive in nature. Pruning, lifting, and squatting/kneeling all are potentially stressful. Moreover, most of us like to work hard on the weekend to get everything done.

The most common injuries related to gardening are “tennis” elbow, shoulder tendonitis, low back pain and knee pain. Tennis elbow is usually caused by forceful and repetitive gripping. It is common with pruning or gripping/squeezing a heavy object like a weedwacker. Shoulder tendonitis usually is related to working overhead. Low back pain is typically related to heavy lifting, digging or repeated twisting while raking etc. Prolonged knelling or squatting usually creates stress on the knees or back.

I recommend using the proper safety equipment like gloves and hearing/eye protection. Use sunscreen and drink plenty of water. Keep all pruning tools sharp. Consider tools with ergonomic handles to reduce stress on your arms. It helps to wear loose and comfortable clothing to allow for unrestricted movement.

Gardening is like a sport and preparation is very important. I advise a warm up and stretching routine just prior to the actual work. It is critical to rest and pace yourself while you work. Frequently changing your activity over the course of the day can help prevent injuries. Ultimately, you avoid stressing the same body parts and allow for some recovery time. One should also consider spreading out the work over several days to avoid the “weekend warrior” syndrome. If you have 20 ft of shrubs to remove you could clean out 5 ft/day and finish the work over 4 days.

Listening to your body sounds simple, but it means stopping when you experience significant fatigue or pain. Consult a Physical Therapist if you have questions or an injury. Happy gardening.

Michael Mangini PT OCS CMP
Geer Physical Therapy
99 S Canaan Rd
Canaan CT 06018
860-824-3820
mmangini@geercares.org

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The “Risk” of Chiropractic Manipulation put into Perspective

April 5, 2010 By

As with all health care providers I have to have “informed consent” from my patients before I treat them. This means that their condition and the benefits and risks of treatment are explained to them. They are also advised as to what their treatment alternatives might be and the risks of their condition going untreated before they “consent” to care. As a chiropractic physician this means that I have to explain the benefits and risks of spinal manipulation. Actually, the risks associated with spinal manipulation are extremely rare.

Many studies over the years have touted the benefits of spinal manipulation. Those studies have shown manipulation to be not only highly effective for treating spinal conditions but also to be beneficial to returning people back to work quicker and at less cost. The crux of this article however is to discuss “risks”.

The most common injury associated with spinal manipulation, particularly in the cervical spine, is stroke. Even though there has been much concern placed on this of late the truth of the matter is that studies have not shown a direct causal relationship between chiropractic spinal manipulation and stroke. Unfortunately, a patient who may be getting ready to have a stroke, could be experiencing symptoms that would be similar to a cervical musculoskeletal complaint- which is a common problem that someone would present to a chiropractor for treatment. Chiropractors are trained to screen patients who may be at risk of stroke. They will take a careful history and will perform tests and procedures to determine if a particular patient is at risk. They would then make the judgement as to whether spinal manipulation would be appropriate for that patient and their condition. Per a recent Canadian study there was no more risk of stroke from a visit to a chiropractor’s office than there was to a family physician’s. The actual risk of stroke is so low that a patient would be more likely to suffer serious injuries in an auto accident driving to the office if they lived over one mile away.

A very common medical treatment for neck and spine pain is the use of NSAID’s or non-steroidal anti-inflammatory drugs. Advil (Ibuprophen), Alleve (Naproxen) and Indocine commonly prescribed NSAID’s. They are considered generally safe and are amongst the most prescribed drugs in this country but the risks associated with them are more than 100X greater at 400 in 1 million risk than those associated with chiropractic spinal manipulation. The most common and serious adverse effects from NSAID’s are gastrointestinal ulcerations, hemorrhage and perforations. A recent study in The New England Journal of Medicine estimated that greater than 103,000 patients per year were hospitalized in the US for serious gastrointestinal complications due to the use of NSAID’s with an estimated 16,500 deaths occurring annually. This would rank them as the 15th most common cause of death in this country. Further putting the risk into perspective lets look at other healthcare risks- overall mortality rate for spinal surgery 7 in 10,000 with a death rate from cervical spine surgery 4-10 in 10,000. Risk of death associated with non-healthcare activities are- soccer/ football 1 in 25,000, motorcycling 1 in 50 and skiing 1 in 430,000.

The low risk of injury from chiropractic spinal manipulation is also reflected in malpractice rates. Malpractice rates are determined by the number of claims made against a particular group of healthcare providers by patients. The average rate for chiropractors across the United States is $1500.00 with rates for general practitioners ranging from $10,000 to $20,000 per year.

Thus, taking into account all of the above information, chiropractic spinal manipulation is not only an effective treatment for spinal pain but is also one of the safest. Should you have any concerns in regards to the safety and efficacy of chiropractic please ask your chiropractor to take some time to discuss them with you.

Dr. David D. Godwin
Chiropractic Physician
2907 South Main St.
Salisbury, NC 28147
704-633-9335

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The Athletic Heart Syndrome

March 22, 2010 By

I recently reviewed an article that appeared in the Archives of Internal Medicine (volume 122, October 1968), written by me and two colleagues. I have chosen to divert from my usual pattern of guest columnists for this week to make the information available to my readers.

THE ATHLETIC HEART SYNDROME
Five-Year Cardiac Evaluation of a Champion Athlete

Peter H. Gott, M.D., Harry A. Roselle, MD, Richard S. Crampton, MD

Although there has been considerable elucidation of the athletic heart syndrome in Europe, this entity has not yet become universally recognized or accepted in the United States. The athletic heart may simulate the diseased heart by exhibiting a systolic murmur, a slow pulse rate, a variety of arrhythmias and disturbances of cardiac conduction, elevation of the S-T segments, and cardiac enlargement by x-ray. Despite the history of athletic endurance, many unfortunate athletes are classified as cardiac patients and are requested to stop athletic training. For the past five years, we have observed a superbly trained athlete with chronic cardiac changes. He has had a large globular heart, an intermittent systolic ejection murmur, sinus bradycardia and arrhythmia, a wandering atrial pacemaker, occasional nodal premature beats, elevation of the S-T segments, broad peaked T waves, and the ability to meet the severe physical demands of training and competitive rowing at world championship level.

Patient Summary

A 23-year-old, single scull oarsman entered the hospital in 1963 for investigation of an enlarged heart discovered on a routine miniature chest x-ray film. He was engaged in an intensive training program preparing for the US Olympic rowing trials. His annual spring and summer training schedule demanded rowing seven days a week. He rowed 8 miles daily in one of two exercise programs. The first program was steady rowing for eight miles; the second rowing program consisted of warm-up for 2 ½ miles, then six sprints of 500 meters each interspersed with 500 meters of slower rowing. There was no history of cardiac disease, dyspnea, orthopnea, edema, rheumatic fever, chorea, syphilis, inadequate diet, anemia, hypertension, or familial cardiomegaly. He had occasionally noticed “weakness,” “faintness,” and vague “chest pressure” after particularly strenuous exercise. He was a tall, well-muscled man with blood pressure 140/80 mg Hg and weight 86.3 kg (190 lb). The heart rate varied between 40 and 50 beats per minute. The area of cardiac dullness did not extend beyond the left mid-clavicular line and right sternal edge. Physiological splitting of the second heart sound and a systolic ejection murmur which varied with postural changes were audible. No diastolic murmur or gallop were present. The rest of the examination and the blood count, sedimentation rate, protein-bound iodine, and Mazzini test were normal. A chest x-ray film showed a globular cardiac shadow with considerable fullness of the left ventricle. The cardiac thoracic ratio (17.4:35.5 cm) was normal, but the radiology department believed the heart enlarged because of an increased area of heart shadow in a man with a very wide thorax. The cardiac esophogram showed left and right ventricular prominence without atrial enlargement. An electrocardiogram showed sinus arrhythmia and bradycardia at 40 to 50 beats per minute. The P-R interval was 0.12 and the QRS complex was 0.06 second. The Q-T interval was 0.41 second (normal range 0.38 to 0.50 second). There was elevation of S-T segments in leads I, AVL, and V-2 through V-6. There was S-T depression in leads III and AVR. Broad, peaked T waves were noted in leads I, II, AVR, AVF, and V-2 through V-6. Increased QRS voltage was present. The intrinsicoid deflection in V-6 was 0.03 second. A phonocardiogram confirmed the auscultatory findings. Cardiac catheterization was performed, but atrial fibrillation began as the catheter entered the right ventricle. The arrhythmia was associated with a rise of systemic arterial pressure and an increase of ventricular rate from 40 to 50 beats per minute to 80 to 90 beats per minute which persisted for the rest of the study. Cardiac output, left ventricular stroke work, and systolic ejection rates were normal. However, the presence of transient atrial fibrillation made precise physiological measurements impracticable. During this arrhythmia, the patient reported sensations similar to those described after stopping very strenuous exercise. The heart returned spontaneously to sinus rhythm a few hours after the procedure. No intra-cardiac shunt was detected.

He left the hospital and resumed intensive rowing. A few months later, at the 1964 Olympic games in Tokyo, he won the semifinal heat with a magnificent sprint finish against the Russian world’s champion oarsman. His winter training program in 1964 to 1965 and 1965 to 1966 included five days of rowing 20 minutes in a dead water tank, followed by a steady ten-minute run, 20 chin-ups, and 50 sit-ups. He also performed a specially designed, vigorous exercise program consisting of a variety of calisthenics and weight-lifting to be completed in 18 minutes. On the days he did not row, he ran 5 miles. His spring and summer training program consisted of rowing 8 miles daily as described earlier. In 1965 an ECG showed sinus arrhythmia and bradycardia (48 per minute), one high nodal premature systole, and the same S-T segment and T wave configuration noted in 1963. A vector cardiogram was normal. In 1965 he won the Diamond Sculls at Henley-on-Thames, England. In 1966 he won the single sculls World’s Championship at Bled, Yugoslavia. For the winter seasons of 1966 to 1967 and 1967 to 1968, his training program consisted of exercise six days a week. For days a week he ran 3 to 5 miles or played one hour of squash, performed 20 chin-ups and 50 sit-ups, and ran one mile, alternating sprints with steady running. On two days, he swam a half mile or rowed 20 minutes in a dead water rowing tank, followed by ten minutes of steady running, 20 chin-ups, and 50 sit-ups. Examinations in March 1967 and March 1968 showed no murmur but were otherwise unchanged from that of 1963. The chest x-ray film showed the large globular heart unchanged from previous examinations. The EKG showed a wandering atrial pacemaker, sinus arrhythmia and bradycardia (39 to 52 beats per minute), and the same increased QRS voltage and S-T segment and T wave configurations across the precordium noted earlier.

Comment

This oarsman’s athletic capacity and achievement during a five-year period provided strong evidence for normal cardiac function. No stigmata of the syndrome of the “hyperkinetic” heart such as ventricular or arterial thrusting, increased systolic ejection rate, electrocardiographic evidence of ventricular hypertrophy, or congestive failure with passage of time were present during a five-year follow-up. In our opinion, his athletic endurance in the presence of a variable systolic ejection murmur, slow heart rate, electrocardiographic changes, and cardiomegaly is compatible with the athletic heart syndrome.

There is evidence that strenuous physical training does produce remarkable alterations in the anatomy of the heart. At autopsy, the hearts of athletes have shown a general increase in size, increased volume of individual chambers, and microscopic hypertrophy of ventricular muscle. An athletic heart has shown marked increase in the diameter of the coronary arteries. Athletic training also modifies the physiological behavior of the heart. The commonest characteristic of the athletic heart is bradycardia. In one study, racing cyclists in the resting, recumbent state had a greater average stroke volume, cardiac output, left ventricular stroke work, and heart size than did sedentary individuals at comparable heart rates. During and immediately after exercise, athletes also have a greater stroke volume. Estimation of heart size by electrokymography and x-ray studies had shown a larger systolic and diastolic heart size in athletes both before and after exercise. Other features distinguishing the athletic heart from the hearts of sedentary individuals include a greater increase of right ventricular filling pressure and pulmonary arterial pressure during exercise, a greater increase of cardiac output during exercise, and less fall of right ventricular filling pressure upon change from the supine to the sitting position.

Disturbances in conduction and rhythm as well as other electrocardiographic changes are frequently seen in trained athletes. These include slow atrial, atroventricular, and ventricular conduction; right axis deviation, increased magnitude of QRS and T vector loops with a shift of the horizontal angle to the right; splintering, notching and widening of the S wave in lead VI; elevation of the S-T segment, increased T wave voltage, bifid T waves, and T wave inversion in the precordial leads, paroxysmal atrial flutter and fibrillation at rest and after exercise; and post-exercise ventricular and nodal premature systoles and nodal rhythm. Of 21 marathon runners in the 1962 Commonwealth Games, 5 had incomplete right bundle branch block (RBBB) and 16 had increased QRS voltage suggesting left ventricular hypertrophy. In another analysis, incomplete RBBB was found in 19.1% of 413 athletes; in those with the largest hearts, 46% had incomplete RBBB. Seven percent of 92 former athletes showed incomplete RBBB; of 20 athletes with RBBB, 10 developed normal conduction after stopping regular sports activity.

It may be difficult to distinguish clinically between a diseased heart and an athletic heart since both may show bradycardia, a systolic murmur, a loud and often palpable third sound, a large globular silhouette, and a variety of electrocardiographic alterations. Usually the history of athletic endurance, cardiac examination before and after exercise, chest x-ray film, and ECG provide adequate information to evaluate the athlete. Difficulties arise from clinical interpretation of the systolic ejection murmur, the enlarged heart, and the electrocardiographic variations. Systolic ejection murmurs occur in up to 40% of young athletes and do not signify cardiac disease in spite of the astonishing suggestion that such persons be put on the “doubtful” list for competitive sports. The suggestion that a diastolic murmur must disqualify an athlete from competition seems superficially reasonable. However, apical diastolic murmurs from increased flow across the mitral valve have been found in normal individuals. The chest x-ray film may demonstrate ventricular enlargement in both diseased and athletic hearts. However, interpretations of chest x-ray films as well as cardiac murmurs and ECGs are usually considered in terms of the sedentary individual and may be misleading in evaluating the well-trained athlete. In the sportsman, the greater chance of recording the cardiac silhouette during diastole in the slowly beating, large athletic heart with an increased end diastolic volume enhances the larger globular configuration on x-ray. Electrokymography and routine chest radiograms synchronized with the cardiac cycle have been used to estimate systolic and diastolic heart size before and after exercise. The diseased heart enlarges during exercise; athletic and normal hearts show a decrease in size and an increase in output during physical activity. Following periods of intensive athletic training when the individual is no longer active, the heart returns to its former size. Electrocardiographic changes may also disappear when the athlete stops training. The criteria for diagnosis of the athletic heart syndrome include a history of athletic endurance; biventricular cardiac enlargement; systolic ejection murmur; third heart sound; increased stroke volume, left ventricular stroke work, and cardiac output; bradycardia and sinus arrhythmia; recurrent atrial and ventricular arrhythmias; cardiac conduction defects; S-T segment elevation; and T wave alterations.

Cineradiography of the heart, as yet unreported in normal individuals or athletes, might be used to show the systolic and diastolic size and contour of the slowly beating heart before, during, and after and after exercise. The resulting standardization of heart size should be useful in evaluating athletic as well as sedentary hearts. In addition, a technique of indirect estimation of left ventricular contractility has been suggested and might be tried in order to assess myocardial function without resorting to cardiac catheterization.

In Summary

During a five-year observation of a superbly trained champion athlete, the constellation of a large globular heart, an intermittent ejection murmur, a variety of arrhythmias, and S-T and T wave alterations suggested the presence of an athletic heart syndrome resulting from anatomical and physiological adjustments to strenuous training.

In distinguishing the athletic heart from the diseased or normal sedentary heart, the use of criteria derived from sedentary individuals is misleading.

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Dry Skin, Baseball Gloves and Ducks

March 8, 2010 By

Many people come into my office beginning in early fall with a chief complaint of dry and cracked skin.  They bring lengthy lists of products — moisturizers, creams and other remedies — that they’ve tried for keeping their skin moist and more importantly, their hands and feet from cracking.  Being unsuccessful, they ask for still other recommendations or products they haven’t used or heard of that might work better. My response always begins with a brief anatomical description of the skin as it relates to moisture and its retention.

A brief account of our outer skin might be summarized by envisioning an ordinary sponge with many nooks and crannies that serve to increase surface area in order to retain more water.  When a sponge is rung out and left to dry it becomes brittle and more susceptible to breakage.
 
I think back to when I was a kid and how I loved to play baseball. I would ride my bike home with my glove on the handlebar and drop both bike and glove in my yard and run inside for dinner.  After many a night left outside, my glove became cracked and dried from nights in the rain followed by sunny summer days. Aside from taking better care, what we were told to do with our gloves was to oil them.
 
So I describe this to my patients and then indicate what most Americans do incorrectly at home each and every. First, particularly in the winter, is to turn up the heat, take hot showers every day, and use lots of the soap.  We get out of the shower and briskly dry ourselves off. We then proceed to moisturize our skin.  So, in review, we dry the heck out of our skin and then proceed to moisturize it. 

So, patients walk into my office with dry soles and cracked heels. The following is what I recommend and why: bathe in tepid water, use very little soap or one with moisturizers, and only pat dry the affected areas.  It is important to thoroughly saturate the dry body part. It is not necessary to bathe every day. A sponge bath or modification thereof can be accomplished by soaking the feet in a basin of water.  If, upon examination, there is cracking or fissuring, apply an oil-base product like Bag Balm, Vaseline or Crisco. In the evening, wrap the foot in a plastic bag or plastic wrap and cover the wrap with a sock, basically forming an occlusive dressing. Remove the wrap and sock in the morning, repeating the process each evening until there is significant improvement in the texture of the area for two days in a row. Then use this method once a week or as needed.

I like to ask people if they use hot or cold water when they wash their dishes. I indicate that if they use cold water, it will be there in the morning still upon the dish.  If they use hot water, the water will evaporate faster and the dishes will be quite dry. This is exactly what happens when we bathe in hot water.
 
It’s important to understand that moisture in the human body most often comes from within, not from without.  A person needs to stay adequately hydrated to protect the outer tissues from dehydrating, which in many cases is self-induced.  Applying moisturizers to skin after a shower or bath will do very little, since moisturizers are water-based and are absorbed rapidly. Vaseline and the like are oil-based, thereby creating a protective barrier between the water content of the tissue and that of your surroundings. 

If you’re still not interested in going to the doctor but have not been successful in healing your own dry and cracked skin, perhaps you need only consider the duck in water.  Or a swimmer crossing the English Channel. That is, they both are well hydrated with an evenly distributed coating of oil that separates them from the outside world.

Dr. Andrew E. Schwartz, D.P.M.
Practice of Medical and Surgical Podiatry

51 Hospital Hill Road
Sharon, CT 06069
860 364 5944

88 Elm Street
Winsted, CT 06098
860 379 3100

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Treating Fibromyalgia Syndrome with Acupuncture

March 1, 2010 By

Fibromyalgia Syndrome affects an estimated 2 percent of the population. Current treatment is largely comprised of prescribing different medications to treat the varying symptoms. Many people with fibromyalgia have turned to complementary and alternative medicine to manage their symptoms. Acupuncture, in particular, has become a popular treatment choice and has shown to be an effective treatment for Fibromyalgia.

Fibromyalgia is a medically unexplained syndrome characterized by chronic widespread pain, a heightened and painful response to pressure, insomnia, fatigue, and depression. While not all affected persons experience all associated symptoms, the following symptoms commonly occur together:

chronic pain
debilitating fatigue
difficulty sleeping
anxiety and depression
joint stiffness
chronic headaches and jaw pain
difficulty swallowing
dryness in mouth, nose, and eyes
hypersensitivity to odors, bright lights, and loud noises
inability to concentrate
irritable bowel syndrome
numbness or tingling in the fingers and feet
painful menstrual cramps
poor circulation in hands and feet.
restless legs syndrome

Fibromyalgia is diagnosed when there is a history of widespread pain in all four quadrants of the body for a minimum duration of three months and pain when pressure is applied to at least 11 of 18 designated tender points on the body. This condition does not result in any physical damage to the body or its tissues and there are no laboratory tests which can confirm this diagnosis.

Symptoms often begin after a physical or emotional trauma, but in many cases there appears to be no triggering event. Women are more prone to develop the disorder than are men, and the risk of fibromyalgia increases with age.

The Chinese medical theory of pain is expressed in this famous Chinese saying: “free flow of QI= no pain, no free flow of QI= pain.”

Pain is seen as a disruption of the free flow of Qi within the body. The disruption of Qi that results in fibromyalgia is usually associated with disharmonies of the “Liver” median.

You can reduce your symptoms significantly by incorporating a few simple life-style changes into your daily routines and habits.

1. Eliminate processed foods from your diet, especially white sugar and white flour products. These products give our bodies little nutrition and over time can damage our digestion.
2. Include all unprocessed foods in your diet, such as proteins, complex and unrefined carbohydrates, vegetables, whole grains and legumes .
3. Avoid overly greasy foods, ice cold drinks, alcohol, raw and uncooked foods, hot, peppery foods, coffee, and too much fruit. Avoid daily juice drinks since these are the same as eating a candy bar in the amount of sugar introduced into the body.
4. Do not drink sodas. Sodas are acidic in nature and are loaded with sugar and chemicals. Sodas are detrimental to both the spleen and the kidneys.
5. Find some type of exercise that you really enjoy and just do it. You would probably benefit most from some kind of cardiovascular exercise to keep to blood moving, such as swimming, yoga, stretching, and bicycling.
6. Take a walk every day. If you live with a dog or cat, play with them daily. Animals live in the moment and love to play. This is a great way to break stressful daily routines.
7. Buy some relaxation tapes with guided imaging. Learn how to really relax. This means bodily relaxation as well as mental repose. Use these tapes daily for the best results.
8. If you know that you have too much stress in your life, then find a solution. This may be finding a new job or new, more supportive relationships. Understand that stress alone can kill you, and if you smoke and consume alcohol to escape stressful situations, you are only fooling yourself.
9. Find a Chinese medical practitioner who can help you maintain good health with Chinese medicinal herbs and acupuncture. If you visit with a practitioner on a regular basis, before you become ill, then you avoid many other more serious problems later. Remember that the strong suit of Traditional Chinese Medicine is prevention.

Alan Rivenson, L.Ac, Dipl in Acupuncture
Affordable Acupuncture
25 Main Street
Canaan CT 06018
860-824-7727
arivenson@att.net

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