Posts Tagged ‘surgery’

International Fascia Research Congress 3 – Vancouver, BC, Day 1

| March 28th, 2012 | No Comments »

***Beware – this post is a total fascia geekfest, if you are not prepared to deal with that, read a different post!  Also, any factual errors are my faulty memory, not faulty presentations.***

 

Today I had the absolute pleasure of beginning my time at the 3rd gathering on scientists and clinicians who have an abiding interest in fascia in all its varied and wonderous forms.  I began the day with a flight to Vancouver and a slightly late arrival – but I got before the real geek-out stuff began, so it is all good.  

After some general introductory speeches we dove right into the first keynote speaker.  A anatomist from Temple University, Mary Barbe spoke to us about her research in duplicating repetitive stress injuries (RSI’s) in rats and the tissue changes that occurred in response to various types (high, low and negligable intensities) of work.  How could this possibly relate to massage therapy you ask? Well the road hasn’t fully been built, but knowing that rest doesn’t always fix the problem and that inflammatory processes have likely come and gone prior to anyone presenting at my office (they peak between week 4 and 8 of performing the task) after months or years of a repetitive task, provides me with insight into what interventions and homecare might best benefit my clients.  simply knowing that there are significant connective tissue changes that occur within weeks of undertaking an repetitive task shouts loud and clear about the importance of the fascial work that I am a huge advocate for.

After a quick break we moved our second speaker, Michael Kjaer, whose topic was the impact of exercise on tendon tissues.  We discovered that exercise (and not a lot, 1x creates 72 hours of increased collagen production which is what builds your tendons) increases the density of tendons.  Interestingly, there seems to be little issue with maladaptive changes in the tissue to repetitive exercise as there is to repetitive work activity (there’s a thinker).  More surprisingly, it turns out men exhibit greater tendon density increase than women, and that within the female population women taking oral contraceptive exhibit even lower levels of tendon response than the general population.  Further interest in gender issues came when it was revealed that in post-menopausal women being on hormone replacement heightened tendon response.  Hmmm, that estrogen, funny stuff.  

 

After a break for lunch we broke into three groups for presentations on specific areas of fascial research.  I chose the “biomechanics” room and got to learn about different means of trying to empirically measure different types of mechanical interventions.  From pressure sensitive pads on fingers to rather medieval looking table devices this part of the afternoon was an interesting insight into the various ways we can try to research the interventions we apply with our hands and their outcomes.  I also gained an interesting insight into the world of research.  Failure, or rather, not proving your hypothesis fully or at all.  Even in those cases it was interesting to see how that research could be used to launch into better studies.

Our next keynote speaker, Albert Banes, was a doozy.  I am pretty sure I learned so interesting things, but they went by so fast I think I might be lucky to catch up with them sometime next week – after reading the paper a few times!  He seemed to be summarizing quite an extensive array of studies in the field of fascia research and had some very interesting things to say – and showed us pictures of some lab grow tendons, but it was a lot in just a little time

The final event of the afternoon, academically, was a panel of  four clinicians presenting of “scars and adhesions”.  One of the exciting bits of us BC RMT’s was having one of our own on the panel – Susan Chapelle of Squamish, BC who talked about the benefits of integretive treatment and the need for increased research that included a manual therapy aspect.  She was preceeded by a surgeon, Dr. Michael Diamond, who discussed post-surgical adhesions (things sticking together that shouldn’t after surgery) which I was surprised to find has a 65-100% incidence rate in abdominal surgeries (though they are not limited to those surgeries).  We were then treated to a new movie by Jean Claude Guimberteau, a French physician, who has now produced several in vivo movies of fascia using endoscopic techniques (his first being “Strolling Under the Skin”, presented at the first fascial congress).  We also had a naturopathic doctor, Hal Brown, present some of his case studies of the impact of the injection of aenasthetic under the skin into scars to improve function in both near and far tissues. 

The day finished with a welcome reception that was very well attended that allowed us all to review and discuss our reactions and thoughts regarding the days flood of knowledge.  I can hardly wait for day two….

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m-Medicine – the future of your doctor’s smartphone?

| January 23rd, 2012 | No Comments »

This weekend I was reading an article in the Globe and Mail regarding the impact of technology on health care, specifically mobile technology.  The article referenced several areas in which mobile technologies can improve health care with remote monitoring, to i-tunes credit for diabetic teens who comply with their insulin regimes.  The focus, and one of the most exciting parts, for me was an improvement in post-surgical care monitoring.  

Dr. Semple, the surgeon-in-chief of Women’s College Hospital in Toronto, is running a pilot project to monitor the ambulatory surgery (in hospital less than 23 hours) patients under his care.  Dr. Semple and his research team have developed an app that allows patients with a smart phone or tablet to be in regular touch with him post-operatively.  This app allows patients to photograph their surgical incisions and send them to Dr. Semple along with text regarding how they are feeling.  From this information Dr. Semple can very accurately assess the progress of their recovery and make decisions regarding any need they may have to return to the hospital for follow-up care prior to their scheduled appointment.  

This seems simple, wouldn’t a phone call do the same?  I see this new evolution addressing several weaknesses in the call-in follow-up.  One, for time pressed surgeons – and patients – there is no need to mesh schedules.  Patients send in their information when they can and the doctor can pick up the information whenever he chooses.  Yes, this sounds a bit like answering machine tag, but there are other factors.  When the doctor picks up that message he is not just listening to a voice trying to squeeze their information into a brief window before the beep – he is reading a summary that the patient has been able to compile at their leisure.  He is also able to pick up that piece of information anywhere.  The other highly valuable piece of information he is getting is the visual.  They say a picture is worth a thousand words, and with this technology it may very well be so,  it may even be worth a life.  The article talks about a scenario where Dr. Semple is able to save himself, his patient and the system, time and money by preventing an unneeded hospital visit from the other side of the globe, but lets look at the other possibility.  What if his patient’s bruising wasn’t benign?

Using the app the doctor could have gotten that patient into the hospital as soon as he saw cause for concern.  Post-surgical care costs can escalate through to means – unneeded return, and delay of needed return.  The later being more costly in the end for all concerned as it would be associated with re-hospitalization, care for the complication that would be more extensive than a promptly dealt with one, and, perhaps, long term health issues or death if an infection was not dealt with for a prolonged period.  Close monitoring has always had benefits in terms of preventing complication but earlier discharge offers huge savings, higher numbers of patients processed and, frankly, more comfort for the patient.  Anyone who has spent time in hospital knows it is not very restful or healing.  The food is awful, it is noisy and people are disturbing you at all hours to check your temperature.  Who wouldn’t prefer the privacy of their own room, in their own home with undisturbed nights?  When those things can be accompanied by closer monitoring we have a winning solution both for the patient, for their health and for the system.

This week there is a conference in Toronto that offers doctor’s the opportunity to explore the options of mobile health technologies and hear from leaders in the field.  I hope my doctor is on her way there! 

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Gastric Bypass

| October 17th, 2011 | No Comments »

I have, over the last few months, gained some weight. I am very aware of the irony of being a health professional and being unhealthy on such a fundamental level. My dissatisfaction has led me to spend time thinking and exploring eating, exercise and weight loss options. All this looking around led me to the various surgical options – which I have always considered risky and extreme – to my surprise there is a high success rate and low risk factor. I believe firmly that eating habits and exercise are the best way to lose weight – have I been wrong?

In the end I think not. When it comes to weight if you burn more calories than you consume you will lose it. If food in and calories burned are the same, your weight will be steady. This equation is not in question. The questions circle how best to do this, how best to successfully lose weight. How do weight loss surgeries have such success? Simply put, the success of weight loss surgery comes from reducing stomach size to force you to eat less. Yes, eat less, reduce the size and frequency of meals, you know, a diet. Basically you are having someone put you a surgically induced diet. Ultimately this means that reducing your eating works.

A recent study actually shows that the family members living with gastric bypass patients lose weight in concert with the patient, believed to be due to the diet and exercise programs they have participated in with the patient. In fact the more I read the more it became clear that the surgery is just the first step in the process of weight reduction. The surgery is a step that is followed by nutritional and personal counselling, personal training and life changes. It turns out I am right – diet and exercise are keys. Whether you get a surgical boost or not, it is how you eat, and how much you move, that determine your weight.

The medical community is coming out more and more in favour of surgical intervention for weight-loss and we are seeing coverage by provincial and extended health carriers. One of the reasons for people to consider surgery is persistent lack of success with diet and exercise. My question is – if we were to divert the $15,000 (the low-end of the cost for gastric bypass – high is $50,000) to offering nutritional counselling and paying for personal trainers (which have no to very low coverage) would the success rate be better for the non-surgical intervention? You can buy a couple of years of 3 day a week personal training sessions for $15,000.

I think this preference for surgery is a part and parcel of our health care system’s preference for fixing with intervention rather than offering outpatient support.  For my situation I would love to access enough money to support my having a personal trainer for a few months to get me back to a reasonable weight and to support some life changes now, when I have no weight-related health problems. Instead I have to do it on my own, or wait until I am worse off in terms of weight and attendant health problems before I can get help – and even then the support will only be for a doctor altering my body – not for me trying to alter my body.

 

More about weight-reducing surgery:

  • In BC the only type of weight-reduction (bariatric) surgery covered by MSP is what is commonly called gastric bypass – which results in the largest weigh losses
  • The most common weight-reducing surgery is gastric banding – which has the quickest recovery but there are more complications and a lower level of weight loss
  • the newest weight-reduction surgery being offered is the insertion of a balloon into the stomach which is then inflated in the stomach. This is fast, reversible and seems to be working. It is the only option that requires no incision and no general anaesthetic.
  • In a study of 243 gastric bypass patients those in the obese and morbidly obese categories had excellent levels of loss and maintenance The “super obese” class (BMI > 50 at time of surgery) had the least success both in terms of amount of weight loss and the maintenance over time.
  • Gastric bypass surgery can cost anywhere from $15,000 to $50,000 NOT including personal training, the bulk of counselling suggested, the wardrobe changes or the cost of any plastic surgery to deal with the changes in body shape that result.

    gastric bypass

    Gastric balloon

     

    the lapband apparatus


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Willem Fourie, again…

| May 5th, 2011 | No Comments »

Last week I spent two wonderful days in Vancouver. With hardly any shopping to enhance the experience. I attended an advanced seminar on post-mastectomy care with Willem Fourie, a leader in the world of fascia. Willem is a physiotherapist from South Africa and has made a study of the specific impacts of breast cancer treatment, due to lump- and mast-ectomies, radiation and reconstructions.

I wrote, glowingly, about my introductory course last June. When the opportunity to attend a more advanced course arose I was quick to sign up. Out of the 75 of us who attended last year’s introductory course 11 of us returned this year to broaden our understanding of approaches to care for breast cancer patients.

One of the things that quickly became clear was that we had all, myself included, found uses for the approaches taught by Willem in the 11 month since the first course. We opened the course with each attendee describing how they had employed the techniques and what they sought to learn. Some had very emotional stories to tell of breast cancer patients who they had been able to help and who had inspired them with their strength and courage. Others, myself included, had taken the approaches and been able to apply them with great results to a number of other conditions, from abdominal surgeries to burn victims. The scope of application and success from these fascial techniques was impressive.

The intensity and integrity expressed in the opening of the course set the tone for the whole two days. Often at this type of course there is a very chatty, social atmosphere as the attendees enjoy a break from their regular routines. Schedules are often quick paced and hands on time limited. None of these was the case for this course. There was chatting for certain, but never disruptive to the course. The tone was quiet and the schedule was full of hands on time and quiet diligence. Where hands on time in other courses might become a bit raucous and unfocused in this instance it was very much about applying the techniques and learning to treat what you found in the connective tissue. Though we had no actual breast cancer survivors, we did apply the techniques to the variety of injuries and old surgeries we collectively brought to the occasion. We addressed armpits, abdomens and breasts without giggles or discomfort.

I came away with a deeper understanding of the anatomy, physiology, surgery and the humanity that are all part of treating any patient, most especially those who have faced such monumental challenges as breast cancer. I am continuing diligence of the course having already found several patients who could benefit from these techniques. I hope that they have found some benefit from those two days I spent in thoughtful pursuit of new information and new ideas.

Willem Fourie’s website

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Healing Series #5 – fractures

| February 22nd, 2011 | No Comments »

Have you ever broken a bone? Felt something go crunch and known that there were things moving against each other inside you that shouldn’t be?   Did you have the trip to the emergency room, the inspection by the doctor and radiology?

not so bad as this picture though...

Say a person breaks their tibia and fibula, that both bones have completely, but cleanly snapped.   They are sent into surgery and have some combination of plates, screws and rods inserted in your leg. You are given a walking cast, told to take it easy, and given follow up appointments. So begins the bone healing.

This is a simplified story of a significant, though straight froward, fracture. You are far better to snap your bone cleanly and completely than to have a crush injury or a significant displacement – both of which have larger risks of complications than a clean break. Though surgery was required to stabilize the fracture site the bones stayed close to alignment and there were no small fragments or jagged ends to contend with. This means that the healing will be relatively easy, with the internal stabilization they will be mobile (avoiding a lot of muscle loss) and should not have issues with alignment or leg length discrepancy.

Internally the healing process has both similarities and differences to soft tissue healing. Bone is well vascularized compared to ligaments and does heal more quickly, but the structure is quite complex and there are several stages between basic reconnection and complete restoration. With bone tissue, like skin tissue we will see regeneration more than scarring. With good healing there can be healing that is almost impossible to detect.

In the first 6-8 hours the blood that is being released by the torn capillaries in the bone forms a clot called a fracture hematoma. This clot means that the to ends of the bone are divided by dead tissue. Any cells within that clot will die and need to be carried away before repair can be carried out. Within a week the torn capillaries work their way into and through the fracture hematoma, reconnecting the to separated pieces and bone and begin delivering osteoclasts (bone destroyers), to dissolve the dead bone fragments. Phagocytes also arrive to carry away the other dead tissues. In this stage the fracture hematoma is transformed into a procallus, a proto-scar tissue made up of granulation tissue,

Over the next two weeks fibroblasts and mesenchymal stem cells invade the procallus. The fibroblasts build a latticework of fibrocartilage across the fracture site and the mesenchymal stem cells become osteoblasts (bone builders). This structure is called a soft (fibrocartilaginous) callus.

From 3 to 6 weeks the spongy bone begins to develop. This process begins close to the healthy bone tissue and works its way across the gap. As the spongy bone is deposited it begins to transform the fibrocartilage into bone too. This stage is the development of the hard (bony) callus stage. Many of you will notice that it is at this point that casts and other fixation devices (internal or external) are removed.

After 6 weeks (really between 4-8 depending on the age and health of the patient, the bone involved and the type of fracture) there is new bone uniting the fracture site, but the healing is not done.

Over the next 3-4 months the body will be industriously remodelling this new bone. Destroying and rebuilding cells, increasing the deposition of the calcium and phosphorous to make the bone harder. In long bones the creation of Haversian canals will occurs as will the redevelopment of a central marrow canal.

This stage is when the bone becomes customized to your usage patterns and habits so that it is strong where and when you need it to be. This type of process is occurring in healthy bones all the time and until it is complete a fracture site is not completely healed.

How can this knowledge of healing help someone recovering from a fracture? By increasing their dietary intake of calcium, magnesium, phosphorus, the primary minerals needed to build bones, they can help encourage speedy and thorough rebuilding. By understanding the importance of circulation in moving cellular, nutritional and waste products to and from the area of injury they can choose massage therapy, acupuncture or physiotherapy to encourage fluid movement without increasing physical activity past safe levels.

 


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Surgery and the Body

| June 8th, 2010 | No Comments »

After surgery your body is very busy indeed. It must finish dealing with the lingering effects of whatever took you into surgery and also heal you of the damage surgery has done.

Strange to think of surgery as damaging, but it is. After all, the surgeon cuts through multiple layers of connective tissue and muscle. Disrupting blood and lymph flow by severing the vessels large and small. And they only repair the large ones!

This is NOT to advocate against surgery, just to point out that it is both a healing and a harming event. The healing benefits should greatly outweigh the harming side effects, but those side effects can still be profound.

As I mentioned, your body is still responding the the cause of the surgery itself. Whether your body was fighting a chronic illness, physical dysfunction or was thrust into red alert status to deal with an accident or injury of some kind, a surgery is generally a brief interruption in this and the body requires time realize the provoking event has stopped.

As it is becoming aware of the decreasing demands of the illness or injury, it is also becoming aware of the new insult it has suffered.

Now, this injury is generally much tidier and cleaner than any real world damage would be, but the body mobilizes the same kind of responses to heal it. Inflammation and a flood of white blood cells and resources flood into the area. Your body may also be discovering that it is stiff and sore from the, often odd, position it has been in during surgery and the minor muscle atrophy and aches of being immobilized.

So what can you do to help this process?

One, eat well and take in lots of fluid. You need to provide the resource components for healing – healthy food it the best way to do that. Keep the meals light, varied and frequent. You have lost blood and inflammation takes fluid out of the circulatory system and puts it into the swollen tissue, so lots of fluid helps the body move everything around and rebuild its blood volume.

Two, rest. Your body is working really hard inside to heal you, try not to ask it to do much else. Light activity is good. Fixing those light meals, going for a short walk. These help your body to move things around and prevent aches and pains. But take a nap, your body does lots of good healing work while you sleep.

Three, follow orders, the doctors and nurses may have sent you home with some self-care – DO IT!!! Take the medication, keep the incision clean, do any exercises (part of you light activity!). This is what the allopathic system does well, surgery and fixing problems. So let them exercise their expertise.

Four, get some massage! Soon after surgery a massage can benefit you by helping move all those resources around and making sure they don’t stagnate at the surgery site. If you are stiff and achy massage therapy can help deal with the soft tissue tension and restriction that is causing that. Should you have a lot of swelling at the surgical site find a RMT who has advanced lymph drainage training (not me!) as they can often make a huge difference. After about six weeks, when the scar has settled, a therapist with connective tissue expertise (me!) can help to ensure that your scar heals functionally.

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Observing Surgery

| June 2nd, 2010 | No Comments »

PLEASE NOTE: Originally published on December 5, 2009 in “Your Body.  Yourself?” my old blog

Earlier this week I had the unique opportunity of observing some veterinary surgery. I am sure many of you are trying to figure out what use this would serve for a Massage Therapist. After all, what does a dog being spayed have to do with massage therapy? Well, quite a bit.

Though I am hoping to observe some more orthopaedic surgeries (i.e knee repairs) being able to observe any surgery was an interesting exercise. When it comes down to it the structure of mammals (the hairy, live young bearing, nursing creatures of the planet) is very much similar. The skeleton is made up of almost exactly the same bones that interact in very much similar ways through the action of very similar muscles. Four-legged mammals to have some differences in how the limbs interact with the torso and the proportions of the bones and muscles are different, but there is more the same than different.

In a general sense seeing the basic process of how you cut into a living being was educational. An opportunity to see all the layers of fascia and tissue that I have learned were there and what they actually look like. Seeing tissue not in a drawing or a film of preserved tissue, but “in vivo” – “in life” – is quite different.

My first surprise though came in seeing how limp the animals were when they are brought, already anaesthetized to the table. For everyone who has seen a truly ASLEEP baby when all the limbs splay out and you are are sure that even swinging by the ankles would not disturb them are less limp than this. Everything is simply floppy. The next surprise was how quickly admission into the body is gained, and how little blood there actually is. The third, and perhaps largest surprise, came once the outer tissue had been cut through and I realized how truly separate the outer layers of skin, fascia and muscle were from all the organs lying underneath. Everything could simply be lifted up so the vet could see around the abdomen, and there was no blood in there. Well, there was blood, but it was all tidily where it belonged, in the blood vessels and the tissue.

All I saw that day were spays, the removal of the ovaries and uterus of young female dogs. The surgeries were quick and even with the poking, pulling, tying, cutting, and a bit of tearing too, there was very little blood and the incisions were virtually invisible. Within about a half hour the dogs were rousing and most did not seem particularly troubled. Though a bit drowsy, only one whimpered a bit, but then she managed to get close to one of the other dogs and she was calm again. None seemed to be in great pain or distress. Having experienced a few surgeries of my own I must say I was not so sanguine after. Apparently our pets are more stoic than ourselves.

From this experience I am taking away an new wonder with the body and the its structure. The amazing way in which all its parts work together with so little muss and fuss. The wonderous way that modern medicine can insert itself (literally) into that system and come away having solved some issue, or prevented some other issue, without having greatly impacted the system as a whole. Thank-you to the veterinarian and vet assistants who made me welcome and were happy to share the whys, wherefore, and how comes of what they did. I hope I will have the chance to come back.

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