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March 2007
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NORTH COLORADO CARD I OLOGY
We've perfected a revolutionary approach to heart care.
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Listening. At North Colorado Cardiology, we know it takes more than just state-ohhe-art technology to care for your heart. It's about understanding your questions and concerns as well as your condition. That's why our experienced cardiologists continue to be the region's leading experts in cardiac treatment, vascular disease and most important-persona[ treatment.
North Colorado Cardiology is here for your cardiac needs. For more information, call us today at t .. soo.. s45 ..4411.
FRONT RANGE CENTER for BRAIN & SPINE SURGERY, P.C. Specialists in Neurological Surgery Since 1978
Comprehensive Neurosurgical Care In a conservative-yet-progressive treatment approach, our neurosurgeons treat patients who have injuries or diseases of the spine, brain, or peripheral nerves that may include: • • • • • • • • • • Timothy C. Wirt, M.D.
Donn M. Turner, M.D.
Hans C. Coester, M.D.
New patients and referrals are welcome.
Ft. Collins: 1313 Riverside Ave. (970) 493-1292 Greeley: 2001 70th Avenue (970) 356-4488 Loveland: 1900 Boise Avenue (970) 669-0470 tr (Sao) 458-0306
ruptured discs • brain tumors head injuries • Kyphoplasty spinal cord injuries chronic neck or back pain carpal tunnel syndrome (wrist) ulnar nerve entrapment (elbow) instability of the spine or spine fractures stenosis (a tightening of the spinal cord) disc arthoplasty (artificial disc repalcement) minimally invasive spine surgery
John J. Viola, M.D.
We serve many insurers and HMOs including: Blue Cross/ Blue Shield o{Colorado and Wyoming. Aetna. Medicare. TRICARE. HMO CO. Sloan :1· Lake. United 1/ealth Care. Great West Life. and others.
www .brain-spine.com
Lydia's STYLE Magazine
ANNOUNCING•••
Mark Loury, M.D., F.A.C.S. Board Certified Former Faculty of John's Hopkins Hospital Listed in 'Best Doctors in America' and 'America's Best Doctors'. Nationally Recognized Expert in Sinus & Nasal Disease.
Steve B. Schaffer, M.D. Board Certified Tulane University Focus on Disorders of the Throat and Voice.
For many types of procedures, we use a special operative scope - a laparoscope - that allows us to make smaller surgica l incisions. laparoscopic (or minimally invasive) surgery means patients are likely to have less pain for a shorter length of time and wi ll recover more quickly. The extensive use of laparoscopic surgery in northern Colorado and Wyoming is unique to us. We also perform the trad itional open forms of surgery when necessary.
Northern Colorado Surgical Associates, P.C. Surgical care since 1956 2121 E. Harmony Road, Suite 250 Fort Collins
970.482.6456 888.699.6272 (toll free) www.ncsurgical.net
Northern Colorado Medical & Wellness
We encourage patients to talk with their primary care provider before seeking surgical consultation. We work with most insurance providers and employer groups. We welcome new patients and referrals.
REDUCED PAIN AND QUICK RECOVERY. Laparoscopic or Traditional Procedures: Hiatal Hernia Surgery (Gastroesophageal reflux disease), Inguinal Hernia Surgery, Gallbladder Surgery, Obesity Surgery, Colo-rectal Surgery, Appendectomy, Splenectomy, Lung Surgery Traditional Procedures: Thyroid/Parathyroid Surgery, Hemorrhoid Surgery, Breast Biopsy, Breast Surgery, Vascular Surgery, Removal of Lesions & Moles, Vein Surgery
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Centennial Radiation Oncolo "Caring for a patient is caring about a person" The mission of Centennial Radiation Oncology, P.C., is to provide safe, effective, and accurate radiation therapy Marie D. Klish, M.D.
to cancer patients in Northern Colorado, in order to cure, palliate, and/ or provide William B. Casey, M.D.
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extended quality of life.
Providing compassionate cancer care to our community since 1982 Providing Radiation Oncology Services: McKee Cancer Center • 2050 B. N. Boise Ave. • Loveland, CO 80538 • (970) 679-8900 North Colorado Cancer Institute • 1801 16th St. • Greeley, CO 80631 • (970) 350-6680 Poudre Valley Radiation Oncology • 2121 E. Harmony Rd., Ste. 160 • Fort Collins, CO 80528 • (970) 482-3328
Northern Colorado Medical & Wellness
style media and design, inc. | 970.226.6400 |
w w w. s t y l e m a g a z i n e c o l o r a d o . c o m Publisher/EDITOR Lydia J. Dody
creative director Austin J. Lamb ASSISTANT Editor Corey Radman Graphic Designer John Gieser
Sales Manager Saundra Skrove (970) 217-9932 Advertising Sales EXECUTIVES Jon Ainslie (970) 219-9226 Karen Christensen (970) 679-7593 Lydia Dody (970) 227-6400 Office Manager Ina Szwec Accounting Manager Karla Vigil Data Entry Betty Frye Contributing Writers Dr. James Anderson, Lynn Dean, Julie Estlick, Dr. Daniel Hatch, Beth Herman, Annette Kahmann, Court Klinck, Dr. George Phillips Corey Radman, Kay Rios Contributing photographers Dana Milner Affiliations Fort Collins Area Chamber of Commerce Loveland Chamber of Commerce Greeley Chamber of Commerce Windsor Chamber of Commerce Estes Park Chamber of Commerce Johnstown Milliken Chamber Of Commerce 2007 Style Magazines January-Loveland/Greeley Medical & Wellness Magazine and Directory February-Building & Remodeling March-Family, Community & Nonprofit March-Northern Colorado Medical & Wellness April-Business of Northern Colorado May-Home & Garden June-Business to Business June-Building & Remodeling July-Fort Collins Medical & Wellness Magazine and Directories August-Women & Business September-Home Interiors & Entertainment October-Women’s Health & Beauty October-Northern Colorado Medical & Wellness November-Holiday December-Winter/Wedding December-Northern Colorado Christian Business Magazine and Directory Style Media and Design, Inc. magazines are free monthly publications direct-mailed to homes and businesses in Northern Colorado. Elsewhere, subscriptions for twelve issues cost $24 annually (53% off newsstand price). Free magazines are available in stands at 75 locations throughout Northern Colorado. For ad rates, subscription information, change of address, or correspondence, contact: Style Media and Design Inc., 211 W. Myrtle, Fort Collins, Colorado 80521. Phone (970) 226-6400. E-Mail: editor@StyleMedia.com Š2007 Style Media and Design Inc. All rights reserved. The entire contents of Style Magazine is copyrighted and may not be reproduced without the expressed written consent of the publisher. Style Media and Design Inc. is not responsible for unsolicited material. All manuscripts, artwork, and photography must be accompanied by a SASE. The views and opinions of any contributing writers are not necessarily those of Style Media & Design Inc.
publisher’s letter Another Leap of Faith
Risk taking is a funny thing. Theoretically each time you risk, it should become just a little easier to do. Well, even though my current leap of faith fulfills a goal and my hearts desire, it was still scary.
I was sure that there were lots of Style readers like myself, that were interested in reading about health issues, healing and wellness as viewed by our Northern Colorado healthcare professionals. Yes, Style already published two medical and wellness issues a year but, frankly I felt we needed at least two more. The health related topics of interest are endless, the baby boomers are a significant segment of our region’s population, and since we are living longer we are facing more health and wellness issues. So the decision was made and you are holding our first Northern Colorado Medical and Wellness issue. This issue is packed full of timely and informative articles with expertise from some of our region’s finest specialists and healthcare providers. When I visit with these exceptional professionals I continue to be impressed with their education, experience, and overall commitment to providing their patients with the highest caliber of healthcare. It was especially fun to feature Dr. Bev Donnelley on our cover; she has been serving women in our region as an ob/gyn for many years and now has incorporated robotic expertise into her surgeries. In fact, last year she performed a robotic hysterectomy on me and I was amazed at my exceptionally quick recovery and minimal down-time.
As many of you know another passion of mine is providing help to women diagnosed with breast cancer, personally and through the Hope Lives Breast Cancer Support Center. This past month I was distressed to learn that two of my friends received this nasty diagnosis. Far too many women are afflicted and we all need to mobilize our fund raising efforts to conquer this devastating disease. This year I am proud to have been asked to be the Honorary Chair/Survivor for the American Cancer Society Relay For Life. This signature fundraising overnight event will be held on June 9-10, 2007, at Fort Collins High School. Consider engaging your friends and co-workers to form a team and join us in our community fight against cancer. For more information contact Diane Cahn at 970-266-1371. I hope you enjoy this issue and it helps you keep informed and in charge of your own health. Thank you for your support and readership as we continually work at providing our region with products that uplift, inform and celebrate our communities. Wishing you good health and a happy heart,
• domestic & foreign collision & mechanical repair • complimentary loaner cars available • all insurance work welcome
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Northern Colorado Medical & Wellness
970.484.3657
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march 2007
CONTENTS
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24
The New Hysterectomy Marla Morine’s decision to undergo a hysterectomy was not one she took lightly.
woman centered care Good health care is about relationships and trust. Choosing the right care-provider is important.
northern colorado medical & wellness
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26
train your brain Our memory - we use it all the time but hardly ever think about it – until we have problems.
The New colonoscopy A friend’s persistence finally convinced Brad Wiggen to get his first colonoscopy.
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continence confidence For some women, the condition is brought on with coughing, sneezing or exercise.
management of type 2 41 million people in the U.S. have what is described as a “pre-diabetes” condition.
on the cover Beverly Donnelley, M.D. demonstrates her expertise in gynecological robotic surgery.
Cover photos by Dana Milner Photography.
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more than beauty rest 40% of the U.S. population will experience some type of sleep problem in their lifetime.
The articles in this issue of Northern Colorado Medical & Wellness are for your general knowledge and not as a substitute for medical advice or treatment. If you have any questions or concerns about your health, please contact your doctor or health care provider.
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balloon sinuplasty The normal drainage process keeps the sinuses healthy. How healthy are your sinuses?
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surgery
Robotic Surgery
Beverly Donnelley, M.D. prepares for performing a hysterectomy using the new robotic technology.
The New Hysterectomy
by Kay Rios
Marla Morine’s decision to undergo a hysterectomy was not one she took lightly. In fact, she had long put off any decision. “Three or four years ago, I was diagnosed with uterine fibroids. They weren’t very big and I was told that approximately 25% of all women have them so I ignored it. Then in 2005, it became a problem and I had issues for months.”
S
he had borderline anemia off and on and, “I cried like a maniac.” Husband Larry Bolt confirms, “Her mood swings were so bad, it was like living out on a playground.” Still she was hesitant. “I didn’t want to take time off work but I finally had to address it.” She had heard about robotic surgery and that piqued her interest because of the difference between that and traditional surgeries: smaller incisions, less blood loss, lower risk of infection, less scarring and shorter hospital stay and faster recovery. “I didn’t want to get sliced open and couldn’t take the eight weeks in bed kind of recovery thing. What I wanted was to do a procedure where they chop up the fibroids and suck them out.”
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She researched the process and found that robotic surgery was available in Fort Collins. Poudre Valley Hospital (PVH) had installed Intuitive Surgical’s da Vinci® robotic system in 2004 and was the first hospital in Colorado to do so. And, in 2006, PVH added another system: Intuitive’s upgraded $1.5 million da Vinci® “S” system. In those few years since the initial system was installed, the number of surgeons in Fort Collins who perform robotic surgery in the four specialties of cardiac, gynecology, urology, and general surgery went from the original pioneers, Drs. Michael Stanton of the Heart Center of the Rockies; Stephen Brutscher, Urology Center of the Rockies; and Warren James, The Women’s Clinic of Northern Colorado to a total of 17 surgeons trained for
robotic surgery. Morine made the decision. “The fibroids had increased dramatically in size and I had small ovarian cysts. I was referred to the Women’s Clinic.” She was paired with Dr. Beverly Donnelley, a physician trained in robotics. “I had read about the robotics procedure that leaves the uterus intact but takes out fibroids, and it’s ten days down at a minimum. But after Dr. Donnelley read the latest ultrasound, she said that wasn’t possible because the fibroids had grown into the uterine lining. It would have to be a hysterectomy but could be done robotically. That still scared me because of longer recovery.” But she finally set the date for December 12th of this past year.
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Northern Colorado Medical & Wellness
13
surgery
Robotic Surgery
It’s really amazing. I didn’t believe it until I had seen it myself. Many new technologies don’t bare out in the long term as far as cost versus benefit but I think robotic surgery is truly the future in medicine. - Beverly Donnelley, M.D. -
Beverly Donnelley, M.D. holds an arm on the “patient end” of the da Vinci® “S” robotic system.
That didn’t mean Morine was comfortable with the decision. “I had a lot of questions. I was ignorant of what would be left. I had no idea about my body and I asked some stupid questions: will it be firm? What holds it in place? What sort of structure would be left? I actually envisioned this thing flapping back and forth.” Donnelley was very patient, Morine says. “She didn’t laugh at my questions. She drew a diagram and talked about how the ligaments would hold everything in place once the uterus was removed.” Bolt also had questions. “I asked about infections because I had a bad experience a year or so before when I had an appendectomy. She said the risk for infection was very low because of the small incisions used.” Morine had other concerns as well. “I was so emotionally overwrought from bleeding so hard for over a year. I was afraid my emotions would go over
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the edge and I wouldn’t have any control after because of hormonal imbalance. Dr. Donnelley said that would not happen. I had been going nuts and crying like a maniac but, by the time I walked out of that pre-op discussion, I felt much calmer. She really helped me.” Donnelley said those fears are normal. “People tend to be fearful especially when you meet someone for the first time and you are talking about their health. I think that we all want to feel like we have control but, often in medicine, we take control from the person. If you give people the sense this is a team effort, and they can decide what they want within the realm of what is safe for them, it helps put them at ease. That’s what I try to do.” Patience is part of the practice, she says. “As far as I’m concerned there are no silly questions. I’m happy to sit and talk to people as long as they need. I want them to know I care about them as individuals and it’s not just another
case to be rushed through.” Because Morine had concerns with hormone replacement, she wanted to keep her ovaries and Donnelley said that might be possible but she wouldn’t know until the surgery. She offered Morine photos of the procedure so she could confirm the decision that Donnelley would make about the ovaries. Morine declined. “By that time, I completely trusted her and felt it wouldn’t be necessary.” Morine made her decision based on her confidence in Donnelley. Also buoying her confidence was knowing that more and more surgeries, from prostate to heart to hysterectomies, are being performed by robotics on a regular basis. With Intuitive Surgical’s da Vinci® system, the entire procedure is conducted from across the room. The surgeon’s hands never enter the patient, but rather operate from a computer console working four robotic arms inserted into four dime-sized incisions. One arm holds a 10X magnification camera and the other three hold microsurgical instruments employing the same 360-degree range of motion as a human wrist and hand. At a console, the surgeon peers into binocular-like lenses at the view provided by the internal camera, changing the surgical view instantly, if necessary, by using foot pedals to zoom in and out. She guides the robot’s work by twisting her wrists in stirrup-like handles and begins to, remotely and precisely, manipulate the instruments attached to the adjustable robotic arms. The tiny tools can snip, stop blood flow and stitch. Currently, about 20 types of surgeries are done at PVH with the original da Vinci®, and, with the new “S” system, a greater number of possibilities exist. For example, the new system could permit surgeons to operate in more than one internal body area without repositioning either the patient or robot. The “S” system also offers greater depth perception allowing for extreme surgical precision. Even with the original system, because smaller incisions mean less blood and with the magnification the robot offers, the doctor can see more clearly. And because hand movements are scaled down, greater precision is possible. Donnelley vouches for that precision. “The name, Intuitive, is so perfect,” she says. “With many instruments in medicine you have to figure out how the instrument works but this instrument works just like your hand.” It has advantages even over laparoscopy, which also uses miniature surgical instruments inserted through small incisions. Laparoscopy provides only a two-dimensional view rather than the robot system’s 3D vision. “Because laparoscopy hysterectomies are done by operating from above and manipulating the instrument, that can put pressure on the incision and can cause injury. But with robotics, there’s no torquing or injury to the tissue at the incision site,” Donnelley says. But, she cautions, not every patient is a can-
Northern Colorado Medical & Wellness
15
surgery
Robotic Surgery
I was more impressed by her than anyone I’ve ever had. She’s caring and patient and there’s this maternal air about her. This was such a good decision. - Marla Morine Beverly Donnelley, M.D., The Women’s Clinic of Northern Colorado, explains the procedure to patient, Marla Morine.
didate. Complicated cases or for those patients who may require multiple procedures, robotics may not be suitable. But, in Morine’s case, it was the perfect choice. The day of the surgery, Bolt sat in the waiting room watching the monitor that would tell him where Morine was –surgery, post-op, recovery. He expected to wait over three hours but was surprised when Donnelley came out in just over two hours. It was the fastest one she had accomplished, she told him, and she was able to save the right ovary. On the other side of the door, Morine was coming out of the anesthesia. “I saw white lights and blue lights and didn’t know where I was and wanted to know what was going on. The nurse said, ‘we’re finished with your surgery,’ and I was dumbfounded. Surgery? I don’t remember a thing.”
By the next morning, Morine was ready to leave the hospital. She settled in, expecting six weeks of recuperation. It was tough at first, both she and Bolt say. “I had a hard time sleeping and I was hot flashing like crazy. I thought that was just the way it was going to be.” Bolt confirms, “We went through some bumps in the recovery process but the worst was over in about two weeks.” At that point, her hot flashes subsided and she began to sleep. And they both noticed a big difference. “At 3 weeks I was sitting here saying ‘I could easily be back to work.’” But she waited. It got even better. “Here was this kinder, gentler Marla,” Bolt jokes, but then adds more seriously, “It’s really a dramatic change and in a short period of time. She’s just more relaxed and easy-going and there aren’t any physical issues.”
Morine praises the robotic system but also adds that she can’t say enough about Donnelley’s ability and skills. “I was more impressed by her than anyone I’ve ever had. She’s caring and patient and there’s this maternal air about her. This was such a good decision.” Donnelley, who has been performing hysterectomies for 30 years, says she’s done over 30 robotic hysterectomies. Again, she says the procedure isn’t for everyone and each case should be looked at individually. She also acknowledges there is a cost factor. “Any technique like this has some extra cost to it but when you weigh extra time in hospital with old methods, it starts to match the money spent to do robotics.” In that sense, it can be an even exchange or close to it, she says. Robotic surgery appears to be the wave of the future with unlimited expansion possibilities.
Here was this kinder, gentler Marla. She’s just more relaxed and easy-going and there aren’t any physical issues. - Larry Bolt -
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The da Vinci® Surgical System is the only commercially available technology that can provide the surgeon with the precision, dexterity and control of traditional open surgery, while only requiring 1-2 cm incisions. The system consists of patient cart with four interactive robotic arms, a high-performance vision System and patented EndoWrist instruments.
Already on the horizon, Intuitive Surgical is exploring a tactile feature that will simulate the sensation of touch for the surgeon. But even in its current form, Donnelley says, “It’s really amazing. I didn’t believe it until I had seen it myself. Many new technologies don’t bare out in the long term as far as cost versus benefit but I think robotic surgery is truly the future in medicine.”
Kay Rios is a freelance writer based in Fort Collins. She is currently a doctoral candidate in Educational Leadership at Colorado State University.
Northern Colorado Medical & Wellness
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longevity
mental memory
train your brain
by Annette Kahmann
Generally we don’t think much about our memory – just like breathing, we use it all the time but hardly ever think about it – until we have problems.
O
ften people notice that their memory is not as sharp as it used to be once they are over fifty. Names of people and places are harder to recall, memories of past events have slipped away, directions to unfamiliar locations are not memorized. All of these examples belong to declarative memory, in contrast to procedural memory. The report Improving Memory, published by the Harvard Medical School, defines declarative memory as, “Memory for facts and for events. In contrast, the report defines procedural memory as, “The long-term memory of skills and procedures, or ‘how-to’ knowledge.” Examples of procedural memory are driving or riding a bicycle. While it is commonly assumed that all memo-
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ry suffers with advancing age, normal age-related memory loss involves only the declarative memory, making it harder to retrieve words or recall information and to multitask. Procedural memory does not disappear with increasing age, but it does become harder to acquire new procedural memories, a fact that can be compensated for with extra effort and willpower. Scientists and laypersons used to assume that all of our memories are stored in one specific place of the brain, a memory bank. Through brain-imaging technology we now know that this is not the case: different types of information are processed and stored in different parts of the brain. For example, language is processed in the left temporal lobe, while melodies are stored in the
left parietal lobe and images may have their home in the occipital lobe. So if you think about a song that brings a specific image to your mind, all three parts of your brain are involved in this memory process, intricately interwoven with each other: “Calling up memories is like doing an Internet search, with one or two words activating many hyperlinks,” according to Improving Memory. What is normal? According to Daniel Schacter at Harvard University there are seven common issues concerning memory, regardless of age. Transience is the brain’s habit of ridding itself of information that is not needed any longer. Absentmindedness is a lack of focus and makes it hard to remember
As is generally the case, one of the best remedies people can offer to their loved ones with memory loss resides in the human heart: Knowing and accommodating [patient’s] limitations and letting them know they are loved, makes all the difference in the world. - Timothy Allen, M.D. -
where we put our keys for example. Blocking occurs when you know that you know something but you just can’t retrieve it at the moment. An example of misattribution would be remembering someone’s name, but confuse where you met this person with someone else. Suggestibility creates memories of things that actually never occurred – false memories – due to someone else’s suggestion. Bias is the tendency to remember things either better or worse than they really were, and persistence is the problem of not being able to let go of old disturbing memories. Out of these seven memory issues, only blocking and misattribution are known to become more likely with increasing age. As a rule of thumb, normal memory loss is recognized by the person who is affected by it, whereas abnormal or pathological memory loss is generally noticed by people surrounding the person in question, but denied by the person who is affected. Sometimes older people suffer from declarative memory loss that is above the norm, but they do not suffer from dementia – a state called mild cognitive impairment. According to neurologist Dr. Timothy Allen of Fort Collins Neurology, people with mild cognitive impairment go in and out of clarity, meaning they are aware of their memory gaps. The report Improving Memory lists the following symptoms: • • • • •
Subjective memory complaint Objective evidence of memory impairment on formal neuropsychological testing Otherwise normal mental function Intact activities of daily living No dementia
Northern Colorado Medical & Wellness
Timothy Allen, M.D. Michael Curiel, M.D. Fort Collins Neurology, P.C.
Memory problems can be due to a wide variety of issues. One reason is that the hippocampus, the part of the brain that plays an integral part in declarative memory, often suffers from age-related changes. While we don’t lose as many brain cells as was assumed in the past, the loss of neurons that does occur affects neurotransmitters like dopamine, acetylcholine and serotonin which play an important role in the learning and memory process. Sometimes memory loss is caused by diseases such as diabetes, poor blood circulation of the brain, high blood pressure, high cholesterol, thyroid dysfunction, stroke, hydrocephalitis, head trauma or Alzheimer’s. However, memory loss can also be caused by stress, lack of sleep, emotional overwhelm, depression, exposure to toxins, lack of exercise and poor nutrition. According to neurologist Dr. Tamara Miller of Advanced Neurology in Fort Collins, telltale signs for Alzheimer’s are problems with spatial navigation and locomotion, forgetting whole experiences (rather than just a part), becoming unable to follow written or spoken directions and gradually losing the ability to care for oneself. To determine the cause and severity of memory loss, people should see their primary care physician or a neurologist. Diagnostic tools include blood tests, cognitive tests and brain screening images.
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longevity
mental memory
Tamara Miller, M.D. of Advanced Neurology, Fort Collins.
Dr. Miller suggests following the recommendations of the food pyramid and eating a diet rich in fruits and vegetables and healthy fats. Fruits and vegetables are high in antioxidants which may protect against age-related deterioration in general. Avoiding saturated and trans fats helps keep reduce the chances of cerebrovascular disease, including small “silent” strokes. How can memory loss be prevented or decreased? “Memory loss is an equal opportunity offender,” Dr. Allen says. While some scientists believe that people with a higher level of education are less affected, he does not think so. “The only difference,” he says, “is that people with a higher level of education start out with a fuller glass,” which makes the mental decline less noticeable. Harvard scientists agree: “Changes in white matter occur to some degree in virtually everyone over age 60 and contribute to normal age-related memory loss.” In Dr. Allen’s opinion, preventing memory loss is really a lifelong pursuit. Key factors are a good diet, regular exercise and an active mind. Dr. Miller suggests following the recommendations of the food pyramid and eating a diet rich in fruits and vegetables and healthy fats. Fruits and vegetables are high in antioxidants which may protect against age-related deterioration in general, the report says, avoiding saturated and trans fats helps keep the arteries clear and thus decrease the chances of cerebrovascular disease, including small “silent” strokes. Non-smokers retain better memory functions, and while moderate consumption of alcohol may reduce the risk of dementia, excessive alcohol consumption is toxic to neurons and thus causes memory loss.
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Sleep is essential for consolidating memory, a good night’s sleep also helps reduce stress and makes it easier to focus. For most people, six to eight of sleep per night is ideal. In addition to the amount, the quality of sleep is important. The Harvard study recommends that people avoid coffee and other stimulants after midmorning, do their most vigorous exercise earlier in the day, avoid napping during the day and establish and maintain a good sleep schedule. Another important part of maintaining good health, and a healthy memory, is exercise. “Physical fitness and mental fitness go together,” states the report Improving Memory. Exercise increases the oxygen that is sent to the brain and lowers the risk for diabetes, high blood pressure and high cholesterol and stroke – all diseases that can also cause memory loss. Dr. Miller recommends that people take a rapid 45-minute walk three times a week to keep themselves in good shape. It may be beneficial to take a vitamin supplement, especially vitamin B12 which is important to neuronal health and sometimes deficient in older people. While generally this vitamin can be absorbed through oral supplementation, there are some cases where it is necessary to have B12 injected due to mal-absorption. Some studies claim that vitamin E has a beneficial effect on preserving memory, whereas another study warns against the dangers of taking too much vitamin E. Gink-
go biloba has gained a reputation for being beneficial to the brain, and thus preserving memory. Currently a large study on the effects of ginkgo biloba is under way in the United States. However, the particular product you want to purchase may be different in composition and content from the ginkgo product that the research data refer to, the Harvard study warns. Another booster for memory loss has been hormone therapy. A study conducted by the Women’s Health Initiative in 2003 came to the conclusion that treating women with a combination of estrogen and progestin (Prempro) not only didn’t improve memory problems, but it doubled the risk for dementia. How natural hormones work in this respect is an open question at this point, just like other natural supplements. “If Pfizer or other major drug companies were selling natural supplements, we would have many studies about their effects,” Dr. Allen says – since this is not the case, there hasn’t been much more than empirical information about the effect of natural cures on memory. Probably the most important tool to boosting and preserving memory is constant challenging mental activity – this is something that all experts, including Fort Collins neurologists, Dr. Timothy Allen and Dr. Tamara Miller agree upon. Do crossword puzzles, learn new skills, read, play mentally stimulating games. If you have not been using the computer or the Internet yet, it may be a good
thing to get into this to prevent memory loss because of the learning curve. There are a number of pharmaceutical treatments available to help with memory loss. Most of them are cholinesterase inhibitors (Aricept, Exelon, Razadyne, Cognex) that are used for Alzheimer’s disease – all three of them are effective, Dr. Miller says; they differ in convenience of use and side effects. They can also be beneficial for mild cognitive impairment, increasing alertness and attentiveness according to a recent study. A new medication on the market for Alzheimer’s is memantine (Namenda), which blocks glutamate from attaching to NMDA receptors, thus protecting against excessive levels of the excitatory neurotransmitter, glutamate. Dr. Allen advises his patients to pursue both natural and Western medical approaches to treating memory loss: “While some of the neurological approaches to memory preservation are only about a decade old, natural medicine has been around for 5,000 years.” Can older people with memory loss ever regain their full memory? Probably not, but following all the recommendations above will help slow or maybe even halt memory loss. To cope with memory loss that has already occurred, it is recommended to stick to routines and schedules, write things down in a journal or on an electronic device, to repeat information out loud and summarize it. People who live with persons with memory loss can support them by avoiding changes in routine or environment as much as possible; help them with good diet choices and exercise. As is generally the case, one of the best remedies people can offer to their loved ones with memory loss resides in the human heart: “Knowing and accommodating their limitations and letting them know they are loved, makes all the difference in the world,” says Dr. Allen. Annette Kahmann is an energy medicine practitioner for people and animals, a teacher and writer.
A New Name, A New Location
Twice the Commitment to Excellence Since 2000, Harmony Imaging Center has provided the most comprehensive, highest quality medical imaging in the Fort Collins area. We’re pleased to announce the opening of our second location next to the new hospital, Medical Center of the Rockies, in Loveland. We’ve also changed our name. Harmony Imaging Center is now The Imaging Center at Harmony, and our new facility is The Imaging Center at Centerra. Both are equipped with the latest technology and staffed by the same excellent technologists and radiologists you’ve come to trust.
The Imaging Center 2127 East Harmony Road, Suite 130 Fort Collins, Colorado 80528
2500 Rocky Mountain Avenue, Suite 150 Loveland, Colorado 80538
Exceptional imaging, exceptional quality, exceptionally fast.
Main 970-282-2900 | Scheduling 970-282-2912 www.the-imaging-centers.com
Northern Colorado Medical & Wellness
21
treatment
female urology Timothy H. Soper, M.D., Michael Lee, D.O., Kevin Nasseri, M.D., Michael J. Eddy, M.D., George H. Phillips, M.D., Stephen P. Brutscher, D.O., Clifford J. Nemeth, M.D., Randy W. Everette, M.D., Urology Center of the Rockies
Restoring Continence &
Confidence for Women
by George H. Phillips, M.D.
Urology is commonly misconstrued as a male only specialty. While urologists treat diseases of the male reproductive system, they also are the primary surgical specialists of both the male and female urinary tracts including the kidneys, ureters, bladder, and urethra. The most common problem urologists treat in females is incontinence.
A
n estimated 17 million American women share this common healthcare concern. For some women, the condition is brought on with coughing, sneezing or exercise. For others, it is a strong urge to urinate and an inability to make it to the bathroom in time. For all of these women, the effects can be devastating. A thorough evaluation with a urologist will distinguish the subtle differences in types of incontinence and set in motion an appropriate treatment plan. Urge incontinence can often be treated with behavioral training and/or medical therapy. Stress urinary incontinence limits lifestyles and relationships because of the embarrassment that accompanies odor and wetness. Typically the symptoms worsen over time, and so lifestyles and relationships are further compromised as the condition progresses. Stress urinary incontinence occurs when there is uncontrolled urine leakage during a physical activity like lifting, sneezing or coughing. It typically is the result of a relaxation of the urethra and bladder neck from their normal positions (often called a “fallen bladder�), and intrinsic sphincter deficiency, a condition in which the urethral sphincter is unable to close tightly enough to hold urine in the bladder. Any single condition or a combination of conditions can lead to stress incontinence. Pregnancy and childbirth, aging, medical conditions, infections, medications, and weight gain are common causes. Currently, there are no medications available to treat stress incontinence. For
22
Female bladder demonstrating stress urinary incontinence.
Suburethral sling in place preventing stress incontinence.
.
Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days.
some women pelvic floor strengthening programs, protective undergarments and bulking injections offer temporary solutions. Fortunately, there also are solutions available designed to be more permanent. One such solution is the female “sling” system for stress urinary incontinence. Doctors treat incontinence by surgically placing a narrow strip of material—called a sling—under the urethra to give it a point of support. The sling procedure is a minimally invasive, highly effective procedure. It generally takes less than 20 minutes and commonly is performed on an outpatient basis. Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days. As with any surgical procedure, inherent risks are present, but rare with this procedure. Clinical studies support the enthusiasm that patients and physicians alike have for sling systems. One study reports more than 95 percent of patients remained completely dry and did not need any protection following the sling procedure. The potential to give someone back their lifestyle before incontinence set in is great with sling systems. It is life changing for so many patients, and yet such a straightforward procedure. A problem frequently associated with stress incontinence is pelvic organ prolapse. Pelvic organ prolapse occurs when pelvic structures, like the bladder or rectum, bulge or protrude into continued on page 43
Northern Colorado Medical & Wellness
23
obstetrics
Midwifery
Marie Foose, CNM Krista O’Leary, CNM Center For Women’s Health, Greeley.
woman centered care
by Corey Radman
Good health care is about relationships and trust. In pregnancy, especially, choosing the right care-provider for your needs is so important.
W
ith any pregnancy your body goes through an incredible transformation: in addition to bodily changes, your moods may change, your weight fluctuates, even your skin and hair changes -- it’s overwhelming! When you seek health care you want to find someone who will guide you, someone with whom you feel safe asking embarrassing or anxiety-ridden questions. You want someone who will listen to you, whom you trust to be honest and caring throughout your pregnancy. A Certified Nurse Midwife can provide you with this type of care. They have the ability to give you additional time in the office setting and furthermore, are able to be with you during your labor, providing support, assistance and expertise during the active phase of your labor. For many women the choice of an obstetrical care provider involves looking at all their options. Those who try out a Certified Nurse-Midwife like those at the Center for Women’s Health in Greeley are immediately hooked. Talking with both patients at the clinic and the two Nurse-Midwives,
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Marie Foose and Krista O’Leary, a common thread that you hear again and again is that the experience is a personal one. Patients and staff at the Center are friends who look forward to catching up as well as coming in for health care. Jamie Finn just delivered her second baby, Grant, with Marie Foose, CNM. “I got a more personal experience using a midwife. I feel like the midwives really tried to get to know me,” says Finn. The delivery of Grant took about two and a half hours total, with only thirty minutes of pushing. (Jealous? Me too.) If Finn were a patient at a typical medical practice, her O.B. would probably not have been able to be there for her entire labor. But Foose was there for the whole thing. “Labor support is one of the biggest differences we are able to offer as midwives,” says Krista O’Leary, CNM. “We are able to stay with the patient through their entire labor.” Labor support includes anything that will help the mother and her family feel more at ease including Jacuzzi and birthing balls. The midwives are also present to
provide encouragement to change positions, to try different things during labor and even give back rubs, but most important is the physical presence of one who has the knowledge, experience, and education to handle anything. Certified Nurse Midwives (CNMs) are different from lay midwives in that they are required to have a background as registered nurses as well as a master’s degree in midwifery. To obtain midwife certification in Colorado, nurses must complete a master’s program through an accredited Nurse-Midwife program. Both Foose and O’Leary worked as labor and delivery nurses before completing their Masters degrees at the University of Colorado. According to the American College of Nurse-Midwives, “Nurse-midwives offer women special skills and an understanding of their unique physical, emotional and spiritual needs. In addition, women who are cared for by a nurse-midwife can expect the same level of safety as they can from a physician.” CNMs have a lower rate of interventions during labor and cesarean sections. O’Leary dispels common misunderstandings
A common thread that you hear again and again among patients is that their experience is a personal one. Patients and staff at the Center are friends who look forward to catching up as well as coming in for health care.
CENTER FOR
Women’s Health
Kevin Hess, D.O. Stewart Abbot, M.D.
• General Women’s Care • Family Planning • Family Centered Birth • Pre-Conception Counseling • High Risk Obstetrics • Ultrasound • Menopausal Care • Pap Smears • Abnormal Pap Treatments • Incontinence & Bladder Problems • Robotic & Laparoscopic Hysterectomy • No Terminations • Accepting Most Insurance, Including Medicaid
We Deliver!
Marie Foose, C.N.M Krista O’Leary, C.N.M.
the kind of birth you want attended by a professional Certified Nurse Midwife who cares about you. The midwives at Center for Women’s Health are the only CNMs delivering at North Colorado Medical Center in Greeley
CNMs Krista O’Leary and Marie Foose admire Jamie Finn’s growing family. continued on page 33
Northern Colorado Medical & Wellness
1275 58th avenue, Suite A • Greeley 970.336.1500 • 877.409.5454 25
prevention
Colonoscopy
?
Colon Cancer
The New colonoscopy
by Julie Estlick
A friend’s persistence finally convinced Brad Wiggen to get his first colonoscopy. It wasn’t typical golf course ribbing, but he’s glad he listened. “My friend is a family physician and we go golfing every year,” says Wiggen. “I was about to turn 60 and he kept bugging me to get a colonoscopy. Everyone said there was nothing to it so I made the appointment.”
W
iggen, a jovial man who sports a fedora, knows the importance of colon cancer screening. He served on the board of the American Cancer Society (ACS) of Fort Collins for nine years and lost three friends to cancer in one year alone. Another friend is currently battling prostate cancer. In fact, Wiggen went for a flexible sigmoidoscopy at age 55, but he was in no hurry to get a full colonoscopy. Both sigmoidoscopies and colonoscopies are usually performed on an outpatient basis using a slender, lighted tube that is inserted into the rectum to look inside the colon. A “flex sig” only exams the lower third of the colon. The gastroenterologist looks for polyps, which are the precursor to cancer, and removes them before
26
they become cancerous. Colorectal cancer (cancer of the colon and/or rectum) is the third most common cancer in men and women and affects both genders equally. According to the ACS, around 55,000 people die each year from colon cancer, a number that has been decreasing for the past several years thanks to colonoscopy screenings. “I had heard horror stories in the past, but then my brother had a colonoscopy and he told me it was easy,” says Wiggen, of Loveland. “I was ready to do it. A week later I had my colonoscopy.” Both men went to the Centers for Gastroenterology in Fort Collins. For many patients, preparing for a colonoscopy is the worst part of the process. To cleanse
the bowel, you must use a laxative and eat no solid foods for at least a day before the procedure. The good news is that there are more prep options than ever to choose from today. For those who have trouble downing a gallon of GoLYTELY, there is a combination of HalfLytely (a half gallon) and four Bisacodyl tablets, 20 Visicol tablets taken over a day or 4 ounces of Fleet Phosho-soda. Each prep includes drinking plenty of water and other fluids to stay hydrated. Wiggen used Fleet Phospho-soda mixed with a sports drink. “It tasted fine,” he says. “I ate my Jell-O and drank my sports drink and it wasn’t a big inconvenience at all.” He remembers very little about the procedure itself. “I’m a real wuss for pain and I told
If they don’t find something it’s good, and if they do then it can be nipped in the bud. It’s a very easy, safe and preventative procedure for finding cancer. It’s a no-brainer to have a colonoscopy - there’s just nothing to be embarrassed about. - Brad Wiggen -
Hugh “Pat” McElwee, M.D. talks with patient, Brad Wiggen.
the nurses that. I laid down, they put in the IV to sedate me and I basically slept through the whole thing.” Even when the gastroenterologist found two polyps, Wiggen wasn’t worried. The polyps turned out to be non-cancerous. “If they don’t find something it’s good, and if they do then it can be nipped in the bud. It’s a very easy, safe and preventative procedure for finding cancer. It’s a no-brainer to have a colonoscopy - there’s just nothing to be embarrassed about.” March is National Colorectal Cancer Awareness Month and clinics around Northern Colorado are using various mediums to get their message out. The Centers for Gastroenterology with sites in Fort Collins, Loveland and now Greeley, are distributing blue rubber bracelets that say
Northern Colorado Medical & Wellness
“Colorectal cancer is preventable, treatable and beatable.” A health fair was also held at the Greeley Mall at the end of February and included a booth sponsored by North Colorado Gastroenterology with handouts and brochures to educate the public on new technology making colonoscopies easier and more comfortable than ever. “Awareness is always an issue because this is the disease no one wants to talk about,” says Dr. Hugh “Pat” McElwee, founder of the Centers for Gastroenterology. “The main benefit of a colonoscopy is that is saves lives.” When should you have a colonoscopy? The ACS recommends anyone age 50 or older should have one done, says McElwee. Factors that put you in the high-risk category include a family his-
tory of colon cancer or pre-cancerous polyps, or personal or family history of inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease. If you fall into the latter category, check with your family doctor to see if you should perhaps get screened at an earlier age. Optional cancer screening includes stool occult blood tests, flexible sigmoidoscopy and Barium enema. “If a patient is really opposed to a colonoscopy, something is better than nothing so we have a chance to catch a pre-cancer condition,” McElwee says. Colonoscopies are clearly aiding in the reduction of deaths from cancer, according to data from the National Cancer Institute. In 2002-2003, 369 fewer people died in the U.S. from all cancers and in 2003-2004 that number skyrocketed
27
prevention
colonoscopy Yazan Qwaider, M.D., North Colorado Gastroenterology.
Colonoscopies are becoming an even safer and more effective way to screen for cancer. There is less and less discomfort for the patient. We are screening this group of residents, who are at average or high risk, because they won’t get the care otherwise and it’s important. - Yazan Qwaider, M.D. -
to 3,014. The largest percentage drop was in colorectal cancer – a decrease of 2,000 deaths in 2003-2004. To put it in local terms, the Centers for Gastroenterology performed around 5,000 biopsies during colonoscopies between 2004-2006. Of those, about 50 were cancerous. While family physicians are doing a good job of referring average-risk patients who are 50 or older for screening, not enough higher risk patients are getting colonoscopies in Northern Colorado, says McElwee. Direct Access Endoscopy, a program that streamlines the process of getting a colonoscopy so patients don’t have to repeat a physical or attend a costly office visit before the procedure, is being used by gastroenterologists to make the procedure cheaper and more convenient. “The goal of screening is to identify people early on to prevent the progression of the disease or cure it,” says McElwee. “We’re not seeing as many people as we should be with high-risk factors. That’s the thrust of increasing awareness right now.” Advances in equipment have made colonos-
28
copies safer than ever, according to Dr. Yazan Abu-Qwaider of North Colorado Gastroenterology. The practice uses state-of-the-art equipment, which is more flexible and provides higher resolution. “Colonoscopies are becoming an even safer and more effective way to screen for cancer. There is less and less discomfort for the patient.” Qwaider and his partner, Dr. Ahmed Sherif, are reaching out to a community that desperately needs screening but can’t afford it. Hundreds of impoverished residents over age 50 in Weld County don’t have insurance coverage or the money to pay for a colonoscopy. So the duo have teamed up with Sunrise Community Health Center, the county’s indigenous clinic, to provide colonoscopies as well as the laxative preparations for their clients. “We are screening this group of residents, who are at average or high risk, because they won’t get the care otherwise and it’s important,” says Qwaider. The downward trend cancer specialists are seeing hasn’t taken hold in Weld County. According to North Colorado Medical Center, colorectal
cancer cases in the county remained steady or rose between 2001-2005. The good news is colonoscopies are about to change forever thanks to Capsule Endoscopy. A capsule-sized camera is swallowed and passes naturally through your digestive tract. Along the way it takes 2,500 pictures over three or four hours and the pictures are transferred from a computer chip into a recording device worn on the patient. The images are then made into a digital movie for the doctor to view on her office computer. The technology is already in use to view the small intestine as well as the esophagus and stomach. Some fine tuning is still needed to allow the camera to make turns in the large intestine and time the pictures so areas that are dark are not shot. Still, McElwee and his peers are excited for the future. “Colonoscopies will be dramatically different in five years thanks to this technology. However, please remember that screening colonoscopies prevent cancer and save lives.” Julie Estlick is a freelance writer and copyeditor living in Fort Collins
endocrinology Thomas Hanson, M.D. FACP
NORTH COLORADO MEDICAL CENTER
THOMAS HANSON. M.D. FACP. specializes in Adult
Monday, Wednesday, & Friday 8:15a.m. to 4:30p.m.
Endocrinology, Metabolism, Diabetology, Insulin Resistant Syndrome (IRS),
MCKEE MEDICAL CENTER
Diabetes Mellitus (Type 1 and Type 2),
Tuesday 9:00a.m. to 3:30 p.m.
and Thyroido logy.
Outpatient diabetes education classes offered weekly.
EAST MORGAN COUNTY (Brush) Thursday 9:00a.m. to 3:30 p.m.
To schedule appointments or for more information please call: 970-378-4676 or fax your referral to 970-378-4315.
Banner Health
1800 15th Street, Suite 200 1 Greeley, CO
North Colorado Medical Center
NORTH COLORADO !
gastroentero ogy
Diagnosis and management of Gastro Intestinal disorders including : d iseases of th e esophagus, stomach, small and large intestines, hepatobiliary and pancreatic diseases. Testing and management for bacteria l overgrowth. A lso specializi ng in diagnostic and thera peutic Endoscopy which includes: state of th e art Endoscopic Ultr a Sound, Sph incte r of Oddi Monometry and Colo rectal cancer screeni ng.
Cl1r ~s at NORrH COLO IAC'u lv'EDICAL C NrER
'-'S )
Edwa rd M a rino. PA-C
Yazan A. Qwaider, M.D. To schedule appointments or for more information p lease ca ll:
Banner Health
North Colorado Medical Center
1800 15th Street, Suite 300 1 Greeley, CO
1-888-557-0505 or 970-378-4475 or fax your referral to 970-378-4429.
prevention
Diabetes
management of type 2 diabetes
by Court Klinck
Diabetes is a common illness, affecting approximately 21 million Americans. In addition, another 41 million people in the U.S. have what is described as a “pre-diabetes” condition - falling somewhere between “normal” and “diabetic.” While controllable for many years with proper management, diabetes is a very serious disease.
I
n people with diabetes, the foodto-energy process is disrupted. This process is critical to every function of the body. It requires the help of insulin, a hormone made by the pancreas. Although sugars, starches and other foods are changed to glucose, a form of sugar, in the normal manner, the pancreas does not produce a sufficient amount of insulin to allow glucose to be converted to energy. As a result, glucose is collected in the blood, resulting in the high glucose levels symptomatic of untreated diabetes. There are two main types of diabetes, Type 1 (formerly called juvenile-onset diabetes), usually occurring in children and young adults, and Type 2 (formerly called adult-onset diabetes), occurring
30
most frequently in adults. Approximately 90% of all diabetics have Type 2. In Type 2, the pancreas produces some insulin but the body has trouble using it effectively. The well-respected United Kingdom Prospective Diabetes Study (UKPDS) of more than 5,000 Type 2 diabetics showed that a person’s pancreatic function diminishes over a 10year period prior to being diagnosed with diabetes - a loss of roughly 50%. The loss of pancreatic function continues after diagnosis. This process usually results in complete insulin deficiency in six to ten years, requiring insulin injections to control blood sugar (glucose) level. People having the highest risk for Type 2 diabetes are those with a family history of diabetes, over the age of 45, overweight (excess fat pre-
vents insulin from working as it should), and having a sedentary lifestyle. Other increased risk factors for diabetes include gout, vascular disease, hypertension, and a type of transitory diabetes - gestational diabetes - that occurs during pregnancy. Minority populations living in the United States, including Native Americans and people with African, Hispanic, or Asian heritage, are at increased risk for diabetes. Some symptoms associated with Type 2 diabetes usually evidence themselves gradually; others, which are the same as for type 1, occur suddenly. Gradually occurring symptoms include repeated or difficult-to-heal skin, gum or bladder infections, blurred vision, drowsiness, and itching and tingling or numbness in hands or feet. Sud-
Diabetes is a progressive disease. We start treating patients with one medication and, as the disease progresses, typically change or add other medicines. Although Type 2 patients normally do not require insulin injections at the onset of their disease, they likely will within 10 years. In this case, insulin will be used in combination with oral medication. - Meriam Izon, M.D. Meriam Izon, M.D., Rocky Mountain Endocrine Consultants.
denly occurring symptoms include frequent urination, excessive thirst, extreme hunger, irritability, dramatic weight loss, weakness and fatigue, nausea, and vomiting. It is easy to test for diabetes. A person needs to fast for 10-14 hours prior to being tested. Blood is drawn and sent to a test lab. If blood sugar test results fall in the range of 100-125, a person is considered to be “pre-diabetic.” By taking prompt action, people in the pre-diabetic category can help prevent or delay for years the onset of the actual disease. Diabetes prevention trial data show that pre-diabetics, by following a program of diet and exercise, can reduce their risk for overt diabetes as much as 58%. The recommended target for weight loss is at least 7% of initial body weight. The recommended exercise goal is 150 minutes per week (e.g. 30 minutes of
Northern Colorado Medical & Wellness
brisk walking five days per week). It is also suggested that pre-diabetics attend diabetes classes such as those offered at the Poudre Valley Hospital Center for Diabetes Services, North Colorado Medical Center in Greeley, Partners in Nutrition and Diabetes in Loveland and other diabetes education organizations in the region. People, whose blood sugar level has been verified to be 126 or above, have diabetes and must immediately begin a program of treatment and disease management. Doctors commonly begin by recommending that the newly diagnosed diabetic attend diabetes education classes. Concurrently, a diet, exercise and weight loss plan is implemented and a medicine program, often involving the drug metformin (Glucophage®, GLUMETZA, FORTAMET®), is begun. Metformin has been shown to reduce blood sugar level by 30%
and is safe for most people to use. Common side effects include nausea and diarrhea. People with significant kidney or heart problems, however, cannot use metformin safely. Doctors also use a number of other diabetes medicines to help control the disease. Sulfonylureas are a class of drugs that are relatively inexpensive and safe. Thiazolinediones (Avandia®, Actos®) can be effective drugs in certain cases but have some risk for fluid retention and may cause weight gain. New medicines that have become available over the past two years include the GLP-1 analog drug exenatide (Byetta®), injected before meals to help control diabetes, and the orally administered DPP-IV inhibitors, sitagliptin (JANUVIA) and vildagliptin (Galvus®). Side effects of these new drugs may include nausea and gastrointestinal problems. Weight loss is more
31
prevention
diabetes
There are roughly 21 million diabetics in the country and only about 2,000 endocrinologists specializing in diabetes treatment. As a result, primary care physicians treat ninety percent of diabetics. It’s essential that these physicians be provided with the latest information available. - Thomas Hanson, M.D. Thomas Hanson, M.D., Endocrinology
likely to occur with exenatide. Pramlintide (Symlin®) is yet another new drug, available only as an injection prior to meals. Like exenatide and sitagliptin, this agent suppresses glucagon, the opposite hormone from insulin. Uninhibited excesses of glucagon cause undesirable post-meal leakage of glucose from the liver storage reservoir. Dr. Thomas Hanson specializes in the treatment of diabetes. His office is located at Banner Health System’s North Colorado Medical Center in Greeley. Dr. Hanson is enthusiastic about the great strides that have been made in diabetes prevention and treatment. “We are in a new era. As an example, the GlaxoSmithKline ‘Dream Study’ results, published in 2006 for one of the thiazolinedione drugs, roseglitazone (Avandia®), that the drug demonstrated a preventive quality; about 60% of the pre-diabetics tested did not progress to diabetes.” Dr. Hanson has given over 50 lectures on diabetes to patients, doctors and other health care providers in the past three years. He emphasizes the importance of diabetes education not only to the general public, but also to the medical community. “There are roughly 21 million diabetics in the country and only about 2,000 endocrinologists specializing in diabetes treatment. As a result, primary care physicians treat ninety percent of diabetics. It’s essential that these physicians be provided with the latest information available.” Dr. Meriam Izon, located in Fort Collins at the
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Poudre Valley Health Systems’ Harmony Campus, also specializes in the treatment of diabetes. She indicates, “Diabetes is a progressive disease. We start treating patients with one medication and, as the disease progresses, typically change or add other medicines. Although Type 2 patients normally do not require insulin injections at the onset of their disease, they likely will within 10 years. In this case, insulin will be used in combination with oral medication.” According to Dr. Izon, in some instances, insulin is administered earlier in the disease’s progression for better control. In addition to the direct treatment of diabetes itself, Dr. Izon points out, “Heart disease is very common among Type 2 diabetics. Diabetics may have ‘silent heart disease’ (with no classic chest pains) and not even know that they have a problem. For this reason, in addition to urging diet and weight control, doctors treat diabetes patients very aggressively to control cholesterol levels.” Dr. Hanson adds, “About 70% of heart attack victims have some type of diabetes or pre-diabetes condition.” People with Type 2 are also susceptible to other health problems. For this reason, Dr. Izon recommends that they have annual eye and foot exams, a yearly kidney screening, and other periodic tests as appropriate. A person with Type 2 diabetes must adhere to a disciplined daily management routine in order to control his or her disease. Medication is typically taken once or twice per day. If insulin injec-
tions are called for, they are commonly self-administered one or two times per day when first started, and as many as four times per day after a period of several years. Initially, blood sugar levels are tested three to four times per day. Once the disease has been stabilized, levels are tested every other day, three times per day. The diabetic performs the tests using a small meter. A small amount of blood is obtained by pricking a finger with a lancet. The blood is applied to a strip that is read by the meter. Results are obtained within five seconds. Blood sugar readings with the diabetes under control should be as follows according to the American Association of Clinical Endocrinologists (AACE): Before a meal.......................80-110 Two hours after a meal.........Below 140 At bedtime...........................100-140 In addition to the above tests, people with Type 2 diabetes take a Hemoglobin A1c test every 3-6 months. This test indicates the average blood sugar level over the previous few months, expressed as a percentage. The closer a diabetic can keep his or her A1c results to 6%, the more the diabetes is under control. In order to get a first-hand point of view from a person with Type 2 diabetes, the writer interviewed Susan, a professional woman in her fifties. Susan experienced gestational diabetes during two of her pregnancies. Gestational diabetes continued to page 34
continued from page 25 about what it is to be a CNM. “We don’t deliver babies at home. We always use the hospital.” (This is as opposed to lay midwives who do sometimes deliver at homes and are not required to be nurses.) Foose adds, “Sometimes women think, ‘If I go to a midwife, they are going to require me to have a natural childbirth.’ This is certainly not the case. We support whatever you want.” The goal at Center for Women’s Health is to educate a mother and her family about the options available and support whatever type of birth they desire. Finn relates that her birth of Grant was so fast, there wasn’t much time for more than an IV dose of meds. However, her first child, Hannah, took twelve hours and she did use an epidural. The Center emphasizes family as a whole participating in both pregnancy and the delivery if it is desired. Foose says, “I like to get families involved – I want the dad to be an active participant in the birth and almost always have him cut the cord. Occasionally I’ll have a dad who wants to help deliver and I fully support that.” Robyn Riggins is currently receiving pre-natal care for her third pregnancy with the Center. She says, “They are more like a trusted friend you can call with questions. Just last week I called Marie [Foose] at 7:00 at night with a question about cramping. She is almost an adopted grandparent to my girls. Even my husband trusts her with questions.” The CNMs and doctors at Center for Women’s Health work together in concert, consulting together on patient care. Foose says, “I think that also gives women piece of mind, knowing that we have the back up of the doctors if needed.” In addition to the CNMs on staff at the clinic are two OBGYNs, Dr. Stewart Abbot and Dr. Kevin Hess, an ultrasonographer, a massage therapist certified in prenatal massage, and an aesthetician, as well as a team of office staff who, all together provide excellent care with the feel of a family. In 2006 the practice as a whole delivered 354 babies, of which 202 were delivered by CNMs, Foose and O’Leary. The collective experience at this clinic is impressive and the stories abound. Both CNMs are also mothers and they agree that it makes a big difference in the care they are able to provide. Foose is a mother of seven children and O’Leary is a mother of three. They remember what it’s like to be pregnant and can empathize with their patients. Their trust in their physicians is also evident; Dr. Abbot delivered several of Foose’s children. As Foose’s oldest daughter, Silky, grew she attended the births as well. She grew in confidence and skill, at times cutting the cord, until the birth of the last baby. When Abbot arrived at the hospital he said, “Well, Silky, what are you going to do this time?” She replied, “I think I’ll catch.” And she did. Silky is now a neonatal nurse and her mother couldn’t be more proud. Providers as dedicated to families as the staff at the Center for Women’s Health are building a legacy of families and children who are well loved. It’s easy to see that care here comes from the heart. Corey Radman is Assistant Editor at Style Magazine.
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prevention
diabetes continued from page 32 usually disappears after childbirth, however women who have had this form of the disease are more at risk for subsequently developing diabetes - most often Type 2. Fifteen years following her second incidence of gestational diabetes, Susan discovered that she, in fact, had Type 2. Susan has been dealing with Type 2 diabetes for over five years. Initially, she had no pronounced symptoms she generally “felt good.” A blood sugar level test from her physician indicated a higher-than-normal level but a follow-up test was normal. It took some time to clearly diagnose her condition as Type 2. After a few years under the treatment of her physician, she decided to see a specialist. The specialist suggested that she attend diabetes classes at Poudre Valley Hospital. Susan found this to be very helpful, as she previously had known little about her disease and how it could be helped by proper diet, exercise, and self-monitoring of blood sugar levels through the use of a meter. Under the care of her specialist, Susan currently follows a medication and testing plan that keeps her blood sugar level, in her words, “under reasonable control.” Although Susan is able to maintain her work schedule and enjoy her life outside of work, she wants people to know that having diabetes is no walk in the park. “It can be overwhelming. It’s wearing on a person. You just get tired of it – taking pills and giving yourself shots. I couldn’t do it alone. My family and friends provide a valuable support group by reminding me to take my medication, eat properly and regularly test my blood sugar.” Susan concludes, “If at all possible, don’t get it. It’s expensive…health-wise and financially.” Court Klinck is a freelance writer living in Greeley.
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Sources for Diabetes Information and Classes: American Diabetes Association General Information (800) 342-2383 Books or Catalog (800) 232-6733 Subscription and Membership (800) 806-7801 Web Site www.diabetes.org Poudre Valley Hospital Center for Diabetes Services, Fort Collins General Information/Class Registration (970) 495-8205 Web site www.PVHS.org Multi-Specialty Clinic at North Colorado Medical Center, Greeley General Information/Class Registration (970) 378-4676 Partners in Nutrition and Diabetes, Loveland General Information (970) 622-9997 Class Registration (970) 613-4106 Weld County Department of Public Health and Environment, Greeley General Information/Class Registration (970) 304-6420, x2389 Inquiries Regarding Free Classes in Spanish (970) 304-6420, x2376
prevention
diabetes effects
the diabetic foot
by daniel Hatch, M.D.
Doctors Hatch and Vaardhal of the Foot and Ankle Center treat a variety of foot and ankle problems ranging from bunions, foot and ankle reconstruction, trauma, pediatric clubfoot, and diabetic foot related problems.
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his latter sub specialty has grown exponentially over the past several years due to the aging population and medical advancements enabling individuals with diabetes to live longer lives. Unfortunately, with advanced years, some patients may experience more long term complications of diabetes that affect the feet. There are four categories of diabetes; however, there are two main types. Type 1 has been known as insulin dependent diabetes mellitus (IDDM). This is a disease process affecting the pancreas with insulin deficiency. Type 2, formerly known as non insulin dependant diabetes mellitus (NIDDM) accounts for more than 90% of the cases observed. This condition results in high levels of blood sugar (hyperglycemia) as a function of insulin resistance. The other categories include genetic causes and gestational. Individuals with diabetes are prone to a variety of foot problems. This is primarily due to two major complications of diabetes: nerve damage (neuropathy) and poor circulation. As a result of these issues, a minor problem to most people, such as a tiny cut or blister, may result in a severe limb-threatening infection. Foot and lower extremity amputation may affect as many as 20% of all individuals with diabetes. More than 80% of amputations are a result of a previous history of foot ulcer and subsequent infection. In the United States, there are over 80,000 diabetic related lower extremity amputations performed yearly. Direct and indirect costs of a lower extremity amputation ranges from $20,000 -$40,000 per event depending on level of amputation, length of stay, and coexisting medical factors. In 1995, lower extremity ulcer patients cost the Medicare system over 1.5 billion dollars. Certainly, these statistics have driven the interest in the treatment of diabetic foot disorders and infections towards rapid intervention and prevention. There are a variety of theories regarding the formation of neuropathy. This condition has variable presentations such as numbness or pain in legs especially noticed at the end of the day or night. It is the numbness that makes individuals at risk to injury and ulcer formation. People with normal sensation in their feet know when there is a problem. An obvious stepping on a foreign object or formation of a “hot spot� or blister is easily known. However when neuropathy is present, any trauma to the foot may not be realized.
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Subsequently a blister with resultant ulcer formation may occur. A team approach is needed to treat diabetic foot complications. Cardiovascular complications are currently the most common cause of pre-mature death among patients with diabetes. Additionally, peripheral arterial disease (PAD) plays a major role in wound healing and level of amputation if needed. The risk for infection is greater and more difficult to treat with diabetes with a mixed type of bacterial involvement and poor administration of antibiotics due to diminished blood flow. Increased awareness and screening for PAD is needed. The vascular flow to the foot is a critical factor in wound healing success. As such, when a diabetic infection occurs, the team of providers also involved may include: vascular surgery, cardiology, radiology, infectious disease, internal medicine, endocrinology, plastic surgery, general
and orthopaedic surgery. After care is also needed and provided by: diabetic education, wound nurses, physical therapy and pedorthist/orthotist. This team approach maximizes the best outcomes for limb preservation. A unique foot condition that is associated with diabetes is Charcot arthropathy. This is a condition usually associated with neuropathy. The foot can initially have the clinical appearance of infection with the presence of redness and swelling. This is due to increased blood flow and underlying micro fractures. If not treated properly, the foot can evolve into a collapsed widened architecture that makes it difficult to wear regular shoes and is
prone to forming ulcerations as a result of boney prominences. It is estimated that 1% of people with diabetes may get this condition however this statistic may be lower due to lack of awareness and diagnosis. New wound healing technologies have evolved in recent years to help with ulcer healing and diabetic foot complications. Endovascular techniques have been developed to improve blood flow by removing blockages within the arteries. Surgical, therapeutic and medical treatments have been utilized to treat neuropathy. Hyperbaric medicine is utilized to treat severe infections and help wounds heal by concentrating oxygen in the tissues. Negative pressure therapy is used to promote wound drainage and the stimulation of a healthy wound bed. Advanced wound technologies may include the use of growth factors, and bioengineered tissues. Prevention of diabetic foot related problems is the paramount issue. This can be accomplished through awareness and education. People with diabetes should have their feet checked annually. Focus should be on any predisposing factors to ulcers such as foot deformities, poor circulation, and decreased sensation. If an individual has neuropathy they should be screened at least twice per year. If someone has had a previous ulcer they should be evaluated at least quarterly. Reduction of trauma to the feet in the form of pressure and shear forces is critical to ulcer prevention. Individuals with pre disposing risk factors (deformity, numbness, poor circulation) and diabetes should wear special shoes and insoles for reduction of the incidence of ulcer formation. Whether it is foot and ankle reconstruction or treatment of diabetic foot disorders, Drs Hatch and Vaardahl are here to serve as partners of the Foot and Ankle Center. Dr Hatch will be president of the American College of Foot and Ankle Surgeons in March 2007. This is a national educational college that serves over 6000 board certified foot and ankle surgeons in areas of research, education, and scientific advancement. He is on staff at Medical Center of the Rockies, Poudre Valley Hospital and North Colorado Medical Center. www.footandanklecolorado.com Author’s note: information and references obtained from: Diabetic Foot Disorders: A Clinical Practice Guideline, supplement to the Journal of Foot and Ankle Surgery,Vol. 45,2006.
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Lydia's STYLE Magazine
prevention
diabetes effects
bunion!
Even the sound of this word makes a person not want one. Whether you call it a bunion or ‘hallux abducto-valgus,’ the proper medical term, you don’t have to have this ugly and painful foot deformity.
by Dr. James C. Anderson, DPM
M
ost foot specialists agree that a large part of what creates a bunion is the foot type that you inherit. Although shoes may contribute, the majority of the problem is caused by poor foot mechanics. When the large first metatarsal bone (big toe) deviates towards the second metatarsal (second toe) this shifting creates an angle between the two bones rather than the desired parallel relationship. This shift creates the bump that you see by the big toe. The bump itself is caused by the misalignment between the metatarsal bones instead of being a boney growth. Treatment options for bunions can include buying shoes that are wider in the toe area. Padding can also be used. Devices that splint the big toe to straighten it have no proven benefit. The two options that podiatrists offer are custom orthotics or surgery. Orthotics can be of benefit to patients who have mild or early stage bunions. It is important to stress the importance of ‘custom made.’ I was recently interviewed by John Ferruga on Channel 7 regarding the large number of consumer complaints about the many orthotic type retail stores that make orthotics. They are made from a weight bearing technique and therefore cannot be made to always support the foot in its ideal neutral position. This is done by standing on a surface and then an arch support is taken off the shelf. Many times they cost as much or more then a custom made orthotic from a podiatrist. It is important to know the difference between the two as it is a common occurrence for patients to have to start the orthotic process over in the podiatry clinic. Proper orthotics can slow down the progression of the bunion and can help with pain. For many, surgery is the treatment of choice. Many people choose this
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option because of its very high success rate. When surgery is performed, the bump on the metatarsal bone is removed but more importantly the first metatarsal bone (big toe) is shifted closer to the second metatarsal (second toe) so they are more parallel. This gets rid of the bump and makes the foot narrower. The importance of shifting the bone cannot be overemphasized. Before this newer technique was done many bunion surgeries gave very little correction and pain often returned. Both feet can usually be done at once and surgical shoes are used for three weeks, gradually transitioning to lace shoes and eventually dress shoes after that. The surgery is done on an outpatient basis under local anesthesia with sedation so general anesthesia is not needed. Post-operative pain is minimized with long-acting anesthetics and a special cooling system that is placed inside the dressing to minimize pain and swelling. We are fortunate to have the only foot surgical center in Colorado and the surrounding states. Our center, The Foot Surgery Center of Northern Colorado, has its own staff of well trained R.N.’s and surgical assistants that have additional specialized training in foot and ankle surgery, creating the ideal location for these types of procedures. So for many that have had to alter their activity level or who find many shoes difficult to wear, there is a solution. The Poudre Valley Foot and Ankle Clinic and Foot Surgery Center of Northern Colorado can help you get active and pain free and allow you the freedom to wear more of the types of shoe you want to. Maybe you’ll be able to get that ugly medical word, ‘bunion,’ out of your vocabulary, and shoes!
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treatment
temporomandibular joint disorder Dr. Overton redies patient, Meredith Dody-Hettler, for TMD treatment.
Do you suffer from frequent headaches or migraines? Do you have facial or jaw pain? Shoulder or neck pain? Sinus pain? Do you hear ringing in your ears? Do you experience numbness and tingling in your fingers and arms? Does your jaw lock up or are there times when you have limited jaw movement? Do your jaw joints click or pop? Do you have sensitive or sore teeth? Do you have worn or cracked teeth?
TMD: New Treatment by lynn dean
If you answered yes to any one of the questions above, you might be among the 15 percent of the population that suffers from TMD or temporomandibular joint disorder and you might not even know it.
“M
ost of the patients I treat with TMD come in with another problem,” says Dr. Thomas Overton, DDS of the Overton Center for Dental Arts in Fort Collins. “Many patients come in to address a cosmetic problem such as worn-down front teeth caused by grinding. After interviewing them I find out that they have a TMD problem.” What causes this common disorder? “It can be caused by a variety of problems,” says Dr. Overton. He explains that TMD can be caused by
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an actual degeneration of the jaw joint itself, or it can be due to a misalignment of the teeth and jaw which leads to a dysfunction of the muscle systems that move the jaw. “When these muscles aren’t functioning properly then people get headaches, joint pain, and referred pain to the teeth and the muscles in the neck and shoulders.” Because the symptoms of this disorder often masquerade as other problems, it is often under diagnosed and its true causes go untreated. That’s exactly what happened to Austin Seley, one of Dr. Overton’s patients. “I suffered with problems
for two years or more,” he says. “I was grinding and clenching my teeth at night and it was really affecting my sleep. I was also getting a lot of headaches. Then I heard about a new technique to treat TMD offered by Dr. Overton. I went in for a consultation.” Dr. Overton studied the field of neuromuscular dentistry at the Las Vegas Institute for Advanced Dental Studies and it was there that he learned how to diagnose and treat TMD using the latest in modern technology. “The first thing I do when I see a patient I suspect has TMD is to order a
When these muscles aren’t functioning properly then people get headaches, joint pain, and referred pain to the teeth and the muscles in the neck and shoulders. - Thomas F. Overton, DDS -
digital CT scan to rule out degenerative problems, which would require a referral.” explains Dr. Overton. “If the problem is muscular, then I’ll proceed with diagnostic tests.” Dr. Overton uses the K7 Evaluation System, which according to its manufacturer, Myotronics, “is a computer-based system for three-dimensional jaw tracking, surface electromyography and temporomandibular joint sound study.” Simply put, according to Dr. Overton, “the machine measures muscle activity in all of the different muscles you chew with. It will tell me whether the muscles are overactive. I can measure the function of the jaw, how people bite together, whether they bite together in the same place each time or if the muscles are trying to figure out what to do each time which leads to a build up of lactic acid and that leads to pain.” The next step of the process is to relax the muscles of the jaw using a TENS (Transcutaneous Electrical Nerve Stimulation) Unit which causes an involuntary contraction, and then release of the muscles through an ultra-low frequency electrical stimulus. “I will TENS all the chewing and shoulder muscles,” explains Dr. Overton. “Once the muscles are relaxed, I’ll use the K7 to determine where the lower jaw is in relation to the upper jaw and compare that position to the bite position. This comparison tells me where we need to go to get to the point where the patient can bite more comfortably.” “We came up with where my jaw should be
Northern Colorado Medical & Wellness
39
treatment
temporomandibular joint disorder
The Tens Unit has given me relief and allowed my jaw muscles to relax for the first time ever. - Meredith Dody-Hettler, patient -
TENS Unit electrodes are affixed to the jaw & neck muscles.
aligned,” adds Seley. “My bite was off. There was more pressure being put on my front teeth than on my back teeth. I was grinding really hard, too.” Meredith Dody-Hettler, a CSU student was experiencing her jaw snapping when she opened her mouth or yawned. She was grinding her teeth at night and when studying she would clench her jaw trying to adjust her bite. She had a lot of tension in her jaw which she just couldn’t relax. After she started the treatment, she said “The Tens Unit has given me relief and allowed my jaw muscles to relax for the first time ever. The splint I wear at night has helped so much. The jaw muscles have relaxed and are allowing my bite to fit in a natural
position, finally.” “Many people are surprised by how long this diagnostic process can take,” says Dr. Overton. “The appointments are long because you have to TENS for at least an hour. The initial appointment lasts three hours.” After this lengthy diagnostic process, Dr. Overton takes bite impressions so that an orthotic for the teeth can be built. “It changes the position of where their lower jaw is to that place where the patient’s muscles are comfortable.” For a lucky few, the orthotic device is all that is needed to end the suffering. For others, however, it is only the first step in the treatment plan. “Often the orthotic is just a diagnostic. If the patient can get away with just wearing it at night, and that’s enough to make them comfortable, then we’re done,” says Dr. Overton. “But, if they have to wear it all the time to stay comfortable- most people aren’t going to want to do that long term. The next option is to fix the way the teeth fit together with orthodontics (braces) or with crowns, or with a combination of them both. Sometimes all that’s needed are slight adjustments to the teeth so that they fit together better.” Dr. Overton cautions that this is not a quick fix. “The initial phase usually takes about three months. Then, if you combine it with orthodontics and restoratives, it can take up to three years.” Even so, his patients feel the tradeoff is worth it. “I wasn’t looking for instant results,” explains Seley. “I went in knowing this was a very slow process. But after weighing the pros and cons of doing surgery on my jaw versus wearing a bite plate, I felt the time commitment was worth it. I used to wake up hearing ringing in my ears and had severe popping when I opened my mouth. Now I sleep better - the neck and back pain from the clenching are gone. I would recommend that anyone who’s having symptoms go in for a consultation. I chose Dr. Overton because of his tolerance and patience during this whole procedure, his ability to communicate a treatment plan, and what the goal of that plan was, and his dedicated follow-up. He’s also got a wonderful staff.” Lynn Dean is a freelance writer in Fort Collins.
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.,% "',- " %&&& ™ l l l # j a i g V W a ^ h h # X d b Dr. Ralph Reynolds is Medical Director at Orthognathic Facial Orthognathic Facial Reconstructive Surgery Bliss Medical Spa. Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Board Certified Oral and Orthognathic Facial Reconstructive Surgery Orthognathic Facial Maxillofacial Surgeon Reconstructive Surgery Orthognathic Facial Reconstructive SurWisdom Teeth • Dental Implants • Orthognathic Surgery Facial Cosmetic/Plastic Surgery gery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Reconstructive Sur2992 Ginnala Drive • Loveland, CO 970.663.6878 • www.reynoldsoralfacial.com gery Orthognathic Facial Reconstructive Surgery Orthognathic Facial Dr. Ralph R. Reynolds, DMD, MD
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icare - intensive care unit
Phoenix, we have a problem No, it’s not Apollo 13’s, James Lovell’s, failing geography. The Apollo commander had effectively communicated with NASA’s hub in Houston during the legendary ill-fated mission. But for the intensive care unit staff at North Colorado Medical Center, Phoenix - or specifically the adjunct community of Mesa, Arizona - has become the command center for what some have called a kind of Star Trek technology - a telemedicine venture saving lives, and solving problems, in quantifiable numbers.
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tardate: February 2006. Following four years of exploration and based on a “radical idea” hatched in 1997 by Johns Hopkins School of Medicine faculty Brian Rosenfeld, M.D. and Michael Breslow, M.D., and based in part on NASA technology, Banner Health introduced eICU technology, or its branded iCare, to four Phoenix-area hospitals. A 16-bed partial launch at NCMC’s intensive care unit followed in March of that year. The technology involves remote, wall-mounted, high resolution cameras in individual ICU rooms with the capacity to sweep the area and all of its equipment (ventilators; heart monitors; blood oxygen indicators and more), as well as key in on specific numbers and graphs and even the patient’s facial expressions as pain is registered. The transmission of these images goes directly to the COR, or Clinical Operations Room, on the campus of Banner Desert Medical Center in Mesa, where it is monitored by an intensivist: a critical care specialist (M.D.) who for this purpose is also trained in eICU technology. According to Forbes magazine, at its inception at Johns Hopkins 10 years ago, Rosenfeld and Breslow set up perfunctory videoconferencing equipment at a Baltimore, MD, ICU, sending video feeds and real-time patient vital signs data to computers in the physicians’ own homes. Taking turns monitoring patients from home for 24-hour shifts, the ICU mortality rate declined at that one hospital by an astounding 50%, causing what would become a technological revolution in patient care. Rosenfeld and Breslow went on to found a company called Visicu to produce and market the venture, which currently serves as Banner Health’s vendor. As Medical Director, iCare, for Banner Health, Dr. Robert Groves oversees the technology’s growth and development throughout its hospital system. NCMC is the only hospital in Colorado to have sICU technology. Ceding that annual hospital, and especially ICU, death rates can be high almost anywhere (nearly 98,000 Americans die each year from “preventable medical errors” according to1999 and 2001 reports by the National Academy of Science’s Institute of Medicine), a number Dr. Groves says is now “…compounded by baby boomers beginning to reach their 50s and 60s in increasing numbers,” he attributes many of these preventable errors to overextended medical personnel and/or understaffed institutions. What’s more, and unbeknownst to many, is that while ICUs are manned overnight by critical care nurses and other personnel, the intensivist (or M.D.) works during the daytime. Though doctors from various disciplines can often be accessed through-
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out the hospital at night, the intensivist, or real expert in managing critical care, has probably gone home and relies on a phone call – and description or interpretation of the problem - from hospital staff to make what could be a life and death care decision in the middle of the night. The intensivist may decide it is prudent to return to the hospital, but the trip can take upwards of 30 minutes. With an absence of physicians continually monitoring patients, one medical publication characterizes so-called off-hours care purely as “crisis intervention.” “The climate for critical care medicine in the United States is a bit chaotic,” Dr. Groves explains. “There’s a tremendous shortage of intensivists coming out of training, largely because the discipline is predicated on years of additional training, certification, and a fellowship after medical school, internship, and residency. We’ve got a supply and demand problem.” In fact, The Leapfrog Group, a Washingtonbased consortium of major corporations and agencies that buy healthcare for their employees and members, has determined that 24/7 intensivist-led ICUs are a healthcare priority today. “Their criteria are only met by about 10-20% of all intensive care units around the country,” Dr. Groves says, adding that compliance would mean training 30,000 intensivists. “The best estimate right now is that we’re going to have 5000 by the year 2020.” The eICU concept, while unarguably providing back-up or secondary care (one expert says while the camera can’t intubate, it can cue the staff that intervention is necessary), nevertheless is a consistent presence in a critical care environment. Undaunted by hefty education and training requisites, Dr. Anthony “Sid” Sado entered critical care 25 years ago. An intensivist who frequently helms the iCare COR in Mesa, he has the distinction of having been the first critical care fellow in the United States Army. Dr. Sado describes both the work and the technology “…like a pilot in the sky constantly monitoring the dashboard to make sure everything is normal.” In his case, “everything” is 76 ICU beds in five Banner Health hospitals spread across 1000 miles, with a projected rollout to encompass all 320 ICU beds in 15 facilities in the next 2-3 years. Where privacy issues are concerned, according to Peggy Connor, NCMC Chief of Nursing Officer, the camera is on only when it needs to be. In fact, while vital signs and the like are constantly monitored, a doorbell on the camera informs the patient that it is now live as it repositions itself to peruse the room and the patient. The intensiv-
by Beth A. Herman
.
ist in the COR can also make voice contact with the patient as an actual bedside physician would during rounds. The technology is totally HIPAAcompliant, Connor says, referring to the Health Insurance Portability and Accountability Act enacted by Congress in 1996, which established national standards for electronic healthcare transactions. She notes there is no video or audio recording capability; everything is done in real-time. Both patients and their families are prepared for the camera prior to ICU admission, with frequent reminders to patients whose memories may be compromised by medication. What does the next generation of eICU technology hold for patients? “Right now,“ Dr. Groves says, “among other things, the technology can actually triage our attention to those patients who need us most: alarms, or alert systems, warn us of adverse trends before they become adverse outcomes.” Patient care decisions are then made by the physician accordingly. In the future, the technology’s intrinsic “clinical intelligence” will become far more sophisticated, he says. “You won’t even need a physician to make those decisions.” Beth Herman is a freelance writer.
continued from page 23 the vaginal wall. This is a common problem and over14 million women in the U.S. suffer from it. In the case of vaginal vault prolapse, it is more common in women who have had hysterectomy. It occurs when the uppermost part of the vagina—called the apex—descends because it does not have the same support that was there when the uterus was present. As a result, the apex pulls the rest of the vagina down into the vaginal canal or even outside the vagina. The pain and discomfort with prolapse can be considerable. Often, women will refrain from sexual intercourse because of discomfort, limit physical activity and may be faced with associated urinary or fecal incontinence. Vaginal vault prolapse can occur alone or along with a cystocele (dropping of the bladder into the vagina); urethrocele (sagging of the urethra into the vagina); rectocele (pushing of the rectum into the vaginal wall); or enterocele (bulging of the small intestine into the vaginal wall). Treatments available for prolapse depend on the type of prolapse that is presenting and its severity. Pelvic floor exercises or a vaginal pessary device placed in the vagina to support surrounding structures are two traditional, non-surgical treatments. Surgery for prolapse has made considerable strides in recent years, and physicians now can offer a number of long-term surgical solutions. Many use a mesh—either synthetic or biologic or both—to provide support for the organs necessary to restore the vagina to its normal anatomical position. Mesh is soft and has large pores designed to allow your body tissue to grow into it, providing a framework of support. The use of surgical mesh is not new. It has been used in surgery for many years. For those women who have more than one type of prolapse, all can often be repaired during one surgical procedure. Surgery for prolapse is an in-patient procedure. After the surgery, most patients notice immediate results. For severe cases of vaginal prolapse, minimally invasive techniques utilizing laproscopic surgery and the DaVinci Robot System are now replacing standard open surgical procedures, thereby minimizing postop recovery times. The best news about pelvic organ prolapse is that women do not have to live with it or its associated pain and discomfort.
Dr. Phillips is one of eight urologists that make up the newly formed Urology Center of the Rockies, P.C. with offices at 1500 S Lemay in Fort Collins and 1647 E. 18th St. in Loveland. The physicians and staff at the Urology Center of the Rockies understand how life-altering incontinence can be. Please contact us at 4846700 in Fort Collins or 669-9100 in Loveland for a consultation about your specific situation and available diagnostic and treatment options.
Northern Colorado Medical & Wellness
43
education
sleep Disorders
Sleep disorders Center of the Rockies’s Cindy Crosby demonstrates the sleep lab patient bed wired with electrodes.
more than just
beauty rest
by court Klinck
Sleep disorder specialists indicate that 40% of the U.S. population will experience some type of sleep problem in their lifetime.
I
n addition to the well-known negative affects of inadequate sleep, sleep-related disorders can lead to serious health conditions such as hypertension, heart attack, stroke, and depression. Fortunately, most sleep disorders can be controlled (although not necessarily cured), and serious medical consequences avoided. Two of the six sleep disorder centers in Colorado accredited by the American Academy of Sleep Medicine (AASM) are located in the Fort Collins-Loveland area. The Poudre Valley Hospital Sleep Center at Mountain Crest is in Fort Collins, and The Sleep Disorder Center of Northern Colorado at McKee Medical Center is in Loveland. Each of the two sleep centers has a sleep lab where patients are tested under actual sleeping conditions. Sleep Disorders Center of the Rockies manages and operates the centers. Dr. Mark Petrun is the sleep program director. Dr. David Kukafka is the director of the Loveland center, and Dr. Mark Neagle is the director of the Fort Collins center.
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Sleep Business Coordinator, Cindy Crosby, provides administrative coordination and support to lab supervisors Chequita Robinson and Jason Buschmann. There are a number of different conditions that fall under the heading of “sleep disorders.” The most significant of these are: Insomnia: Defined as not being able to fall asleep or remain asleep. This condition can have a variety of physical and psychological causes. Sleep Apnea: Obstructive apnea is the most common type of apnea in which breathing is temporarily blocked during sleep by the tongue and other soft tissues of the throat. This results in loud snoring and lapses in breathing that can occur hundreds of times a night. Symptoms include daytime sleepiness or falling asleep easily during the day without meaning to, gasping or snorting during sleep, being tired even after a full night’s sleep, waking up with a headache, and memory impairments. Sleep apnea is extremely under-diagnosed and, left untreated, can lead to problems such as high blood pressure, heart attack and
stroke. Patients with this condition represent, by far, the highest percentage of those treated at the Fort Collins and Loveland sleep centers. Snoring: Similar to sleep apnea, snoring is caused by some disruption of airflow during sleep. Dr. Kukafka cautions, “People who snore are at risk for sleep apnea or respiratory event related arousals (RERAs). If a child snores, he or she may have sleep apnea. Removing the child’s tonsils can help significantly.” Dr. Petrun adds, “Snoring in children is never normal and should be treated expeditiously. Many children are misdiagnosed because snoring manifests itself as decreased school performance and ADD type symptoms.” Narcolepsy: This condition, usually occurring in young adulthood, involves recurring episodes of daytime sleep and frequently disrupted sleep at night. Symptoms often include: attacks of extreme generalized muscular weakness, sleep paralysis, and hypnagogic hallucinations (very vivid dreams). Parasomnia: This condition encompasses unusual sleep behaviors during the night such
Sleep lab testing usually includes use of a device called CPAP (“see-pap”) – Continuous Positive Airway Pressure. During the sleep lab session, the sleep lab technician evaluates the patient’s condition for the first part of the night and, if necessary, uses CPAP during the second part. CPAP is relatively simple and is the preferred method for treating sleep apnea. as complex motor acts (e.g. sleep walking), night terrors, urinary incontinence (not due to physical causes), and nocturnal seizures. When a patient first arrives at one of the NCPC sleep centers, a medical history is taken including all relevant data associated with the specific sleep problem. A physical examination is then performed. According to Dr. Kukafka, “The main complaints we get from patients are ‘I don’t sleep,’ ‘I don’t sleep well,’ and ‘I’m tired during the day.’ We begin with these broad symptoms and narrow them down to obtain a specific diagnosis.” The doctor determines whether a visit to the sleep lab is required to more precisely diagnose the patient’s condition and identify treatment options. In the case of the Fort Collins and Loveland sleep centers, approximately 70% of incoming patients are scheduled for tests at the sleep lab. The writer was invited to visit the Fort Collins sleep lab to observe two patients being tested. Let’s call them Charlie and Christine. Charlie is a big man in his 60s. His doctors diagnosed possible
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Critical Care
Sleep Disorders
Diana Breyer, M.D.
Stan Gunstream, M.D.
James Hoyt, M.D.
David Kukafka, M.D.
Rick Milchak, M.D.
Mark Neagle, M.D.
Mark Petrun, M.D.
Eric Stevens, M.D.
Kristin Wallick, M.D.
Pulmonary Disease | Asthma | Emphysema COPD | Hypoxia | Critical Care | Sleep Disorders | Pulmonary & Exercise Testing FOrT COllinS 2121 E. Harmony Rd., Ste 300 Fort Collins, CO 80528 970.224.9102
lOvElAnD 1808 N. Boise Ave. Loveland, CO 80538 970.461.9124 45
treatment
sleep disorders
People who snore are at risk for sleep apnea or respiratory event related arousals (RERAs). If a child snores, he or she may have sleep apnea. Snoring in children is never normal and should be treated expeditiously. Many children are misdiagnosed because snoring manifests itself as decreased school performance and ADD type symptoms. Mark Petrun, M.D., Northern Colorado Pulmonary Consultants, P.C.
sleep apnea while he was in the hospital for heart surgery. He was tested in the sleep lab soon after surgery but was unable to sleep long enough for conclusive results. He came back to the sleep lab for a second test. Christine is a trim, petite woman in her 40s. She has had a serious snoring problem for about 20 years and has had problems sleeping for about five years. A friend noticed that she was gasping for air a number of times during the night. She was afraid of having a stroke and came to the sleep center. The sleep lab is configured with testing areas much like hotel rooms to give patients a feeling of comfort and allow them to relax as much as possible in order to fall asleep. Charlie and Christine were each escorted to their own private room, and each was connected to a number of measuring devices. Sleep technician Rene DeMattei made the connections and handled all aspects of the subsequent testing. Roughly twelve tiny discs, called electrodes, were attached to each patient’s head and face. The electrodes measure brain waves, eye movements, and muscle tone. Two additional electrodes were attached to the chest to measure heart rate. To measure breathing patterns, two sensors were taped under the nostrils, and belts were placed around the chest and abdomen. A probe that shined a light through the patient’s finger was connected to measure blood
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- Mark Petrun, M.D. -
oxygen. Electrodes attached to each shin measured leg movements. For patients such as Charlie and Christine who are suspected of having sleep apnea, sleep lab testing usually includes use of a device called CPAP (“see-pap”) – Continuous Positive Airway Pressure. During the sleep lab session, the sleep lab technician evaluates the patient’s condition for the first part of the night and, if necessary, uses CPAP during the second part. CPAP is relatively simple and is the preferred method for treating sleep apnea. It consists of a small blower motor (easily fitting on a night table), connected to a hose, which passes through a container of water to add moisture, and is then connected to a mask held in place over the patient’s nose. It blows room air (not oxygen) through the mask into the patient’s nose. The air holds the patient’s airway open, allowing the patient to simultaneously sleep and breath. Crosby emphasizes the importance of the CPAP mask. “There are several types of masks, some covering just the nose or nostrils, and some both the nose and mouth. One of the really critical aspects of using CPAP effectively is getting the patient comfortable with the mask.” After Charlie and Christine completed their testing, Crosby and Robinson reviewed the approximately 1,000 pages of test data for each.
Test data for Charlie indicated a moderate case of sleep apnea. In the first half of his test, he was experiencing lack of sufficient airflow (called an “event”) 29 times per hour. CPAP was employed during the second half of his testing, bringing the number of events down to two per hour. In Christine’s case, she was also diagnosed with moderate sleep apnea. This did not show up until late in the test so there was not enough time to employ CPAP. Dr. Petrun, Christine’s physician, recommended a second study using CPAP. Patients with sleep apnea are typically asked to use CPAP (obtained through a home health care provider) at home for four to six weeks and then return to the sleep center for evaluation. If the patient’s condition has improved significantly, continued CPAP use will likely be recommended. If problems persist, a second sleep lab study may be suggested. If CPAP eventually turns out not to be a complete solution, other complementary corrective measures such as installing dental devices or having surgery may be necessary. For more information on sleep disorders and treatment options, contact your doctor or Sleep Disorders Center of the Rockies at (970) 663-3377 or toll free at (888) R-SLEEP-N (888-775-3376). Court Klink is a freelance writer in Greeley.
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Anthony F. Girardi, DDS David M. Jones, DDS Kelly B. Jones, DDS, MS Jason E. Maines, DDS, MS
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surgery
otolaryngology benefits of Balloon Sinuplasty: + Safety and effectiveness. While every surgery involves some risk, studies have demonstrated the Balloon Sinuplasty system to be safe and effective in eliminating sinusitis symptoms. + Minimal invasiveness. Devices used are small, soft and flexible and are inserted into the sinus area through the nostrils. + Less bleeding. There may be less bleeding, since, often, no bone or tissue is removed during surgery. + Faster recovery. Recovery times vary with each patient, however some patients have been able to return to their normal activities within 24 hours.
Balloon Sinuplasty
by court Klinck
Sinuses are air-filled pockets located around the nose. There are four sinuses on each side of the face. Each sinus has an opening for mucus drainage. The normal drainage process keeps the sinuses healthy. How healthy are your sinuses?
S
inusitis, a condition affecting 37 million people in the U.S. annually, involves inflammation of the sinus lining caused by infections or structural blockages of the sinus opening. When the sinus opening is closed, mucus drainage cannot occur, leading to sinus inflammation and infection. Common symptoms include: nasal obstruction, facial pain and pressure, loss of smell, headache, and discolored nasal discharge. For selected patients suffering from sinusitis, a new FDA-cleared surgical procedure, Balloon Sinuplasty, uses catheter-based technology - the Relieva Sinus Balloon System developed by Acclarent - to provide an improved method of surgical treatment. Balloon Sinuplasty widens a blocked sinus opening (ostium), often without having to remove tissue or bone. By gently dilating the ostium, normal sinus drainage and functionality are restored. Balloon Sinuplasty is an out-patient procedure done in the hospital or outpatient surgery center under anesthesia. An endoscope is inserted into the patient’s nose, allowing the doctor to observe
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the procedure. Using direct visualization with the scope, a thin wire is then inserted through the nose into the sinus cavity. The x-ray image allows the doctor to make sure that the wire is in the proper location. Next, a hollow sheath with a balloon attached is inserted over the wire and into the ostium. The balloon is inflated for 10-15 seconds and then the balloon, sheath and wire are removed. The procedure is repeated for other ostia that need to be opened. Dr. Mark Loury, a Board Certified Otolaryngologist located in Fort Collins, specializes in the management of ear, nose and throat disorders. His sinusitis patients typically have had recurrent sinus infections (three or more per year) requiring treatment with antibiotics, or have had individual sinusitis incidents of long duration. He is trained in the use of Balloon Sinuplasty and is offering the procedure to certain of his sinusitis patients as an alternative to conventional sinus surgery. Dr. Loury emphasizes that there is a progression of examination, diagnosis, and sometimes other treatment that occurs before Balloon Sinuplasty is recommended. First, the cause of the
sinusitis needs to be identified. In many cases, surgery is not indicated and the problem can be treated with medicines. For example, a patient whose sinusitis is caused by allergies may be effectively treated with antihistamines or steroid sprays. Patients of Dr. Loury whose diagnoses do not indicate treatment with medicines, and those who have already tried medicine treatment without success, are given a CT scan. The doctor attempts to have the scan performed when the patient is in a “best case” condition with sinusitis symptoms at the minimum. The scan clarifies the anatomy of the sinuses, pinpoints where sinuses are blocked and not draining properly, and identifies the extent of mucus membrane inflammation. A patient is a candidate for Balloon Sinuplasty if the results of the CT scan indicate that the sinus drainage openings are too narrow or obstructed, or if sinus inflammation exists even though the sinus anatomy is fairly normal. In Dr. Loury’s words, “Balloon Sinuplasty is another tool we now have to treat patients with extensive sinusitis. We are comfortable with the new procedure as it is similar to balloon angioplasty, used for several years with heart patients to open arteries.” Only doctors who have been qualified by the device manufacturer, Acclarent, are authorized to perform sinus surgery using the Relieva Sinus Balloon System. Dr. Loury received his qualification through attendance at Acclarent’s comprehensive Relieva Balloon Sinuplasty lecture and hands-on professional education program. He and other doctors who attended were able to interface with leaders in the field of otolaryngology as part of the interactive learning sessions. The program provided doctors with the opportunity to work with Balloon Sinuplasty devices and obtain the necessary skills to use the devices in their surgical practices. Acclarent, Balloon Sinuplasty, and Relieva are trademarks of Acclarent, Inc., Menlo Park, California. Some information in this article was obtained from published Acclarent material. Court Klinck is a freelance writer in Greeley.
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treatment
hand pain
Hands-on care
by corey radman
Maryann was working 12 hour shifts as a data entry clerk when she began experiencing severe pain in her elbows and hands. She had severe tendonitis in her forearms and thumbs. After trying multiple therapies with limited success, she found Brenda Cummings at Harmony Hand & Physical Therapy Center.
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ummings, a Registered Occupational Therapist and Certified Hand Therapist, implemented a multi-pronged approach to Maryann’s tendonitis. By utilizing an electrical modality that delivers stimulation and medication, ultrasound, joint protection training, manual therapies including deep tissue massage and neural gliding, and custom splints, Maryann is back at work. She still has much work to do in the coming months to fully heal her hands but the pain is manageable and she is “armed” with strategies to maintain her health now and in the future. Cummings has instructed Maryann on self-stretching exercises that she does every hour throughout the work day. Though she still has more occupational therapy to complete, she says, “I’m feeling much better.” Cummings relates that overuse injuries like Maryann’s, which was caused by prolonged typing in an awkward position, are very common. “When employees are sitting at a computer station incorrectly and for too long, it’s harmful. Take any opportunity you can to get your hands off the keyboard for a few minutes. Take a walk to the copier or go talk to a co-worker in person to allow your tendons/muscles to rest,” says Cummings. When Cummings sees a patient, she believes that her job is not only to treat the injured body part but also to educate the person about how they can best move and stretch to heal faster and prevent injuries in the future. By using anatomy diagrams, she is able to explain the interrelated nature of the muscles and tendons and the ways one can best put them to use. “The hands are such a reflection of the individual. Everyone uses their hands so differently for their own lifestyle. When I am part of the team to help give someone back the use of their hands, it is so rewarding.” Indeed, it is giving them back their life.
Prevention Harmony Hand & Physical Therapy Center offers job site analysis to assess the ergonomic correctness of patients with problems or to proactively avoid future problems. This can be done for specific employees or for whole companies. She explains that a proper sitting position should include 90º angles at the elbows, hips, and knees with your feet resting evenly on the floor or a stool. Your wrists should be straight, not lifted up or calked downward (the way that they often are when using a laptop). Your monitor should line up
evenly with your head so that your straight gaze hits the center of your screen. Often, it doesn’t require an investment in expensive new furniture to correct problems that can lead to long-term health issues. Minor adjustments can make a big difference. Think through your posture when evaluating your own work space. Cummings advises, “Make a straight line through the center of your body so your ears line up over your shoulders, which line up with your hips.” And remember to change po-
Treatment In addition to hands, Harmony Hand & Physical Therapy also employs two physical therapists on staff to help treat other injuries and traumas. From strains or sprains to arthritis joint pain, they have you covered. Treatments at the center are individualized and can include deep tissue massage. Sessions may also include passive and active stretches where therapists will stretch you and then teach you how to stretch yourself. They can create custom splints for injured hands. Cummings’s passionate commitment to healing people shows in her genuine connection to each patient. She is the owner of Harmony Hand & Physical Therapy, which now boasts two locations to serve northern Colorado. Her Fort Collins office is at 3744 Timberline Road, Suite 103. Phone: 204-HAND. The second location, located at 9299 Eastman Park Drive in Windsor is situated close to several local industries to best serve workers who use their hands and backs for a living. Phone: 674-WORK. Corey Radman is the Assistant Editor for Style Magazine.
Stretch wrist flexors bil (prayer)
AROM radial nerve stretch
• Place palms together over head.. • Keep palms together and move hands downward as far as possible.
• Stand with arms at sides, palms at sides. • Lower shoulder, keeping elbox straight. • Bend wrist and rotate arm inward. • Bend neck to opposite shoulder. • Move arm backward.
Special Instructions: Perform 1 set of 3 repetitions, three times a day. Hold exercise for 10 seconds.
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sitions regularly. “It’s all about movement. Sitting too long in any one position – even a proper one - is not healthy.” Also consider your work station at home in addition to your desk at work. Work at home can be as much a source of strain as that at the office. Stretching is vital. “Just like any other form of exercise, you should stretch your muscles before and after you use them.” Some simple stretches that can be done by most any person are diagramed and explained below. As with any exercise, if you experience pain when trying these, please stop and consult a health care professional before trying them again.
Special Instructions: Always keep elbow straight. Perform 1 set of 3 repetitions, three times a day. Hold exercise for 10 seconds.
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