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	Featured Article T'AI CHI DETAILED COURSE DESCRIPTION BIOMECHANICS OF WHEELCHAIR PROPULSION PATTERNS HEALTH & FITNESS QUICK-TAKES READERS' FORUM

T'AI CHI DETAILED COURSE DESCRIPTION

Improving Balance and Decreasing Fall Risk Using T'ai Chi A groundbreaking one-day seminar for Therapists and other Professionals working with patients who are at risk for falls According to the most recent statistics from the Center for Disease Control (CDC), falls are the primary reason for accidental deaths, the 5th leading cause of death for Americans age 65 and older. In that age group, 30 percent of community dwelling elders and 50 percent of nursing home residents fall each year. The research literature supports T'ai Chi as the best balance exercise for elderly people at risk for falls. This interactive seminar will provide you with all the tools and skills you will need to begin a T'ai Chi balance program as soon as you return to the clinic. You will also learn creative techniques for engaging patients who are withdrawn and reluctant to participate in other forms of therapy. After practicing each exercise during this one-day seminar, you will leave with a clear understanding of how to progress your patients through the sequence of T'ai Chi exercises toward higher function with decreased fall risk. Finally, you will learn how to include T'ai Chi in the multidisciplinary Care Plan, and how to document the therapy sessions for maximum reimbursement from Medicare Parts A and B and all other types of insurance plans. This course is designed to be participatory and fun, and after initiating the program in your own clinical setting, you will be pleasantly surprised to find your patients looking forward to their next T'ai Chi session with you. What You Will Learn · Understand how Eastern and Western approaches to balance differ · Learn postural corrections that have an immediate effect on balance · Use kinesthetic imagery to improve cognitive, emotional and physical function · Demonstrate movement strategies that maintain balance control · Practice T'ai Chi exercises in sitting and standing that strengthen lower extremity and postural control muscles, increase range of motion and improve balance · The three common mistakes in stance that decrease balance and reaction times · Reprogramming neuromuscular responses using kinesthetic imagery · The tan tien: The key to controlled and centered movement · Tailoring the T'ai Chi exercise progressions to individual patient needs · Incorporating T'ai Chi in the Care Plan and documentation for reimbursement Who Should Attend · Physical Therapists · Occupational Therapists · Recreation Therapists · Nurses · Restorative Team members · Physicians · Clinical Managers · Educators · Administrators · Athletic Trainers · Anyone involved in the care of someone who has issues with decreased balance About the Speaker Jon Ruttenberg holds a Masters Degree in Physical Therapy from Boston University, and he is a Certified Ergonomic Assessment Specialist. He has trained patients in T'ai Chi principles while working as a Physical Therapist in a variety of settings, including nursing homes, retirement communities, hospitals, sports medicine clinics, outpatient clinics and occupational medicine. Mr. Ruttenberg has taught therapists and other health care professionals how to design T'ai Chi balance programs in seminars sponsored by various health care facilities and by ADVANCE Magazine. He is the owner of Oak Tree PT, which is a private practice specializing in orthopedics, balance and ergonomic assessment and consulting for various industries. Mr. Ruttenberg is a speaker with experience, energy and enthusiasm for one of the most practical and exciting seminars you will attend this year.

BIOMECHANICS OF WHEELCHAIR PROPULSION PATTERNS

Manual wheelchair users are at high risk for sustaining painful musculoskeletal injuries (MSI) at the shoulder and wrist due to repetitive stress and strain. Special attention must be paid to the upper extremity joint angles, especially at or near the points of contact between the hands and the pushrims. According to Alicia Koontz, PhD, ATP, and Michael Boninger, MD, writing in Rehab Management, "individuals who apply greater forces and more rapidly load the pushrims at higher stroke frequencies" are more likely to develop median nerve injury resulting in Carpal Tunnel Syndrome (CTS). Also, those "who push with a greater number of strokes for a given speed" also increase the likelihood of developing CTS. Koontz and Boninger propose that changing both the technique used when pushing the wheelchair and the configuration of the wheelchair itself could lead to reduced propulsive forces and lower stroke frequency, thereby lowering the risk of MSI. TECHNIQUE The authors of this article identify four distinct patterns used during the propulsion cycle (See figure above). The patterns are defined by, "hand motion during the recovery phase of propulsion--the time when the hand is off the rim and preparing for the next stroke". 1) Semicircular (SC): The hands fall below the pushrim during the recovery phase. 2) Single-looping-overpropulsion (SLOP): The hands rise above the pushrim during the recovery phase. 3) Double-looping-overpropulsion (DLOP): Begins with the hands rising above the pushrim, then crossing over and dropping under the pushrim during the recovery phase. 4) Arcing (ARC): The hands follow an arc along the path of the pushrim during the recovery phase. According to the authors, "The semicircular pattern has been associated with lower stroke frequency, greater time spent in the push phase relative to the recovery phase, less angular joint velocity and acceleration, and increased efficiency." They note that, "The semicircular pattern makes sense in that the hand follows an elliptical pattern with no abrupt changes in direction and extra hand movements. It is the same pattern used by wheelchair racers." WHEELCHAIR CONFIGURATION Koontz and Boninger cite several studies in addition to their own that support lowering the seat position to a height that allows for 100 to 120 degrees of elbow flexion. They also recommend moving the seat as far rearward as possible without compromising wheelchair stability. They list the following benefits of these changes: * Less muscle effort * Joints move more smoothly (less joint acceleration) *Greater push and recovery times * Lower stroke frequencies * Fewer strokes to get to a targeted speed * Greater hand contact angles enable more of the pushrim to be utilized. This leads to a decrease in the stroke frequency required to reach a desired speed, and lower forces and rate of loading on the joints and on the median nerve. As an aside, Rodgers, et al., publishing in the Journal of Rehabilitation Research and Development, found that while flexing the trunk during wheelchair propulsion does not increase VO2, it "may, in fact, lead to painful upper limb injury which limits physical performance and quality of life." They attribute this increased risk to "kinematics, kinetics, muscle activation patterns, and propulsion temporal characteristics". However, they do not address the fact that this is also the style favored by wheelchair racers. They sampled only non-athletes in this study, and they recommend "strength and endurance training of the muscles critical to propulsion", because they found that the non-athletes in their study who use the "trunk flexion style . . . appear to be compensating for peripheral muscle fatigue." Further study on wheelchair athletes certainly seems to be in order. Please see the short, related "Quick-Take" below in this newsletter on the new mechanical elliptical wheelchair propulsion systems. See also this technical note . . . »

HEALTH & FITNESS QUICK-TAKES

Researchers report in Chest that bed-bound patients with marked muscle atrophy, who received Electrical Stimulation in addition to Active Range of Motion exercises significantly improved muscle strength and decreased the number of days needed to transfer from bed to chair. According to abstracts that will be presented at the APTA Combined Sections Meeting 2004 in Nashville, 13 of 14 able-bodied subjects preferred a wheelchair with a new elliptical propulsion system over the standard wheelchairs in use today. The subjects rated the new propulsion system higher for comfort, and the investigators feel that the elliptical system "shows promise for reducing energy expenditure for wheelchair propulsion." In an October 23rd New England Journal of Medicine article, researchers reported that the presence of high levels of an enzyme known as MPO is directly linked to increased arterial inflammation, and can reliably predict the occurence of a "cardiac event" within the next six months. This enzyme can be detected with a simple blood test. Boston University scientists studied 3,507 Chinese 60-year-olds who were all life-long chopsticks users. They found a significant increase in the incidence of arthritis in the hand that used the chopsticks. The joints in the fingers most stressed by chopstick use--the thumb and the second and third fingers--displayed the most damage. Using this information, the researchers may try "to design more ergonomically friendly chopsticks". They reassure Western diners that occasional social use poses virtually no risk. Abstract: Chopstick Arthropathy. The Beijing Osteoarthritis (OA) Study National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2002. Handout on Health: Osteoarthritis (What is Osteoarthritis?) A recent study published in the Journal of Bone and Joint Surgery (American), Chronic Rotator Cuff Injury and Repair Model in Sheep, found that "earlier repair of the tendon results in more rapid recovery of both muscle function and tendon elasticity compared with a more delayed repair", and that "there may be a 'point of no return' in rotator cuff injury after which the elasticity of the muscle-tendon unit does not return to normal." According to the Washington Post on Sunday November 16, 2003, American businesses are cashing in on the U.S. obesity epidemic. Among the products offered in response to the problem: scales and stretchers with higher maximum weights, and oversize models of coffins. American Obesity Association The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity CDC Report On Obesity This is the now the height of cold and flu season. Immunologists at Harvard University discovered that people who drank five cups of black tea a day for 2 weeks transformed their immune system T cells into "Hulk cells" that pumped out 10 times more cold and flu virus-fighting interferon than those of the non-tea drinkers. The researchers postulate that drinking large amounts of black tea may help ward off any conditions that the body fights with interferon, including infected cuts, athlete's foot, and a host of diseases. SOURCES: Jack F. Bukowski, M.D., Ph.D., assistant professor, medicine, Harvard Medical School, and staff rheumatologist, Brigham and Women's Hospital, Boston; Joseph Simrany, president, Tea Council of the USA, New York City; Hasan Mukhtar, Ph.D., Helfaer Professor of Cancer Research and director and vice chairman, research, Department of Dermatology, University of Wisconsin, Madison; Sept. 8, 2003, presentations, American Chemical Society national meeting, New York City Health On the Net Foundation article: Does Tea Belong in the Medicine Chest? NIH Publication: Is It a Cold or the Flu? CDC: Colds and the Flu: What to Do If You Get Sick In an effort to reduce high blood pressure among African-American men, researchers at the University of Texas Southwestern Medical Center at Dallas are training Dallas barbers to record customers' blood pressure using automated devices. When they identify customers with untreated hypertension, they make the appropriate medical referrals. Black males represent the group with the highest rate of uncontrolled hypertension in the U.S. The program takes advantage of "the remarkable long-term patronage and high frequency of haircut visits", according to the principle investigator in the study. See Full Article 43 New Mexicans who are considered at moderate risk for a heart attack have been given automated external defibrillators to keep in their homes, and their families have been trained in their use. A study of cardiac arrest survival rates shows that the equipment is important in saving lives. That is why many of the devices have been installed in public places such as airports and health clubs. But according to a researcher involved in the New Mexican study, "About 70 percent of cardiac arrests seem to occur at home". If the study shows increased survival rates among the group given the defibrillators, health insurance may begin to cover the cost of these expensive devices when a doctor writes a prescription for one. See Full Article A 1996 Norwegian study published in the European Journal of Clinical Nutrition (October) suggests that people with musculoskeletal pain experience less pain if they take cod liver oil. As of January 1 of this year, American families may contribute up to 100 percent of their normal health insurance policy deductible, or $4,500 in pretax dollars annually into a tax-free medical savings account. Single individuals may contribute up to $1,000 annually. This plan is a provision of the Medicare reform legislation signed by President Bush in December. Any unused funds stay in the account and accrue tax-free interest.

READERS' FORUM

This spot features answers to questions from our readers. Send your physical therapy-related questions to: pt@oaktreept.com. If we answer your question in this column, we will send you an Oak Tree PT ergonomic pen. Please be sure to include your mailing address, to be used strictly for mailing the pen only, and no other purpose. I will also be happy to publish in this Readers' Forum any original, relevant, well-written articles submitted by readers. Just forward your material to: pt@oaktreept.com. **Editor's note: People must still be recovering from the holidays. We hope to revive this section of the newsletter next month. NOTICE!!! OAK TREE PUBLISHING IS NOT CONNECTED WITH OAK TREE PT IN ANY WAY. WE HERE AT OAK TREE PT WILL BE HAPPY TO TRAIN YOU IN PROPER LIFTING TECHNIQUES. --Oak Tree PT Management Team