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Sunday, April 28, 2019

Ultra-rapid treatment reduces odds of post-stroke disability

Nearly a third of Americans will develop osteoarthritis of the knee before age 70. With no “cure” beside knee replacement on the horizon for this painful joint condition, relief often has to come from pain pills. Assistive devices such as wedge insoles are often prescribed as a less drastic, side effect-free treatment option. But do they really work? A research review published today in JAMA indicates that these shoe inserts do little—if anything—to relieve arthritis pain.

The review looked at the use of lateral wedge insoles for medial knee osteoarthritis, which affects the inner part of the knee. Lateral insoles are thicker at the outer edge of the foot. Slightly tilting the foot is thought to reduce the load on the inner knee joint.

Walking directs more force to the inside part of the knee (the medial aspect) than the outside part (the lateral aspect). The medial compartment is where osteoarthritis usually appears first. “A lateral wedge insole is intended to reduce pressure transmitted through the lower leg to the medial compartment of the knee during walking,” explains Dr. Robert Shmerling, clinical chief in the Division of Rheumatology at Beth Israel Deaconess Medical Center, and associate professor of medicine at Harvard Medical School.

To see whether lateral wedge insoles actually relieve arthritis pain, an international team of researchers evaluated the results of 12 different shoe-based clinical trials that included a total of 885 participants. Trials comparing the lateral wedge insole to a neutral insole didn’t find a significant improvement in pain.

The findings echo new osteoarthritis treatment guidelines released by the American Academy of Orthopaedic Surgeons (AAOS) in May. Based on current research, the AAOS said it couldn’t recommend lateral wedge insoles for people with medial knee osteoarthritis.
Is it worth wearing insoles?

Doctors who recommend these inserts for their patients may want to re-evaluate their decision based on the most current research, says Dr. Shmerling. Yet you don’t need to toss out lateral wedge insoles if they’ve worked for you, because everyone’s response to treatment can be different. “I think it makes sense to recommend insoles on a case-by-case basis, because even though the average response was no different between wedge insole users and non-users, individual response can vary,” Dr. Shmerling says.

You just might not want to splurge on the priciest options at first. The cost of lateral wedge insoles can range from $10 for ones you buy off the shelf at your local pharmacy or shoe store to $500 for a pair of custom-made insoles your podiatrist or orthopedist orders for you. “Considering the results of this study, I think it’s hard to justify a big investment in wedge insoles solely to treat knee pain from osteoarthritis,” Dr. Shmerling says. “My advice would be to go with inexpensive insoles, and if you’re no better, and if nothing else is working, you could consider seeing a podiatrist or orthotist for higher-end options.”

An alternative to inserts is using a cane to improve your stability. So can buying the right shoes. There is evidence that wearing flat-heeled, flexible shoes—especially ones that mimic the natural movement of walking barefoot—may do more to slow knee osteoarthritis than any insert you stick inside them. When it comes to treating stroke, time is brain and every minute counts. That tenet was supported yet again by an international study showing that the sooner clot-busting treatment is begun, the greater the chances of surviving a stroke without a disability.

Writing in the journal Stroke, researchers led by Dr. Daniel Strbian, an associate professor of neurology at Helsinki University Central Hospital in Finland, reported that giving the clot-busting drug alteplase within 90 minutes of the start of stroke symptoms was more effective at preventing long-term problems than giving the drug within 4.5 hours. Current guidelines recommend that a clot-dissolving drug (generally known as a tissue plasminogen activator [tPA]) be administered within 4.5 hours of the onset of symptoms. After 4.5 hours, these drugs are less effective and the risk of bleeding outweighs the small risk of benefit.
Stroke types

Each year, nearly 800,000 Americans have a stroke. Most of them are ischemic strokes. That means they are caused by something blocking blood flow to part of the brain. That something is usually a blood clot. The clot may form in a blood vessel within the brain (causing a thrombotic stroke), or it may form elsewhere in the body and travel to the brain (causing an embolic stroke).

Types of stroke About 10% of strokes occur when a blood vessel in the brain bursts. This causes bleeding in the brain, and also cuts off blood flow to part of the brain. These are called hemorrhagic strokes.

In the study published in Stroke, patients were divided into three groups based on the severity of their stroke: minor; mild-to-moderate; and moderate-to-severe. Those with mild-to-moderate strokes got the most benefit from ultra-rapid treatment. Less benefit for rapid treatment was seen in those with minor strokes, because they are already at low risk of disability, and in those with severe strokes, probably because their blockages were extensive and more resistant to tPA therapy.

But that’s not to say that patients with severe stroke symptoms shouldn’t be hustled to the hospital and receive early treatment. They, too, should always be considered for intravenous tPA therapy.

In addition to patients’ delaying a call to 911 or trip to the hospital, there’s another factor that can slow the delivery of tPA. A doctor must be sure that the stroke is not caused by bleeding into the brain. To determine that, an MRI or CT scan must first be done.
Brain attack

Strokes, even “minor” ones, are a medical emergency similar to heart attacks. That’s why many experts call stroke a “brain attack.” When one strikes, brain cells die quickly. The faster you recognize a stroke and get to the hospital, the faster treatment can begin. And the greater your chance of near or complete recovery, especially if the symptoms are mild to moderate.

If you suspect that you or someone you are with is having a stroke, think FAST:

    Face: Ask the person to smile. Is one side drooping?
    Arms: Ask the person to lift both arms. Does one drift back down?
    Speech: Ask the person to repeat a simple sentence. Is it slurred or incomplete?
    Time: If one or more stroke signs are present, act quickly. Call 911, and get the person to the nearest hospital with an emergency department. If possible, it should be a hospital with a stroke center.

If you think a stroke is in progress, the best thing to do is to dial 911 or your local emergency number. Let the person on the other end of the line know that you suspect a stroke is happening. That way the emergency department can be ready to do a brain scan. During the summer, I take much of my speech-language therapy practice out of the classroom and office and move it to summer camp. It can be a treat to help preschoolers develop language and social skills with their peers outside on warm summer days.

Around late July, my preschoolers who are heading to kindergarten often need some extra attention. Kids are pretty smart about these transitions and sense the unpredictability of going to a new classroom. They wonder about making new friends and getting used to a new teacher—will they be able to find the bathroom, where will they eat snack, how will they fit in?

Some children, like 5-year-old Kara, are very direct about expressing their fears. One day she climbed out of her kayak and dashed across the dock to greet me. She crossed her arms across her chest, stood in front of me with a wide stance, and said, “Ann, I’m so scared. I have to go to kindergarten soon!” (You can read the entire conversation with Kara below.)

Other children aren’t quite as direct about their worries. Another one of my rising kindergartners dumped a bucket of water on my head (I was not dressed for swimming). I knew his behavior wasn’t because he was in the mood for a good prank, but rather because he had something he wanted to talk about and wanted my full attention. The topic was going to kindergarten.

If you have a child headed to kindergarten in September, here are some ways you can help ease the transition.

    Try to do some play therapy at home. Small figures, stuffed animals, or puppets will do. Have your “actors” experience a transition to a new place. Don’t forget to “act out” coping strategies, for example, “Mr. Elephant feels scared. So what can he do? Maybe he could tell his teacher!”
    Talk about the transition to your child in a positive way and try not to let your own anxiety about the change show too much.
    Visit the school as soon as you can this summer. If your school offers visiting days, do your best to have your child attend. If your child’s kindergarten provides a daily schedule of activities ahead of time, go over it with your son or daughter. Take photos of the school, the classroom, and the new teacher, if possible.
    See if you can find out some of your child’s new classmates, and set up a play date. Some schools offer late summer playground dates for incoming kindergarteners.
    Role play as much as you can (dramatic play is very important to help preschoolers learn how to accept change and how to begin new roles).
    Tell your child how you felt when you had to go to kindergarten—and what made you feel better and how it turned out okay (that is if you can remember!)
    Ask your child’s siblings to tell her/him about their experience.
    Remind your child “It’s okay to be afraid. But, you’ll feel better each day that you’re there. Lots of kids feel just like you do.” It can be tempting to try to brush off a child’s fear (after all, you know it will be okay). Instead try to acknowledge your child’s fear as real and appropriate while offering reassurance.
    Preschoolers need to feel that their parents believe how they feel is true.
    Give your child time to talk to you about their fears.
    With your child, write a story about his or her first day at kindergarten (with your child as the main character!) Include logistics, feelings, etc.
    Read to your child about starting kindergarten. Some good choices are The Night Before Kindergarten (Reading Railroad Books) Paperback, by illustrators Natasha Wing and Julie Durrel; Miss Bindergarten Gets Ready for Kindergarten, written by Joseph Slate and illustrated by Ashley Wolff; Kindergarten Rocks! by Katie Davis; Look out Kindergarten, Here I Come! by Nancy Carlson; and I Am Too Absolutely Small for School (Charlie and Lola), by Lauren Child.

Talking with Kara about starting kindergarten

One of the camps I work with is in a large wooded area with tall trees, a lake and a boat dock. Kara, a 5-year-old, climbed out of her kayak, and dashed across the dock to greet me. She crossed her arms across her chest, stood in front of me with a wide stance, and said, “Ann, I’m so scared. I have to go to kindergarten soon!”

I told her, “I know it’s so hard at first, but it gets better!”

She looked down at the ground and then around at her camp friends, looking for support. One friend offered an idea, “Why don’t we have a longer summer?”

I said, “Well, I’d love to spend more time swimming at the pond, but in the fall we all have to go to work to learn.”

Kara, spun around and said, “Ann, I just can’t go. I won’t have my friends there. I miss my preschool teacher!”

I responded, “Have you met your new teacher, yet?”

Kara, looking down again answered in a small voice, “No.”

I asked, “Why don’t you ask your mom if you can visit your new school and meet that teacher before school starts? Some schools let kindergarteners do that.”

Kara, “Okay. Maybe. But, I’m still scared.”

I asked, “What scares you the most?”

Kara whispered, “I don’t know what it’s like. Will I get to play a lot? Do I have to do a lot of work? What if I can’t do the work? I can’t read yet, and a ton of my friends can read!”

I asked, “Kindergarten is a place where lots of kids learn to read. It’s okay.”

Kara snapped back, “Oh, yeah, but they’ll know I can’t read. Well, I can read a little, a few words, like “cat” and “bat”, but I can’t REALLY read, like a whole book!”

I suggested, “What if your mom got some of the classroom books to read to you at the end of summer?”

Kara, “Yes. That would be good.”

I asked, “Have you seen your classroom, yet? That will help you think about what your new school will be like.”

Kara whispered again, “Okay. I’ll ask my mom. But, what if the school says no?”

I responded, “They might, but you can at least try!”

Kara paused, looked at me, and announced, “Okay, but I might cry!”

I answered, “It’s okay to cry and feel lost at first. It’s okay.”

Kara snapped again, “No! It’s not. I have to be ‘grown up’ now and I don’t want to.”

I tapped her shoulder and said, “I think you are a little grown up already. You can talk about how you feel. That’s good. You can tell your teachers and parents how you feel.”

Kara crouched down to the dock and sat “criss-cross, applesauce.” She rested her arms on her kayak paddle. I sat down near her and put my hand on the paddle. We looked at the water and watched the boats move and bump the dock. When they hit, we moved a little, too. I waited until she spoke.

She whispered, “Will you visit me in kindergarten?”

“Yes and I can’t wait to hear all about it!” I answered.

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