TOTAL ANKLE REPLACEMENT: 2nd in Series of 2 Columns on Ankle Pain (Read Part 1)

NEED A TOTAL ANKLE REPLACEMENT?

Total ankle replacement (TAR) is recommended for severe ankle pain which has not responded to conservative treatment: weight loss, activity modification, physical therapy, anti-inflammatory medication and cortisone injections. Severe ankle pain can result from the following:

• Osteoarthritis (Degenerative Joint Disease): cartilage wears out, bone rubs on bone causing inflammation leading to pain, swelling, stiffness, instability and deformity; most common type; usually genetic.
• Trauma: if hip bones do not heal properly after a fracture (break) from a fall or blow, the joint slowly wears away leading to arthritis.
• Inflammatory Arthritis: enzymes which destroy cartilage are released in response to inflammation (e.g. Rheumatoid arthritis, Lupus, psoriatic arthritis)
• Avascular necrosis (osteonecrosis): part of the ankle bone loses its blood supply and dies; most common causes: steroid use and alcohol abuse; other causes: radiation therapy, fracture, vasculitis, infections and sickle cell diseases.
• Prior surgeries to repair fractures in the bones of the lower leg and ankle or deformity.

Ankle pain can manifest in the shin, ankle, and shin. It usually increases with activity and alleviates with rest. It may occur at night and prevent sleep. This pain is associated with stiffness, limping and functional limitation which significantly affects quality of life.

A TAR is the surgical implantation of an artificial ankle (prosthesis). The worn out joint surfaces of the end of the shin bone (tibia) and the top of the ankle bone (talus) are removed. Extreme care using precise instruments are used to insure a level surface for the implant. A metal and plastic implant is inserted into the prepared bone ends to create a new joint surface. Because the artificial ankle joint has smooth surfaces, like cartilage, complete, or near complete, pain relief is experienced which allows improved motion, enhanced function and less limping.

A Good Candidate for Total Ankle Replacement:

Ankle replacements have become better designed and more successful. A good candidate is older, less active with an average body weight. Therefore, a poor candidate is young (under 50 years old), active and overweight. For this group with disability and chronic pain an ankle fusion surgery may be more appropriate than a joint replacement.

Predicting the longevity of a TAR on an individual basis is impossible. According to Guido LaPorta, DPM, ankle implants of the 1970’s were not good and resulted in poor outcomes. Those of the 1990’s were good but not great. However, there is an 82 to 90% chance that new TAR’s will last 10-12 years in the appropriate patient.

What to Expect with Total Ankle Replacement:

• Post - Op
  • 3-5 days in the hospital is typical. The leg will be elevated and ankle immobilized in a splint. You will get out of bed and in a chair soon after surgery.
  • Limited weight bearing using walker or crutches for several weeks. (6 weeks non weight bearing is typical). However, the boot will be removed to begin early range of motion exercises in just a few days post-op.
  • 6 weeks – begin more aggressive physical therapy for range of motion, strengthening and partial weight bearing.
  • 3 month rehab for recovery
•  Complications:
  • Infection
  • Wound healing
  • Pain
  • Alignment for normal gait
  • If complications are unresolved, surgical fusion may be an option
•  Exercise
  • Regular exercise is important.
  • Housekeeping, gardening, driving and dancing are encouraged.
  • Low impact activities (walking, swimming and biking) are recommended.
  • High impact activities (jogging) increase prosthetic wear and should be avoided.
• Maintain Ideal Weight:
  • Increased body weight increases amount of force on TAR.
  • Increased forces lead to increased prosthetic wear or loosening.
• Infection Precautions:
  • Antibiotics prior to procedures (surgical, podiatric, and dental) usually are not required after second year.
• Periodic Visits to the Surgeon:
  • Varies according to individual. First visit is usually 4 to 6 weeks after surgery.
  • Helps diagnose any potential problems.
  • Informs surgeon of any status changes.

Recovery following TAR takes 12 weeks. The ankle may be warm/swollen for 3 to 6 months (ice and elevation will help). The ankle will show improvements in function for up to a year. Overall a TAR relieves pain and stiffness, improves mobility and restores quality of life! Instead of limping in pain, you will return to walking painfree and maybe playing golf!

SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum”  in the Scranton Times Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSM.

I have been advising my patients to exercise, keep active, and walk as long as they can in order to stay mobile and healthy. However, seniors often tell me activities that require prolonged walking is limited by ankle pain from arthritis. They often ask, “What is arthritis of the ankle?” How does it happen? What can I do about it?

Three Most Common Forms of Arthritis of the Ankle 

• Osteoarthritis – is also known as degenerative arthritis. It is the most common form of arthritis in the ankle. It is usually a gradual, slow and progressive process of “wear and tear” to the cartilage in the ankle joint which eventually wears down to the bony joint surface. It is most often found in middle-aged and older people and in weight bearing joints such as the hip, knee and ankle.
• Rheumatoid Arthritis (RA) – is a form of inflammatory arthritis in which many joints of the body can be affected. It is very destructive to the cartilage, joint and tissues surrounding the joint. It can occur at any age and usually affects multiple joints.
• Post-Traumatic Arthritis- is a form of arthritis that can occur following a trauma or injury to the ankle. It is a form of osteoarthritis that is triggered years after a fracture or ligament injury. Those of you who know Jim Gouldsbury, Jr., a local letter carrier for the United State Postal Service, may know the effects of prolonged weight-bearing on injured limp. Jim suffered from an ankle injury several years ago and worked in a job that requires constant weight-bearing. He is now suffering from traumatic arthritis at a relatively young age.

Symptoms of Arthritis

• Pain - usually occurs gradually. However, a sudden onset can occur, especially associated with a sudden twist or fall. Pain is often worse in the morning and improves with movement. Changes in the weather or barometric pressure can cause pain associated with arthritis.
• Swelling – can swell after increase activity at the end of the day.
• Stiffness – is more noticeable in the morning and improves with movement. However, overuse can create more pain and swelling and lead to stiffness also.
• Weakness – from disuse associated with pain and can lead to occasional buckling of the ankle when walking or climbing steps.                   
• Loss of Function- is associated with pain, swelling, weakness and stiffness which limits walking, stair climbing etc.

Diagnosing Arthritis

Your family physician will examine your ankle to determine if you have arthritis. In more advanced cases you may be referred to a specialist such as a podiatrist,  orthopaedic surgeon or rheumatologist for further examination and treatment. X-rays will show if the joint space between the bones in the ankle is getting narrow from wear and tear arthritis. If rheumatoid arthritis is suspected, blood tests and an MRI may be ordered. The diagnosis will determine if you problem if minor, moderate or severe.

Treating Arthritis

Conservative Treatment

 In the early stages your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You and your family physician, podiatrist, orthopedic surgeon or rheumatologist will decide which choices are best.

• Anti-inflammatory Medications: such as aspirin, acetaminophen or ibuprofen to reduce pain and swelling in the joint.
• Orthopedic Physical Therapy: such as heat, cold, ultrasound, electrical stimulation, joint mobilization, range of motion exercises, strengthening exercises, partial weight bearing aerobic exercises.
• Activity Modifications: such as eat well and lose weight, doubles tennis instead of singles, sitting or lying leg exercises instead of standing, walk instead of run, soft bed treadmill instead of hard surfaces, avoid squatting, kneeling, and bending.
• Supportive Devices: such as ankle sleeves, light bracing, orthothics (inserts), use good running shoes for exercise and walking, use good quality supportive shoes for work/dress.

Conservative But More Aggressive Treatment

• Corticosteroids: stronger anti-inflammatory medications than those above which are injected directly into the ankle joint.
• Viscosupplementation: a type of synthetic fluid, injected into the ankle joint and designed to imitate the joint fluid of the ankle to promoted healing and mobility.
• Glucosamine and Chondroitin: supplements taken orally to control the pain of osteoarthritis and promote healing.
• Rheumatoid Medications: specifically designed for RA

Surgical Treatment

When conservative measures no longer succeed in controlling pain and deformity, improving strength and function then more aggressive treatment may be necessary.

• Arthroscopic Surgery: uses a scope to clean and repair damaged tissues inside the ankle joint.
• Fusion Surgery: the ankle bones are surgically fused together to limit movement of painful joint.
• Total Ankle Replacement: replaces severely damage joint surfaces with metal and/or plastic.

SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons, Guido LaPorta, DPM, Dunmore, PA

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in the Scranton Times-Tribune. Next Week: Part 2 of 2 on Ankle Arthritis, “Ankle Joint Replacement.”

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSM.

Many people living in Northeastern Pennsylvania exercise outdoors year round. The psychological benefits are many. We live in such a beautiful environment. Each season brings its own beauty: The fresh green spring, the warm summer breezes, the colorful fall leaves, and the silent white blanket of winter snow. However, you may have to make some adjustments in equipment, clothing and food for each season and temperature changes that go with it. Soon, local temperatures will drop into single digits and it is critically important to make changes and adjustments in training according to the weather and temperature.

Over the past five years great strides have been made on understanding the effects of extreme temperatures on performance. Current wisdom from the University of Otago in New Zealand has found:

• WARM-UP: Optimal warm-up in cold weather is very different than in the heat

• THE BRAIN: Can anticipate changes in body temperature, with feedback from the skin, and will adjust the intensity automatically. Subconsciously, the brain calculates the outside temperature and the duration of the activity and will automatically slow down the performance even before fatigue occurs. If the performer attempts to override the brain, the cerebrum will respond by creating severe symptoms and sensation of exhaustion such as those associated with heat strain. Therefore, the temperature in which you intensely perform in will overpower even the fittest athletes.

STRATEGIES FOR OPTMIMAL PERFORMANCE IN FOUR TEMPERATURE ZONES: 

Researchers have developed various strategies for athletes to stabilize their core temperatures in extreme hot or extreme cold conditions:

• BELOW 45 DEGREES FAHRENHEIT – CAUTION/COLD: Humans possess limited physiological defenses against the cold.
  • Clothing – it is important to layer clothing. Use UnderArmor (headgear, shirts and pants) to allow sweat to breath away from the skin to the next layer of clothing. Use a facemask to cover your mouth and nose to prevent frost bite and warm air before it enters the lungs.
  • Warm-Up – gently warm up inside but don’t break a sweat. The best warm up in very cold weather is to begin your activity SLOWLY! Runner’s, for example, should run a ¼ the normal pace for 3-5 minutes, then ½ pace for 3-5 minutes, then ¾ pace for 3-5 minutes to prevent injuries. After 10 to 15 minutes, you may open up the throttle.
  • Safety – is important. Be alert for icy patches and poor visibility for cars.
  • Cross-Train- if it is very snowy, skip the run and try cross-country skiing or snow shoe walking or jogging for a change. It is a great running substitute and vigorous workout!
  • Food & Drink – is different for activities in the cold. For a short-term exposure (1-4 hours) make sure you fill your muscles with lots of glycogen by getting 4 grams of carbohydrates for every pound of body weight. During exercise consume extra carbs by drinking 5 to 6 ounces of sports drink every 15-20 minutes. Hikers and campers performing vigorous activity in the cold for days at a time will require extra fat in their diet and on their bodies to store for energy. This is no time to count calories or fat intake. As anyone who has climbed the high peaks!
• 45 TO 50 DEGREES FAHRENHEIT – OPTIMAL: Many physiologists and outdoor enthusiasts consider this temperature range to be optimal. It still requires 10 minutes of slow warm-up by ½ to ¾ pace running or cycling. Also, layers are advisable to start off warm, keep warm and shed before you become overheated. Food and drink requirements are still important as with all long duration activities but may be ¼ to ½ the above requirements.
• 50 TO 70 DEGREES FAHRENHEIT – GOOD: It is much easier to get warmed up and loose in this temperature range. A pre run warm up and stretch will allow you to get into the run immediately. However, don’t be fooled – you can still overheat in this temperature with high intensity activity for moderate duration (75 to 90 minutes). Competitive athletes would be wise to train in the temperatures they will compete in for 7-10 days before the event. Also, don’ overexert on warm-ups longer than 5 minutes. Hydration days before, during and after the activity is critical.
• ABOVE 70 DEGREES FAHRENHEIT – CAUTION/HOT: Warm temperatures present great challenges for vigorous and prolonged outdoor activities. Dispensing excessive body heat is difficult. Some studies suggest that pre-race cold baths or air conditioned room can significantly improve endurance. Early morning or evening workouts are best. As stated above, train in temps for 7-10 days before the event. Also, avoid overexert on warm-ups longer than 5 minutes and hydration days before, during and after the activity is critical.

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in the Scranton Times-Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.

Worried Sick? Be Happy in 2017! Part 2 of 2

Special Feature “ Health & Exercise Forum” with Geisinger Commonwealth School of Medicine (formerly The Commonwealth Medical College) – The 3^rd Monday of every month!

Guest Columnist: Kathryn Schmidt

Personal Bio: Kathryn majored in psychology at the University of Wisconsin-Madison and completed a post-baccalaureate pre-medical and health program at Northwestern University. Throughout school, she worked as a research assistant, first with stem cell transplant recipients and women affected by gynecological cancers, and then with solid organ transplant patients. Kathryn also worked as a medical aid to man affected by diabetes and blindness. Presently, as a 2^nd year medical student at the Commonwealth Medical College in Scranton, PA she serves as a volunteer at the Care and Concern Clinic, as well as at an organization called Pathstone, acting as a mentor to men and women who are transitioning back into the community after having spent time in prison. Kathryn’s academic interests include: cancer, colorectal disease, mechanisms of addiction and adolescent psychiatry. When not studying, working or volunteering, she likes to play tennis, kick-box, ski, and be in the company of good friends or family, whether that be taking a weekend trip to a new place or just having a board game night. Something that makes her really happy is traveling… she has been to all 7 continents and is always ready for the next adventure!

In medical school, when things outside of school become turbulent, it is very easy to lose focus and to become distracted and distressed. Perhaps, more importantly, in the midst of studying, it is difficult to find the time to do the kind of soul-searching necessary to feel happy again. An overload of new information is thrown at you each day, leaving little time to see family or friends, to get out of town for a few days to clear your head, or to allow thoughts of the outside world to come tumbling into your mind and onto the textbook page you’re currently reading about the musculoskeletal system (or whatever the day’s topic is). And there’s definitely not time for our immune systems to crash and fail us when we need them most.

This same situation is applicable to people outside of medical school though; balancing kids with other obligations or working multiple jobs can’t be easy. SO, my point is, we don’t have time to let our psychological state negatively affect our physical health and immune systems, and if we are sick with something serious, we need to do everything in our power to give ourselves the best fighting chance at recovery. Just knowing that mood and psychological well-being affect our physical state is motivation in itself to decide that we are going to choose happiness. This is not to say that you can’t ever be in a bad mood… you can! We all have bad days, but we should work harder to not let our bad moods consume us.

But, what else can we do?

Ten easy ways to increase your inner happiness: 2017 is the Year to Start!

1. We all know this is easier said than done though. So choose to do things that fulfill your daily exercise needs, but don’t feel like a chore. For example, go hiking! It’s a great workout, and there’s usually a pretty cool destination waiting for you at the end. I admit though, I like the view from the top more than the (sometimes torturous uphill) hike itself. Need more ideas? Play tennis or ultimate Frisbee, dance with Wii, or if you’re like my mom, powerwalk through the mall before the stores open while catching up with a friend (Bonus, you get to window shop!). If you’re in school and busy studying like me, grab a fellow classmate and quiz each other while you take a walk.
2. Fake it until you make it. It sounds silly, but the more you smile, even if it’s fake, positively affects how you feel because it triggers something in the brain that makes you happier…AND LAUGH. Only second to loving, laughing is the easiest way to feel like everything is going to be okay.
3. Spend more time outdoors. Fresh air, scenic views, and a little vitamin D from the sun can make all the difference.
4. Treat yourself. A new car would be nice, but a cupcake from your favorite bakery might have to do. And on that note, be kind to yourself. If you mess up (maybe a diet, for example), don’t lose sleep over it. You will do better tomorrow.
5. Have something to look forward to, big or small.
6. Don’t fixate on things that are making you either sad or mad. It takes too much energy out of you and is distracting. It’s okay to have these feelings, but allot yourself a certain amount of time to vent or think about it each day, and then, cut yourself off. Sometimes, we have to be harsh with ourselves.
7. Get out of your own head. Talk to someone about how you feel. It might be uncomfortable at first, but it gets easier, and you’d be surprised at the people who will listen and may even be able to relate.
8. Take some time for yourself. It’s okay to be selfish sometimes. This has been a hard lesson for me to learn, and I still have trouble with it at times. It is natural to want to do nice things for the people we care about and to put them first, but we shouldn’t lose sight of what makes us happy in the process.
9. Set goals. Self – motivate. We are resilient. We can pick ourselves back up. We don’t even realize the inner strength we have until put to the test. Find the inner motivation to challenge yourself to be the very best version of yourself. Sometimes, the hardest part is just admitting that there is something to be worked on. We can love ourselves just as we are while acknowledging that there’s always room for improvement.
10. Be silly. Go out of your comfort zone. Show off your weirdness (to me, weird equals unique, and is a good thing. There is weird in all of us). Seek your inner child. Dress up. Attend a themed party. Go to trampoline world. Take your niece to a tea party. Play charades. Do anything that makes you feel like “Wow, this is just ridiculous, but I am having so much fun.”

So smile more, stress less, and if you have to, “fake it until you make it.” And if you’re someone who is reading this and feeling like the weight of the world is just too heavy right now, be reassured that you’re not alone and that it’s okay, even normal, to feel overwhelmed and inadequate at times. BUT force yourself to do something different, to do something that will help you to float when you are sinking. Do something that reminds you that the world is a beautiful place.

If you’re someone who thrives when challenged, try the 100 Happy Days Challenge. The idea behind this challenge is to enjoy and appreciate the environment and yourself in that moment. For 100 days, you simply submit a picture of what made you happy each day. It surely won’t be the most exciting picture every single day, but remember, this challenge is for you, and the little things that make you happy are important and valid. It could be as simple as your morning cup of coffee in your favorite mug, your pet doing something funny, the sunset you saw driving home from work, or observing a random stranger doing something nice for someone else. People who have completed this challenge report being in a better mood, noticing what makes them happy each day, and feeling blessed or optimistic, and when you’re finished, you will have compiled 100 happy moments to remind you how to live when life knocks you down. You can find more information at http://100happydays.com/.

Read Dr. Mackarey’s Health & Exercise Forum – every Monday. This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine (formerly The Commonwealth Medical College).

Worried Sick? Don’t Worry, be Be Happy in 2017! Part 1 of 2

Special Feature “ Health & Exercise Forum” with Geisinger Commonwealth School of Medicine (formerly The Commonwealth Medical College) – The 3^rd Monday of every month!

Guest Columnist: Kathryn Schmidt 

Personal Bio: Kathryn majored in psychology at the University of Wisconsin-Madison and completed a post-baccalaureate pre-medical and health program at Northwestern University. Throughout school, she worked as a research assistant, first with stem cell transplant recipients and women affected by gynecological cancers, and then with solid organ transplant patients. Kathryn also worked as a medical aid to man affected by diabetes and blindness. Presently, as a 2^nd year medical student at the Commonwealth Medical College in Scranton, PA she serves as a volunteer at the Care and Concern Clinic, as well as at an organization called Pathstone, acting as a mentor to men and women who are transitioning back into the community after having spent time in prison. Kathryn’s academic interests include: cancer, colorectal disease, mechanisms of addiction and adolescent psychiatry. When not studying, working or volunteering, she likes to play tennis, kick-box, ski, and be in the company of good friends or family, whether that be taking a weekend trip to a new place or just having a board game night. Something that makes her really happy is traveling… she has been to all 7 continents and is always ready for the next adventure!

Most people have heard the expression, “worried sick,” but did you know that you can worry enough to the point where it results in emotions that leave you physically ill? For the normal person, this isn’t good, but for the cancer patient, this is just downright dangerous. During my undergraduate education at the University of Wisconsin-Madison, I worked in a research lab that examined various predictors of recovery from cancer. Specifically, we examined the extent to which mood disturbance impacts cancer patients’ recovery following hematopoietic stem cell transplantation (HSCT), which is just a fancy term for a medical procedure in which a donor’s stem cells can be given to a patient suffering from certain cancers of the blood or bone marrow, like leukemia or multiple myeloma. Without getting into the complexity of the study, at the most basic level, we wanted to find out if patients who found meaning in their illness, didn’t avoid unwanted thoughts and emotions, and generally felt less depressed prior to transplant had more successful recoveries and stronger immune systems post-transplant. Our study results echoed the conclusions of similar studies conducted prior to ours, demonstrating that there is indeed crosstalk between our psychological states and the neuroendocrine and immune systems, or in other words, our mental state can affect our physical state.

In patients undergoing HSCT, this is particularly salient, given the critical role of immune restoration in preventing recurrence of cancer, reducing complications, and ensuring survival. Distress, depression, and anxiety have been associated with a downregulation of immune responses relevant to tumor containment among cancer patients, and depressed mood has been linked to relapse and poorer survival following HSCT.¹ So now that we know these things, if you are a cancer patient, fighting for your life, the importance of being happy is no longer just for your sanity, but is quite literally one way to increase your chances at a successful recovery. Interesting, right? But how does this apply to you? Well, you don’t have to have cancer for depression or other emotions to weaken your immune system. This basic concept is applicable to all of us in our everyday lives, and this link between the mind and body may be more powerful than you think.

Here are just a few examples of what I’m talking about…

• Stress can suppress the immune system and over a long period of time, can lead to damaging levels of inflammation, increasing the risk of coronary heart disease and type 2 diabetes.²
• Social isolation can be a powerful predictor of poor health. One study found 209 genes distinguishing lonely people from sociable ones. While the genes of the lonely peole were associated with an inflammatory response, the genes of the sociable ones were associated with an anti-viral response.³
• Women with early-stage breast cancer who completed a ten-week stress-management program had decreased inflammation, less metastasis (spreading of the cancer), and were better able to fight their tumors, as evidenced by certain physiological markers. Women who only attended a one-day educational seminar did not have the same benefits.⁴

……Thus, MOOD MATTERS.

I wanted to write this article, because I know how easy it is to let our moods affect us for the worse. I have never been shy with my emotions and wear my heart on my sleeve, for the better or for the worse. When someone asks me how my day is (as part of social convention, but not really expecting the person they asked to say much more than “good, thanks, how about yours?,”), and I’m having a particularly bad day, I reply “Not so good!” or something blunt and honest along those lines. I’m sure the people asking the question are a bit caught off guard and think to themselves, “Wow, overshare.” Most of the time, temporary moods like this are just fine; however, when powerful emotions overcome you with such force, and it feels like a tidal wave is crashing down over you, one after the next, it is quite literally very difficult to pick yourself back up – to see the light at the end of the tunnel, to remember all the happy things in life, to not succumb to your emotion rather than fulfill your responsibilities. Some people experience these emotions when they come face to face with tragedy or loss of loved ones, others when dealing with heartache, self-esteem, failure, friendship woes, or moving away, just to name a few.

In medical school, when things outside of school become turbulent, it is very easy to lose focus and to become distracted and distressed. Perhaps, more importantly, in the midst of studying, it is difficult to find the time to do the kind of soul-searching necessary to feel happy again. An overload of new information is thrown at you each day, leaving little time to see family or friends, to get out of town for a few days to clear your head, or to allow thoughts of the outside world to come tumbling into your mind and onto the textbook page you’re currently reading about the musculoskeletal system (or whatever the day’s topic is). And there’s definitely not time for our immune systems to crash and fail us when we need them most.

This same situation is applicable to people outside of medical school though; balancing kids with other obligations or working multiple jobs can’t be easy. SO, my point is, we don’t have time to let our psychological state negatively affect our physical health and immune systems, and if we are sick with something serious, we need to do everything in our power to give ourselves the best fighting chance at recovery. Just knowing that mood and psychological well-being affect our physical state is motivation in itself to decide that we are going to choose happiness. This is not to say that you can’t ever be in a bad mood… you can! We all have bad days, but we should work harder to not let our bad moods consume us.

NEXT WEEK: Part 2: Tips to Being Happy for Your Health!

Read Dr. Mackarey’s Health & Exercise Forum – every Monday in the Scranton Times-Tribune. This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine (The Commonwealth Medical College).

There are many reasons we exercise. Some people exercise to prevent illness such as cardiovascular disease or osteoporosis. Others exercise for mental health and as a stress release; others do it to improve strength, flexibility, and endurance to prepare for a sport. However, the number one reason people exercise is TO LOSE WEIGHT!

When it comes to losing weight, patients have asked me a wide variety of questions over the years. However, certain questions are consistent. “What exercise is the best to burn calories?” “Even though I exercise 2-3 times per week, why can’t I lose weight?” “What is BMR?” “Are there any tools that I can use to help me track my calories and exercise output?” “Is there anything I can do to speed up my metabolism?”

Which Exercise is the best to burn calories?

Have you ever heard people say that they never felt better or burned more calories as they did when they ran? Well, they may be right! The following numbers are base on the average male weighing 150 pounds: running 6 miles per hour will burn 700+ calories (11-12 calories per minute); vigorously skipping with jump rope or fast cycling will do the same; vigorous walking at 4 miles per hour and moderate biking will burn 600+ calories (10 calories per minute). The 400-500 calorie club includes the following activities: slow jogging, swimming, football, basketball, baseball, tennis, skiing, and moderate walking (3.5 miles per hour). Light gardening burns more calories than golfing using a cart (250 vs. 180).

Why you may not lose weight even though you exercise? What is BMR?

How many times have you heard people say, “It is hard for me to lose weight because I have a slow metabolism?” What does that mean? To explain this in detail you first must understand BMR. BMR, basal metabolic rate, is the number of calories that your body requires to operate basic body functions that you don actively control, such as continuing to breathe, and keep your cells and organs working each day. The BMR is influenced by age, height, gender, body fat, and fitness level. BMR is inherently different (high or low) in each individual. While you can’t change your gender or height, you can influence some things to influence your BMR and burn more calories at rest. One, exercise for longer durations, with greater intensity and more frequently. Two, lower your body fat by eating less calories, especially fat and carbohydrates in your diet. Simply, eat less calories than you burn! Three, improve you muscle/fat ratio by weight training.

Basal Metabolic Index (BMI):

BMI:          < 18.5 = Underweight

BMI:  18.5 – 24.5 = Normal Weight

BMI:   25. - 29.9 = Overweight

BMI:          >30.   = Obestiy

For example, a 58 year old male, weighing 150 pounds at 5 feet 8 inches tall with a BMI of 22.8

*Calculate you BMI by entering you gender, height and weight and find how many calories per food item at: www.calorie-counter.net

TIPS TO BOOST YOUR METABOLISM AND BURN CALORIES!

FUEL THE FIRE

While it might seem counterintuitive, you need to eat to improve your metabolism…but do so properly. Don’t skip breakfast because it can “jump start” your engine (metabolism). Some foods speed up your metabolism better than others. For example, protein is better than carbohydrates, so try an egg instead of pancakes to start your day. Some studies show that spicy foods with cayenne pepper also increase the metabolism…so spice up the chicken breast! Oh, and don’t forget the coffee or green tea because it will add fuel to the fire!

TURN UP THE FIRE

Exercise will increase your metabolism but some types are better than others. For example, aerobic exercise (walking, running, swimming, biking) are great to run the engine and burn calories, but mixing it up will speed up your metabolism even better. One day run, the next swim or bike, etc. Also, mix up the speed and intensity. For example, walk, run or bike at one speed for 5-10 minutes, then increase the speed and sustain it for 2-3 minutes, slow down for 5 minutes and repeat the high intensity again for several cycles. And, don’t forget to weight train because strengthening your muscles will also increase your metabolism. Light weights with high repetitions will do the trick and prevent injury. 

REGHARGE THE FIRE

Sleep is essential to your health. Without it, your metabolism will not have enough energy to burn your calories and overtime this will lead to weight gain. Additionally, positive energy and laughing are associated with a more efficient metabolism to burn calories. So, in addition to exercise, diet, and sleep, makes sure you go to a funny movie, visit a comedy club and hang-out with positive, fun-loving people.

Remember, depending on exercise alone to lose weight is an exercise in futility. Losing weight is an intelligent and consistent combination of a balanced diet with portion control, proper nutrition, adequate and proper exercise and activity grounded in lifestyle changes.

Read Dr. Mackarey’s Health & Exercise Forum – every Monday in the Scranton Times-Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine.

HAPPY AND HEALTHY NEW YEAR 2017!

NEW YEAR’S RESOLUTION: GET A “RUNNER’S HIGH” ON LIFE!

The number one New Year’s Resolution in the United States is to lose weight. A close second is to gain control over one’s life. One of the best ways to lose weight is thought diet and exercise. It can also be a very effective method to begin taking control of one’s life. This is especially true for those suffering from stress, anxiety and depression. This year make your New Year’s Resolution to “Get a Runner’s High on Life!”

Specifically, aerobic exercise (exercise that increases your heart rate for 30 minutes or more) such as walking, biking, running, swimming, hiking, elliptical & stepper machines to name a few, is the secret to “runner’s high.” This exercise euphoria is not limited to runners alone, but all who engage in aerobic exercise are more likely to experience high energy, positive attitude, and mental wellness – not to mention burn calories.

Physical activity, specifically aerobic exercise, while well known for its importance to one’s physical well being has also been scientifically proven valuable for preventing and easing stress, anxiety and depression. Studies have found improvement in mental health for groups that engaged in aerobic running, jogging or walking programs, 30-45 minutes 3-5 days per week for 10-12 weeks when compared to a control group and a group in counseling.

EXERCISE FOR PHYSICAL HEALTH

• Loss or Maintained Body Weight
• Reduces LDL /Raises HDL Cholesterol
• Improves Circulation and Blood Pressure
• Reduces Risk of Heart Disease
• Prevents Bone Loss
• Reduces Stress/Muscle Tension
• Lowers Risk of Depression
• Improves Sleep Pattern
• Improves Strength and Flexibility
• Improves Balance/Reduces Risk of Falls
• Improves Immune System
• Improves Pain Threshold

EXERCISE FOR MENTAL HEALTH

• Helps a person gain control over their lives
• Increases self-esteem
• Diverts attention away from worry, concern or guilt
• Improves mood – with visible signs of improvement in physique & body weight
• Increases sense of pleasure and satisfaction
• Anger management – release pent-up frustration, anger and hostility
• Increase in brain serotonin (natural mood elevator chemical in brain)
• Increase in beta-endorphins (natural mood, stress & pain control chemical in brain)
• Improvement in natural sleep patterns

 

HOW TO BEGIN EXERCISE TO GET THE “RUNNER’S HIGH” ON LIFE

• Consult your primary care physician. Be sure that your symptoms are not related to other health problems. Also, if you are using antidepressant or other medications discuss the impact it may have on your exercise program with your physician.
• Recognize and fight stress, anxiety and depression symptoms that are contrary to or prohibit physical activity such as: fatigue, lack of energy, slow motor skills. Work hard to recognize and overcome these symptoms to begin an exercise program. An aerobic exercise routine should eventually lessen these symptoms.
• Be realistic. Expect that aerobic exercise will take time to have a noticeable benefit. Do not get overly ambitious and set yourself up for failure.
• Begin with an aerobic exercise program that is practical and destined to succeed. For example: inactive and deconditioned people should begin walking 5 minutes per day, 3-5 days per week for 1 week. Then, add 3-5 minutes each week until you attain 30-45 minutes per walk 3-5 times per week. Younger and fitter people can begin to walk for 15 minutes and continue until they attain 45-60 minutes per walk, 3-5 times per week. Remember, what seems impossible today will be easier and routine in 3-4 weeks so JUST DO IT !
• Find a pleasurable environment: a beautiful park (Nay Aug), a scenic lake (Lake Scranton), quiet countryside (rural farmlands of Dalton). Use a mall in inclement weather.
• Find a friendly, uplifting group or individual to walk, talk and exercise with. This may be more appropriate for people feeling isolated or withdrawn. Others may enjoy the peace and quiet of exercising and meditating alone.
• Be specific and compliant! Make a serious commitment. Keep a journal or exercise log. Mark a calendar. 30-45 minutes, 3-5 days per week – NO EXCUSES! Get and exercise buddy you can count on and help keep you compliant!
• Make it fun! Mix it up. Walk 3 days, swim or bike 1-2 days, some days alone, some days with a buddy.
• BE RELIGIOUS! Be religious about exercise BUT don’t get too compulsive!

Read Dr. Mackarey’s Health & Exercise Forum – every Monday in the Scranton Times-Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine (formerly The Commonwealth Medical College).

Healthy Holiday Gift Idea…a Book! Part 2 of 2

A recent study in the journal, Social Science & Medicine, found that reading books is linked to living longer! So, give a healthy holiday gift…a book! (See Part 1)

While it does not appear obvious at first glance, the Lackawanna County Library System’s Library Lecture Series contributes to the health and wellness in NEPA. For the past several years, I have had the pleasure of meeting with a group of volunteers to discuss books and authors with the hope of engaging authors to speak to the residents of Lackawanna County. Since 2005, the “Library Lecture Series,” which takes at Scranton Cultural Center several times throughout the year, has improved the quality of life for thousands of library card holders, free of charge. Attendees have had the pleasure and benefit of being enlightened by historian David McCullough, novelist Salman Rushdie, children’s book author and television personality Henry Winkler, presidential historian Michael Beschloss, deep sea explorer Robert Ballard, theoretical physicist Michio Kaku, Civil War historian James McPherson and many others.

So how does the Lackawanna County Library System’s Library Lecture Series improve health and wellness in NEPA? While the libraries are not staffed with health care providers, by promoting reading, they are fostering health and wellness…a recent study in the journal, Social Science & Medicine, found that reading books is linked to living longer!

Over 3,500 participants, 50 years and older, were engaged in a large research study on health and wellness. Subjects were divided into three groups: non-readers of books; readers up to 3-4 hours per week; readers of more than 3-4 hours per week. The results found that group three, readers of more than 3-4 hours per week, tended to be college educated females from higher income groups. However, when adjusting for education and wealth, the health and wellness results were staggering. Readers of up to 3-4 hours per week were 17% less likely to die and readers of more than 3-4 hours per week were 23% less likely to die compared to non-readers. Readers of newspapers demonstrated a similar but weaker trend.

It is often said that when a word has been created to describe something in a society it reflects a substantial current trend or cultural impact. Bibliotherapy is a term used to describe the practice of using books as therapy in the treatment of mental or psychological disorders. It is also advocated for individuals undergoing a difficult time in their lives such as divorce, career transition or illness.

TOP REASONS READING BOOKS FOSTERS HEALTH, WELLNESS AND LONGEVITY!

 Improve/Maintain Cognitive Skills

 The simple act of reading stimulates the brain in a way that challenges the neurotransmitters of the brain. Some studies show that readers score higher on cognitive tests at younger ages and demonstrate fewer declines with aging.

Improve Life Journey

 As my friend, Dr. Jim Haggerty says, “Reading makes you a more interesting person.” I might add, reading also makes your life more interesting! A good book allows you to travel and experience the world. While I have never sculled a boat on Puget Sound in Washington State, the book, “Boys in the Boat,” by Daniel James Brown, made me feel as if I were there, struggling to row and feeling the burn as the high winds power washed my face with rain. I often think about it on a windy, overcast spring day while rowing my kayak at Lackawanna State Park, making the challenge more interesting.

Improve Sleep

 According to the Centers for Disease Control (CDC), insufficient sleep is a public health problem, effecting as many as 50-70 million Americans. The problem leads to poor work and school performance, as well as accidents while operating motor vehicles. Reading has been found to help the body unwind and prepare for sleep, as long as the subject matter is not too upsetting. Also, readers are advised to read a hard copy or an electronic device with a night light setting to prevent overstimulation.

Improve Relaxation

Reading not only relaxes you to sleep better, it also relaxes you during the day. Studies show that readers benefit from a lower blood pressure, heart rate, and respiratory rate while reading. It is not uncommon for a reader to say, “I got lost in the book?” Reading can be a great escape from everyday pressures and demands. I am a fairly hyperactive person, but my family is amazed at my ability to sit on the beach for 8 or more hours. It would not be possible without the help of a good book and lots of breaks for swimming, walking, can jam, and bocce ball.

 Improve Mental State

 A recent study from the University of Manchester showed that those suffering from depression can benefit from self-help books and books with uplifting and pleasant subject matter, in addition to typical treatment such as support groups.

Rethink Healthy Holiday Gifts!

So, if you want to give a healthy gift, but can’t afford an expensive treadmill, elliptical or electronic fitness tracker, GIVE A BOOK…AND PROMOTE LONGEVITY!

Contributor: Mary Garm, Administrator, Lackawanna County Library System

Source: npr.org

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in Scranton-Times Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.comPaul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.

Authors: Steven Scheinman, MD & Kelly Scheinman

Dr. Scheinman is the president and dean of The Commonwealth Medical College with campuses in Scranton, Sayre, Williamsport and Wilkes-Barre.

Kelly Scheinman is a health care consultant and former hospital administrator. She serves on the boards of United Way of Lackawanna and Wayne Counties and St. Joseph’s Center.

This column is a monthly feature of “Health & Exercise Forum” in association with the students and faculty of The Commonwealth Medical College.

Healthy Holiday Gift Idea…a Book!: Part 1 of 2

A recent study found that reading proficiency at the end of third grade is a benchmark in a child’s educational development and ultimately their health and wellness!

When parents think of their child’s health, they typically focus on things like a healthy diet and on safety measures, such as choosing the right car seats and bike helmets. We all tend to think good health is more dependent upon what’s in the pantry than what is on the book shelf. Mounting evidence tells us this thinking should change. One of the healthiest things adults can do for children is to read aloud to them and encourage them to make regular reading a lifelong habit. In fact, a book is the best gift you can give a child you love this holiday season.

There is persuasive evidence linking higher education levels to better health and even more startling data showing clear connections between early reading and academic achievement. Here are some of the eye-popping conclusions from the Centers for Disease Control (CDC):

• Obesity among boys and girls 2–19 years of age decreased with increasing education of the head of household.
• Students with higher grades are significantly less likely to have engaged in behaviors such as:
  • Carrying a weapon
  • Smoking cigarettes
  • Drinking alcohol
  • Being sexually active
  • Watching television three or more hours per day
  • Being physically active less than 60 minutes per day
• And the truly terrifying finding: The gap in life expectancy at age 25 between those with less than a high school education and those with a bachelor’s degree or higher education is increasing: On average, 25-year-old men without a high school diploma have a life expectancy 9.3 years less than those with a bachelor’s degree or higher; women without a high school diploma had a life expectancy 8.6 years less than those with a bachelor’s degree or higher.

There are obviously clear health benefits gained by getting as much education as possible, but how does reading a picture book to a toddler influence whether he or she goes to college? The answer is that academic achievement is like a chain a person begins to assemble at the very dawn of life. Talking and reading to babies and toddlers is one link, it steeps them in words and builds their vocabulary. A rich early vocabulary prepares a child for the next link, pre-school and kindergarten, where they begin to amass the functional tools of reading, like “phonemic awareness” and word recognition. These tools help first and second-grade readers gain fluency. By third grade a vital link appears, one which children must successfully forge, otherwise all subsequent learning suffers.
What happens in third grade? Reading’s focus shifts. Children are no longer “learning to read,” they are reading to learn. Suddenly, success in other subjects increasingly relies on the student’s ability to comprehend the written word. This is a crucial transition and multiple child-health studies confirm that third-grade students who are not reading at grade level are at risk of a particularly grim “snow ball” effect: a failure to keep up academically, which accumulates exponentially through the grades and ultimately “explains differences in graduation and college enrollment rates.”

This seems like a tremendous burden to place on an eight or nine-year-old child. Fortunately, there are effective, proactive things parents, guardians or any concerned adult can do to help:

• Talk constantly to babies and toddlers – their brains are making an astonishing 700 new neural connections every second. Immersing them in language gives them an edge in reading readiness.
• Give books as gifts and enrich those gifts even further by offering to read them aloud.
• Encourage the children in your life to get a library card. It’s free and librarians are an amazing resource, ready to help children discover the rich, imaginative worlds that await them in books.
• Ask your librarian to recommend age-appropriate books.
• Ask your doctor to screen for potential developmental delays that could impact your child’s learning. There are a variety of local resources to aid parents of children with even minor developmental delays. Addressing the problem early ensures the “snow ball” effect does not begin gathering momentum.
• Be sure your child has his or her annual vision exam.
• Limit your child’s “screen” time. That means television, as well as electronic devices.
• Do not place a personal computer or television in a child’s bedroom. Instead, create a reading-friendly space in another room in your home. Keep age-appropriate books on shelves children can reach and keep these shelves appealing and organized.
• Volunteer to read at your local library.
• Host a book drive in your workplace and donate the haul to a daycare center.
• Volunteer to be a mentor.
• Reach out to the United Way of Lackawanna and Wayne Counties (UWLWC). UWLWC can connect you to a host of resources focused on helping every child to become a lifelong reader.
• Rethink Healthy Holiday Gifts!

So, if you want to give a healthy gift, but can’t afford an expensive treadmill, elliptical or electronic fitness tracker, GIVE A BOOK…AND HELP A CHILD BECOME HEALTHY ADULT! Visit The Children’s Library of Lackawanna County on Vine Street in Scranton, PA

SOURCE: Reading on Grade Level in Third Grade: How Is It Related to High School Performance and College Enrollment? A Longitudinal Analysis of Third-Grade Students in Chicago in 1996-97 and their Educational Outcomes . A Report to the Annie E. Casey Foundation, University Of Chicago, Joy Lesnick Robert M. Goerge Cheryl Smithgall Julia Gwynne , 2010

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in the Scranton Times-Tribune. Next Week: Part 2 of Reading for Health!

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.comPaul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.

DANCE FOR EXERCISE FOR THOSE WITH PARKINSON’S DISEASE

“Dance like nobody’s watching!” This is one of my favorite quotes from Mitch Albom’s book, Tuesdays With Mori, because it represents interesting facts about human behavior. One, of course, is the ability to be comfortable in your own skin. The other, maybe less obvious benefit, is that challenging your balance through dancing, even if it’s not pretty, is very effective in maintaining or improving quality of life for those with challenges in gait and balance, as found in Parkinson’s disease (PD). In fact, “Dance for PD^R”, a new and popular treatment for PD, has recently been validated in the scientific literature as a valuable treatment tool for those with PD.

 Research published in the Journal of Neural Transmission, shows that dancing is shown to help people with PD improve their ability to walk and enhances their quality of life. The program was applicable to those at various stages of PD, including those using walkers. Moreover, the results found that, in addition to physical improvements, participants also had psychological and social benefits through camaraderie, joy of movement and less isolation.

Participants, none of whom had ever engaged in a dance class before, performed a structured dance program for 16 sessions over 8 weeks. Each class was 75 minutes long with seated warm-up activities 50% of the time.  Results showed: 10% improvement in overall movement, 26% improvement in walking and 18% improvement in tremor.

Parkinson’s disease is a chronic, degenerative disease that leads to slowness of movement, balance disorders, tremors, and difficulty walking. PD results from the loss of dopamine-producing nerve cells in the brain. Dopamine is critical to stimulate the nerves of the muscular system in the body. PD affects approximately 1.5 million people in the USA with 60,000 new cases each year according to the National Parkinson Foundation. Most people know someone affected by PD.  PD typically affects those over 65 years of age and only 15% are under 50.

While there is no current cure for PD, exercise is well documented to relieve some of its symptoms. Specifically, exercise can help keep muscles strong, joints mobile, and tissues flexible. Exercise will not stop PD from progressing but it will improve balance, enhance walking ability, reduce muscle weakness, and minimize joint stiffness. In 2007, a study published in the Journal of Neuroscience revealed that exercise may benefit individuals with PD because exercise encourages the remaining dopamine cells to work harder to produce more dopamine. Also, the researchers discovered that exercise decreases the rate at which dopamine is removed from the brain.

Exercise to improve strength, balance, and flexibility can be performed independently at home or supervised at a rehab or exercise facility. Supervised exercise can include physical therapy, recreational therapy, water therapy, yoga, and Tai Chi. Physical therapy can improve walking ability, enhance balance, reduce fatigue, increase strength, promote flexibility and minimize pain. Physical therapy uses movement techniques and strategies as well as various pieces of equipment to enhance an individual’s level of independence and improve his quality of life. PT can also incorporate leisure activities (e.g. golfing and ballroom dancing) to reduce the symptoms and associated limitations of PD. Tai Chi, a total mind and body workout, is a series of individual dance-like movements linked together in a continuous flowing sequence. Particular benefits for people with PD include reduced stress, increased energy, improved concentration and focus, better circulation and muscle tone, and significant improvements in balance.

According to Dance for PD^R, their program offers internationally-acclaimed dance classes for people with Parkinson’s disease in Brooklyn, New York and, through a network of partners and associates, in more than 120 other communities and 16 countries. In Dance for PD classes, participants are empowered to explore movement and music in ways that are refreshing, enjoyable, stimulating and creative. For more information visit: www.danceforpd.org

So, if you like to dance, “keep on dancing!” If you don’t dance and notice some changes in balance and coordination, or if you have PD…it’s a good time to start!  “Dance like nobody’s watching!”

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in the Scranton Times-Tribune.

 This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com. Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.