Health Information

ข้อมูลสุขภาพ

Articles by PhysiciansArticles by PhysiciansNewsletterVDOPodcast

Search

How Do Golfers Breathe While Playing Golf?

How Do Golfers Breathe While Playing Golf?   How do golfers breathe while playing golf? You may ask golfers the same question while they are swinging their clubs. If a golfer is preoccupied with thoughts about breathing, they may forget their swing and fail to putt the golf ball into the hole.   According to Dr. Virayut Chaopricha Orthopedic Surgeon at Vibhavadi Hospital, here are some points to consider regarding breathing while playing golf:   Ask golfers in the same group about their breathing pattern while they are swinging. If a golfer is preoccupied with thoughts about breathing, they may forget their swing and fail to putt the golf ball into the hole.   The author asked a skilled professional golfer how they breathe while playing golf, and the golfer replied, "Honestly, I don't know exactly how I breathe." This is a correct answer because if a golfer lacks focus during the game, it would be difficult to achieve the desired results.   Golfers who perform well have a smooth swing and normal breathing. They don't consciously observe or control their breathing. However, if they experience stress, which often creates self-imposed pressure, they may lose control and their breathing becomes irregular or even held, resulting in muscle tension and an inability to control the swing as intended.   To achieve better control over the swing, it is important to have smooth and regulated breathing. We should pay attention to our breathing in more detail to benefit our health, emotional control, and improve our golf game. We already breathe in and out approximately 25,000 times a day. It seems like we have extensive experience and nothing more to learn. However, understanding and practicing breathing frequently can allow us to have better focus, improve our ability to control our breath, and ultimately enhance our performance. This is more effective than letting our minds be disturbed by external factors that are beyond our control.   Every cell in our body requires oxygen to sustain life. However, our body cannot store oxygen naturally in an unpolluted environment, where the oxygen concentration is approximately 21%. Oxygen cannot penetrate the skin. We must inhale air containing oxygen into the lung alveoli to oxygenate the blood that passes through them. After passing through the lung alveoli, the blood exchanges carbon dioxide for oxygen, and the waste gas carbon dioxide is then exhaled when we breathe out.   The act of breathing encompasses two distinct types of respiration working in conjunction.   Thoracic breathing involves the movement of the chest cavity during inhalation. The ribcage and sternum expand while the abdominal area remains relatively flat or experiences minimal movement.   Abdominal breathing relies on the motion of the abdominal wall. When inhaling, the abdominal wall protrudes outward, while during exhalation, it flattens and moves closer to the back. This type of breathing primarily engages the diaphragm.   Mechanisms of the respiratory system: The muscles involved in normal inhalation:   The diaphragm plays a crucial role in breathing. It attaches to the inner surface of the lower ribs (ribs 7-12), the xiphoid process, and the first to third lumbar vertebrae. Contraction of the diaphragm pulls the central tendon downward, increasing the vertical dimension of the central compartment.   The external intercostal muscles, situated between the ribs, contract and lift the ribcage, expanding the thoracic cavity. This expansion causes the pressure inside the lungs to decrease below atmospheric pressure (typically 760 mmHg), facilitating the entry of air into the lung's air sacs until the pressure reaches approximately 762 mmHg.   Normal exhalation: This process involves the relaxation of the diaphragm and the elastic recoil of the lungs, returning them to their resting state. The pressure inside the lung's air sacs exceeds the atmospheric pressure, resulting in the expulsion of air from the body until the pressure drops to approximately 756 mmHg.   Increasing inhalation strength: To enhance the force of inhalation, the muscles responsible for elevating the ribcage, including the scalene and intercostal muscles (ribs 2-5), are utilized, allowing for a more forceful intake of breath.   Increasing exhalation: Intentionally exhaling rapidly or engaging in strenuous physical activity activates the abdominal muscles and the internal intercostal muscles, aiding in forceful exhalation.   During periods of rest, breathing typically relies on the diaphragm. However, in times of stress, tension, arousal, or fear, individuals may resort to thoracic breathing, wherein the abdominal muscles and rigid back are engaged minimally. After the stressful event subsides, the abdominal muscles relax, resulting in a relaxed, full-breath experience that provides a sense of relief and spaciousness. This mindful breathing technique allows for a qualitatively enhanced respiration.   Many golfers may be familiar with the feeling of abnormal breathing during moments of stress, as the thoracic muscles become tense, inhibiting the natural swinging motion. This reflexive breath-holding reaction is present in everyone and is referred to as the trauma reflex. Similarly, it is observed in various animals and serves as a survival mechanism. It involves shallow breathing and breath-holding to minimize sound and motion, avoiding detection by potential threats.   Training, the transformation of rigid breathing into relaxed breathing.   Sit on a chair or the edge of a bed, with your feet firmly on the ground. Relax your arms and neck, and start leaning back, allowing your body, back, and neck to relax. Take slow, deep breaths, feeling as if the air is entering your abdomen. Count from 1 to 10, then slowly lean forward, letting the air flow out as you lower your neck. Count from 1 to 10. Practice this frequently, and you will gradually feel a relaxed and effortless breathing pattern, using your diaphragm and allowing your lungs to expand and release naturally, without tension.   When feeling stressed or under pressure, take slow, deep breaths, feeling your lower abdomen and ribcage expand. Then release the breath slowly until you regain control of your sensations.   Golf Swing Practice: Skilled golfers who have a smooth, natural swing without tension often exhale while swinging or immediately after exhaling. They may not even be aware of it. Golfers who struggle with their swing tend to have a breathing pattern that resembles inhaling sharply and holding their breath, using chest breathing. This creates a trauma pattern, causing muscle stiffness and restriction.   You can test this yourself:   Swing the golf club 2-3 times while inhaling and holding your breath.   Swing the golf club 2-3 times while exhaling slowly. David Leadbetter recommends using this technique by inhaling during the backswing and exhaling slowly when starting the downswing.   After exhaling completely, tense your abdominal muscles, start the backswing, make the downswing, complete the swing, and then relax and breathe in. Gay Hendricks, Director of the Academy for Conscious Golf and Business in California, found that this method improves accuracy in golf swings.   Repeat the test multiple times, and you will personally feel whether your golf swing improves with technique 2 or 3, which involves exhaling while swinging or exhaling completely. Similar to other sports such as weightlifting or tennis, when lifting weights or hitting a tennis ball, you will hear the sound along with your exhale.   Recommendations for golfers:   Take a moment to breathe deeply and relax. When you inhale, let your abdomen expand, and when you exhale, allow your abdomen to contract. The author suggests that students try this exercise, but many of them struggle because they are either not focused or tense. When the diaphragm muscle, which is responsible for breathing, doesn't function properly, the chest muscles have to work harder, resulting in less air intake. Try practicing the following exercise: if you don't understand it, lie down on your back, bend your knees, and interlock your fingers. Exhale while tensing all the muscles in your body, including wiggling your toes, pulling your hands, tensing your leg muscles, abdomen, neck, and facial muscles as much as possible. Hold your breath for as long as you can and then release all the muscles at once. You will feel a full breath entering your body along with your relaxed abdomen. Follow this with a full exhalation, allowing your abdomen to deflate. This is diaphragmatic breathing. Practice diaphragmatic breathing frequently until it becomes natural. You will increase your strength and reduce fatigue.   Choose to practice your golf swing while exhaling or immediately after exhaling, and repeat this frequently until you become proficient. The goal is to be able to swing without being conscious of your breath. When there is pressure, take a deep, slow breath in and out, controlling your breath, and then swing while exhaling or immediately after exhaling, as you have practiced. You will be able to control your swing.   Engage in aerobic exercise 2-3 times a week. This will greatly improve your respiratory and circulatory systems, allowing you to play golf without feeling fatigued.   Avoid activities that are harmful to the respiratory system, such as smoking or being in poorly ventilated areas with high levels of pollutants.

See More

Knee Injuries

Knee Injuries By Dr. Virayut Chaopricha Orthopedic Surgeon at Vibhavadi Hospital   In the year 2004, there was a question raised by those in the golfing community about what happened to Tiger Woods, who had emerged victorious in the Majors from 1999 to 2002, securing seven titles, including four consecutive wins known as the Tiger Slam. However, he had been unable to win any tournaments for a whole year.   Tiger Woods had made a change in his coach at the beginning of 2003, transitioning from Butch Harmon to a new coach, Hank Haney, which sparked much speculation about whether he would have another grand comeback. This change was motivated, in part, by the fact that Tiger Woods had experienced discomfort in his left knee and back due to his previous swing technique. After undergoing arthroscopic surgery in 2002, it was discovered that there was fluid in his knee joint and a tearing of the anterior cruciate ligament (ACL). The ACL plays a crucial role in maintaining the stability of the knee and its mobility during sports activities.   In his book "How I Play Golf," Tiger Woods mentioned a technique he employed to increase his distance by 20 yards. He would snap his left leg straight to achieve a more aligned position, and during the swing, he would generate power by rotating his hips quickly and rotating his left leg while keeping it flexed and then snapping it straight immediately during the downswing. This created a significant torque on his left knee. In 2002, Tiger Woods revealed in an interview with Golf Digest magazine that he experienced knee pain and had to take pain medication before playing. He also mentioned the need to minimize excessive pressure on his knee during the downswing.   It is important to understand the anatomy of the knee joint, its stability, and the management of the muscles surrounding the knee to strengthen and stretch them effectively, reducing the risk of injury.   Anatomy of the knee joint:   The knee joint consists of three bones: the femur (thigh bone), the tibia (shinbone), and the patella (kneecap). The contact surfaces between these three bones are covered by articular cartilage and enclosed within a synovial membrane.   Between the articular surfaces of the femur and tibia, there are C-shaped cushions on the outer and inner sides, known as menisci. They help reduce the impact on the knee joint and contribute to its stability, as well as improving the lubrication of the joint surfaces.   The stability of the knee joint depends on the intactness of the femur and tibia, which form the knee joint, the menisci as cushions, and the surrounding muscles.   The important muscles involved are the quadriceps muscles, located at the front of the thigh, responsible for knee extension, and the hamstring muscles, located at the back of the thigh, responsible for knee flexion. If any of these muscle groups are compromised or not functioning properly, the stability of the knee joint can be compromised.   The stability of the knee joint relies on four major ligaments:   Lateral collateral ligament: prevents the knee from buckling or tilting sideways. Medial collateral ligament: prevents the knee from buckling or tilting inwards. Anterior cruciate ligament (ACL): prevents the knee from buckling or sliding forward. Posterior cruciate ligament (PCL): prevents the knee from buckling or sliding backward.   The lateral and medial collateral ligaments prevent varus and valgus stress on the knee joint, respectively. The anterior cruciate ligament prevents anterior displacement, while the posterior cruciate ligament prevents posterior displacement of the knee joint.   Perilous conditions that can cause severe knee dislocation or excessive knee movement beyond normal include falls, dislocation, excessive hyperextension or lateral movement of the knee. These incidents can result in a complete tear of the ligaments that hold the knee joint, leading to a single or multiple ligament tears or injuries along with fractures of the joint surface. Additional injuries such as a dislocated knee pillow or supporting cushion can also occur.   The severity of ligament tears can be categorized into three levels: Level 1 involves tearing within the tissue of the ligament, but the ligament is still intact or the tear is not clearly visible. Level 2 indicates partial tearing of the ligament. Level 3 signifies complete separation of the ligament. Symptoms and findings: In general, knee injuries from playing golf are usually not severe. Apart from falling or stumbling, such injuries are often associated with standing and striking the ball on uneven terrain. It is common to find injuries in the left knee of right-handed golfers due to the significant torsion and weight-bearing on the left knee during swings.   Severe injuries are more frequently encountered in sports such as football, rugby, and tennis. The severity of symptoms may vary depending on the extent of the injury, such as:   Swelling and pain around the knee joint Tender pain at the site of ligament tear, along the joint line, which is the position of the knee pillow Inability to bear weight or walking with significant abnormal pain Restricted knee flexion or extension, with the knee getting stuck in certain positions, potentially due to a missing knee pillow obstructing the joint Sensation of swelling or deformity in the knee, which may result from a complete ligament tear or fractured bones   Medical examination findings:   Examination of joint fluid or blood within the knee joint, which often presents significant swelling Evaluation of the stability on the lateral sides of the knee joint Assessment of anterior-posterior stability of the knee joint Assessment of range of motion, knee rotation, to determine if the knee pillow is missing or not   Image 3: Evaluation of anterior-posterior stability of the knee joint in the supine position with the knee flexed at 90 degrees. If pulling the tibia forward results in anterior displacement, it indicates an anterior ligament tear. If pushing the tibia downward leads to posterior displacement, it indicates a posterior ligament tear. Knee X-ray: Performed to identify any fractures or joint dislocation.   Arthroscopic surgery: It is a minimally invasive procedure used to examine the interior of the knee joint, allowing for an accurate and clear diagnosis. Most patients receive an injection into the posterior capsule to numb the lower part of the body, enabling them to undergo surgery without feeling pain. A tourniquet is applied to the upper leg to prevent bleeding during the surgical procedure.   During the surgery, a hole is drilled near the front of the knee, close to the patellar tendon, and a 4.5-millimeter metal tube with lenses and fiber optics is inserted into the knee joint. This allows for visualization of the internal structures of the knee joint, which are displayed on a television screen. The magnification can range from 5 to 10 times the actual size, and the procedure can be recorded as a video for future reference.   Image 4: Arthroscopic Surgery for Knee   Abnormalities Examination:   When examining the knee through arthroscopic surgery, various conditions can be observed, such as soft cartilage, front ligament, back ligament, knee pad, and joint tissues, in order to identify abnormalities or irregularities. These conditions can be corrected through surgical intervention, such as smoothing the cartilage and removing the right knee pad, front ligament, and back ligament.   Postoperative Care:   After the wound has healed well, the patient's knee will be wrapped with thick bandages and compressed with an elastic bandage to reduce swelling for approximately 3-4 days. Then, the patient can begin to exercise and strengthen the quadriceps muscles.   Muscle Conditioning and Physical Therapy after Surgery   Once the wound has healed properly, the patient can start exercising to strengthen the quadriceps muscles. Start muscle conditioning without putting weight on the knee, such as swimming or cycling. Muscle conditioning using weights (weight training).   Muscle Stretching Exercises Quadriceps Stretching:   Stand near a wall or table, bend one knee, and bring the foot towards the back, feeling a stretch in the front part of the extended leg. Hold this position for 5-7 seconds, repeating 6-10 times on each side.   Hamstrings Stretching:   Practice bending one knee and extending the other leg, leaning forward and backward to feel a stretch in the back of the extended leg. Hold this position for 5-7 seconds, repeating 6-10 times on each side.   Muscle Strengthening Exercises Quadriceps Muscles:   Sit on a high chair, bend the knee, lift the foot, and extend the knee against resistance. Sandbags or resistance bands may be used. Hamstrings Muscles: Lie face down, bend the knee, and resist against the force. Weights can be tied to the ankles or resistance can be provided using resistance bands.   Recommendations for Golfers:   Warm up and stretch the muscles to increase flexibility and joint mobility before playing golf. Start exercising slowly and gradually increase intensity. Avoid overexertion or causing injury during exercise. Consistently work on strengthening the muscles. Play golf within your own limits, considering time, tempo, and balance as important factors. This will greatly reduce the risk of injury. If you experience knee pain or abnormal movement, seek medical attention for proper diagnosis and treatment.

See More

Peripheral Nerve Injury

Peripheral Nerve Injury   Injuries to peripheral nerves' distal branches are common issues encountered by medical professionals. Particularly, injuries to the nerves of the hand and arm often present a challenge as they may go unnoticed by the patient. Sometimes, these injuries may not be accurately diagnosed or adequately examined. Consequently, devising a treatment plan, communicating treatment outcomes, and providing patients with proper guidance on self-care become crucial aspects. The recovery time for nerve injuries can vary significantly, ranging from days to months or even years, depending on the severity of the damage. Having a solid foundation of knowledge regarding nerve injuries, selecting appropriate treatment methods tailored to individual patients, and effectively explaining expected outcomes or changes throughout different stages of recovery can instill confidence in patients, fostering a strong doctor-patient relationship. Moreover, it enables long-term monitoring of treatment progress. The peripheral nervous system connects with the central nervous system, namely the brain and spinal cord, extending to various parts of the body. This system consists of cranial nerves and spinal nerves, which include the nerves that branch out to the arm and hand. In the arm, these spinal nerves exit the spinal cord through the C5-T1 roots. The spinal nerves comprise: Motor fibers that connect to muscle end plates. Sensory fibers originating from receptors located in the skin, muscles, tendons, and joints. Autonomic fibers that supply blood vessels, sweat glands, and hair follicles. When examining patients suspected of peripheral nerve injuries, it is necessary to evaluate all three aspects: motor function, sensory perception, and sympathetic nerve activity, which regulates sweat production. Specifically: Motor examination involves assessing muscle strength and weakness in the groups of muscles innervated by the injured nerves. Sensory examination focuses on evaluating loss of sensation after nerve injury, particularly in the arm and hand. Patients may experience numbness or loss of sensation in the skin supplied by the affected nerves. However, in the chest region, where the nerves form plexuses before branching into the median, ulnar, and radial nerves, the course of the nerves is more distinct. Sensibility examination following injury to the peripheral nerves in the arm and hand, the patient will experience a lack of sensation in the corresponding skin areas supplied by the affected nerves. The distribution of sensory loss will be distinct along the nerve pathways, particularly in the arm, as the nerves converge into a plexus before branching out into the median nerve, ulnar nerve, and radial nerve to innervate the arm and hand. The evaluation of sudomotor function in the region supplied by the injured nerve will reveal no sweating within 30 minutes after the injury.   Characteristics of nerves when studied under a microscope:   Each nerve fiber is surrounded by connective tissue called Endoneurium, which contains collagen fibers and blood vessels. Multiple nerve fibers are grouped together into fascicles, surrounded by connective tissue called Perineurium, which is a strong protective covering that helps prevent compression and distension forces on the nerves. It also acts as a diffusion barrier, preventing the passage of solutes into and out of the axons.   Fascicles, which are groups of nerve fibers, are bundled together within the nerve trunk. The nerve trunk is covered by a thick and strong connective tissue called Epineurium, which comprises approximately 60-85% of the cross-sectional area when the nerve is cut.   The Epineurium is further divided into two parts: the external epineurium, which covers the entire nerve, and the internal epineurium, which closely surrounds the fascicle groups in contact with the perineurium. During nerve surgery, the external and internal epineurium are sutured separately.   Nerve microcirculation involves multiple blood vessels that enter the nerves, passing through loose areolar connective tissues and penetrating into the nerves as intrinsic epineurial, perineurial, and endoneurial plexuses. This extensive blood supply ensures adequate nourishment to each individual nerve fiber and facilitates easy nerve separation during surgery by cutting the supplying blood vessels without affecting the flow within the nerve. This allows for the use of free vascularized nerve grafts, utilizing only the blood vessels that supply the nerves.   Stretching the nerves increases the intrafascicular tissue pressure, which affects the blood flow. Lundborg's studies have shown that stretching a nerve by 8% has an impact on venules, and when the nerve is stretched by 15% to increase its length, blood flow in arterials and capillaries stops. Therefore, excessive tension during nerve suturing can affect nerve circulation.   Nerves have the ability to move and slide within the surrounding tissues, such as during wrist, elbow, or shoulder movements. This mobility is important in preventing nerve traction or compression when the hand or arm is in motion. The excursion of nerves above the elbow during elbow flexion and extension is as follows: the median nerve moves 7.3 mm, and the ulnar nerve moves 9.8 mm. In the region above the wrist, the median nerve moves 14.5 mm, and the ulnar nerve moves 13.8 mm.   Digital nerves at the base of the fingers move 3.1-3.6 mm. The movement of these nerves does not affect microcirculation.   This study helps explain the occurrence of nerve compression and irritation due to edema and fibrosis, which reduce nerve mobility, causing adhesion between the nerves and surrounding tissues. This results in nerve traction and reduced blood flow during hand movements, which progressively worsens over time.   Surgical dissection of nerve fibers must strive to avoid excessive damage to the surrounding tissues as it can reduce the excursion of the nerve fibers.   The interaction between neuronal cell bodies and target organs involves communication in both proximal and distal parts of the neuron through anterograde and retrograde axonal transport mechanisms. End organs are stimulated by nerve cells, while nerve cells receive neurotrophic factors from end organs and Schwann cells through retrograde axonal transport. Axonal transport, which involves the transmission of substances between cells and target organs, occurs in two forms:   Fast transport: Nerve cells send membrane proteins, secretory proteins, and peptides to target organs. Nerve growth factor and neurotrophins, crucial for the growth and maintenance of nerve cells, are transported back to the necessary cells, originating from Schwann cells, the skin, and target organs. In cases where there is a lack of nerve growth factor and neurotrophins due to injury, nerve cells can die, especially when the injury occurs close to the nerve cells. The rate of fast transport is approximately 200-400 mm per day. Slow transport: This type of transport is essential for the axon's sprouting after injury. The rate of slow transport is approximately 1-4 mm per day, representing the rate of axon sprouting.   The transformation of nerve fibers when severed When a segment of the nerve fiber is severed from the nucleus, it undergoes degeneration and is destroyed through phagocytosis. The process of degeneration in the distal end of the nerve fiber, which is severed from the nucleus, is referred to as Wallerian degeneration or secondary degeneration. Changes occur in the portion above the region of loss and are known as primary, traumatic, or retrograde degeneration.   When an axon is severed, there is a complete transformation of the axon's distal end. Electrical stimulation does not elicit a response after the injury for 18 to 72 hours. After 2 to 3 days, the axon undergoes progressive degeneration and shrinks into small fragments. By day 7, macrophage cells come in and consume the fragments of the axon, which are completely cleared within 15 to 30 days. Schwann cells proliferate and replace the axon and myelin sheath. Primary or retrograde degeneration occurs at least in one node of the nerve fiber, depending on the severity of the injury. The changes and transformations resemble Wallerian degeneration.   On day 7 after injury, noticeable changes occur in nerve cells. There is swelling of the cytoplasm and nucleus, and they may be displaced to one side (eccentric placement). The nerve cell may die or recover to repair the damaged area, with clear changes observed 4-6 weeks after injury, when the swollen nucleus will return to the center.   Within the first 24 hours after injury, axons may sprout in the area of damage, provided that the distal end has not been severed or separated. The axon will then grow in the same direction towards the target organ, influenced by neurotrophic substances at the end of the nerve fiber. This process is called axonal growth and orientation.   Lundborg conducted experiments utilizing the Y chamber within a Silicone block, connecting it to both ends of the Sciatic nerve, followed by nerve graft and tendon graft. It was observed that nerve structures grew into the ends of the nerve graft while being composed of small, interconnected tissue fibers merging with the tendon graft.   Cellular repair versus cellular proliferation When a nerve is severed, it loses its axoplasmic content and the distal ends that have been cut off. Axon regeneration involves the regrowth of axoplasm from the original nerve cells, without an increase in the number of nerve cells. In the area surrounding the severed nerve, there is an increase in connective tissue cells, resembling the characteristics of local wound healing processes.   The classification of nerve injuries according to Seddon includes three types:   Neurapraxia: This is a physiological condition where there is no alteration in the nerve itself. Axonotmesis: The axon is disrupted, but the nerve sheath remains intact, resulting in degeneration of the distal portion. Neurotmesis: The entire nerve, including its fibers, is completely severed. Sunderland classified nerve injuries based on their severity, ranging from Grade 1 to 5.   Important physical examinations after a nerve injury:   Examining the physical condition of a patient to ensure there is no nerve injury can sometimes be challenging. If the patient does not cooperate, the examiner may overlook certain signs. In some cases, physical examinations may yield inaccurate results due to variations in the nourishing nerves or tricks in movement. For instance, when asking the patient to straighten their fingers, if they are unable to do so and instead bend their wrist, it becomes evident that they cannot fully extend their fingers.   A missing digital nerve may go undiagnosed if not suspected or thoroughly examined. When a flexor tendon is missing in the hand, one should suspect the absence of a digital nerve, either partially or entirely. Sensation at the fingertips must be assessed, and when performing surgery, the incision should expose the nerve to determine its normalcy.   Examining the Radial nerve involves assessing sensation on the back of the hand, specifically in the webbed area between the thumb and index finger. To assess motor function, the patient is asked to flip their hand, causing the thumb to extend away from the palm. If the patient can perform this action, clearly revealing the EPL tendon, it indicates a normal Radial nerve.   When examining the Median nerve, sensation at the fingertip (autonomous zone) is evaluated. If sensation is normal, it indicates an intact nerve. The Abductor Pollicis Brevis muscle is also examined by having the patient spread their thumb perpendicular to the palm while the examiner observes movement and palpates the muscle. If there is muscle contraction, it indicates a normal Median nerve.   To examine the Ulnar nerve, sensation in the autonomous zone at the pinky fingertip is evaluated. Additionally, the motor function of the Dorsal Interossei muscles is tested by having the patient place their hand flat on a surface and move the middle fingers sideways on both sides without lifting them. If this action can be performed, it indicates a normal Ulnar nerve.   The treatment of nerve injuries depends on the severity of the injury within the Neurapraxia group, or Grade 1, and Axonotemesis, mostly Grade 2 and 3, where surgical intervention is not necessary. In the Neurotemesis group, or Grade 4 and 5, if surgery is not performed, the treatment outcomes are not favorable.   Therefore, it is important to consider how severe the injury is and whether surgical intervention should be performed promptly or avoided if unnecessary. Unnecessary surgeries should be avoided because they may cause further severe injuries or delay surgery in cases where immediate intervention is required, resulting in weakened muscles and unfavorable surgical outcomes.   Non-surgical treatment aims to prevent joint stiffness, protect the insensate skin from developing wounds, and maintain good muscle function and strength. Indications for surgical treatment in cases of nerve injury, such as Neurotemesis, Neurapraxia, and Axonotemesis caused by compression, for example, by pulling the bone into the site of humeral fracture that compresses the radial nerve, include surgical repair of the nerve or correction of the underlying cause of the injury from compression, which helps restore nerve function.   The important indications are as follows: Visible nerve gap when the sheath is sharp near the nerve. Severe injuries, such as explosions, should be debrided, and the nerve should be examined for planned nerve repair after a clean wound without infection. Non-penetrating injuries or deep-penetrating wounds, such as stabbings or gunshot wounds, should be treated, and the nerve should be monitored to see if it will recover within an appropriate time frame, usually within 3-6 weeks. If there is no reinnervation of the muscle supplied by the injured nerve, surgical treatment should be considered. In cases where the bone is pulled into the socket, causing nerve injury, especially in cases of oblique humeral fractures where the radial nerve passes through the fracture site, it may be compressed by the bone. In such cases, surgical treatment should be performed promptly.   The timing of surgery for nerve injury following trauma:   Surgical intervention for nerve injury should ideally be performed within 6-8 hours in cases where the wound is clean and the edges are well approximated, a technique referred to as primary repair. If all the necessary conditions are met, including experienced surgeons, an operating room, surgical instruments, a microscope, or a loupe, the procedure should be promptly carried out. However, if the conditions are not met or there is no experienced surgeon available, the surgery may be delayed to 5-7 days, still considered as primary repair. This is because nerve repair should be performed optimally during the first instance, as "first repair must be the best repair possible."   Surgical intervention performed between 7-18 days is termed delayed primary repair. This may involve waiting for the patient's condition to be suitable for surgery or dealing with areas where the nerve is absent but without signs of infection. If the surgery is performed after 18 days or three weeks, it is referred to as secondary repair. In such cases, neuroma and glioma at the nerve endings are often addressed, and issues related to the presence of gaps between the nerve endings are addressed.   The steps involved in nerve surgery are as follows: After opening the wound to locate the nerve, it is advisable to start from a good area close to both ends of the nerve and then identify the nerve stumps. This approach makes it easier and avoids cutting blood vessels near the area of nerve absence, where there is significant scar tissue. Preparation of the nerve stumps involves cutting the ends of the nerves until clear fascicles without scar tissue are visible. This preparation allows for the proper connection of the nerve.   Identification of Motor and Sensory Fascicles:   When reconnecting a digital nerve that contains only sensory fibers or a nerve that solely innervates muscles (motor fibers), there is no issue with switching groups. However, when dealing with a mixed nerve that contains both motor and sensory fibers, the outcome of switching groups is less predictable. Therefore, to achieve desirable outcomes, it is important to select the appropriate approach for reconnecting the nerve, either maintaining the nerve in its original group or mixing motor and sensory fibers together.   Various techniques can be employed for nerve repair based on specific factors:   Anatomic technique: This technique can be used during primary repair if the nerve groups and the blood supply are clearly visible. Electrophysiological method: This method should be performed within 2-3 days after injury, as stimulating the distal part of the nerve beyond this timeframe may not yield results due to nerve degeneration. Histochemical parameter: This involves examining both nerve stumps and assessing the presence of acetylcholine esterase on the cut surface of the stumps. This helps to categorize motor fibers into appropriate groups.   Methods of nerve suturing:   Epineurial Neurorrhaphy Group Fascicular Neurorrhaphy   The choice of suturing method does not significantly affect the treatment outcome. It depends on the nature of the nerve stump. The most appropriate approach should be considered based on the principle of suturing the nerve fibers together correctly, ensuring that there is no scar or tension in the nerve endings.   For primary repair, epineurial repair is chosen when the nerve stump is not clearly divided into distinct groups. If the nerve stump is clearly divided, group fascicular repair is performed.   Partial Neurorrhaphy is performed when a portion of the nerve is missing. The nerve fibers that are intact are separated from the neuroma, and the neuroma is excised. Then, the missing part is sutured, allowing the good nerve fibers to bend without the need for further excision.   When both ends of the nerve are far apart:   Mobilization: Nerve mobilization is done after 3 weeks. The neuroma is excised until good fascicles are visible, creating a gap between the nerve stumps. Both ends of the nerve can be dissected, and blood vessels near the stump can be cut to facilitate the alignment of the nerve ends. Position of the extremity: When suturing the median nerve or ulnar nerve near the wrist or elbow, the elbow flexion should not exceed 90 degrees, and wrist flexion should not exceed 40 degrees. This helps in the successful nerve suturing. Excessive flexion of the elbow or wrist after the procedure may cause problems in joint extension, hindering normal working or resting positions, as it may not allow the nerve to stretch properly. Transportation of Ulnar Nerve: If the ulnar nerve is missing near the elbow, and even after flexing the elbow, the nerve cannot be sutured, it can be transposed to the front of the elbow. This allows for nerve suturing and enables flexion and extension of the elbow. Bone Resection: When the nerve is missing along with a fractured humerus, in the case of a comminuted fracture, the fractured ends of the bone may be trimmed evenly to facilitate nerve suturing. Bone resection is not performed if there is no bone fracture. Nerve Grafting: Excessive tension during nerve suturing can lead to impaired microcirculation in the nerve. In such cases, nerve grafting is used to address the issue. Sural nerve graft is commonly used due to its minimal donor defect and its availability in lengths of 30-40 cm.   Postoperative Evaluation of Nerve Transection Using the Medical Research Council System   End-to-side nerve suture procedure:   Reports on surgical procedures have emerged, involving the connection of the distal portion of the missing nerve to a nearby donor nerve through an end-to-side approach. This technique demonstrates comparable outcomes to the standard method, with no deficits observed in the donor nerve. The advantages of the end-to-side nerve suture procedure lie in its simplicity, as it eliminates the need for nerve grafts and accelerates nerve recovery time. It serves as an alternative approach when the nerve deficit is substantial, although long-term outcomes and the efficacy across multiple institutions should be carefully considered.   References: Birch R. Nerve repair. In: Green's DP. Green's Operative Hand Surgery. Fifth edition. Vol. 1. Churchill Livingstone, 2005; 1075-1112. Jobe MT. Nerve Injuries. In: Terry Canal. Campbell's Operative Orthopaedics. Volume 4. 9th edition. St. Louis: Mosby, 1998; 3429-3444. Jobe MT and Wright II. Peripheral Nerve Injuries. In: Terry Canal. Campbell's Operative Orthopaedics. Volume 4. 9th edition. St. Louis: Mosby, 1998; 3827-3852. Lundborg G. Nerve Injuries and Repair. Churchill Livingstone. New York, 1988.   By Dr. Virayut Chaopricha Orthopedic Surgeon at Vibhavadi Hospital

See More

Back Pain May Be A Warning Sign Of Osteoporosis

Back Pain May Be A Warning Sign Of Osteoporosis   Dr. Virayut Chaopricha, a specialist in bone and joint disorders at Vibhavadi Hospital, provided an interview with Thairath newspaper, warning about the importance of not underestimating back pain and the threat of osteoporosis.   Indeed, the absence of illness is considered a precious blessing, yet it does not mean that we have full control over our body's functions. Dr. Virayut Chaopricha cautioned that osteoporosis has become a global menace, with an estimated rate of two bone fractures per minute within the next 50 years.   Dr. Virayut enlightened us on the current significant issues regarding bone diseases, namely osteoporosis and easy fractures. Numerous patients seek treatment at hospitals on a daily basis, often requiring surgical interventions for conditions such as hip fractures. Some individuals visit doctors due to severe back pain, spinal deformities, or debilitating bone pain that hinders their ability to walk. These symptoms serve as alarming indicators of potential osteoporosis. This disease is becoming a major global problem, on par with the World Health Organization's initiatives to educate the general public about osteoporosis. Within the next 50 years, it is estimated that there will be two bone fracture patients per minute worldwide.   Regarding the risk factors contributing to the development of osteoporosis, Dr. Virayut stated that there are numerous causes, with one of the main factors being chronic illnesses, such as diabetes, kidney disease, and thyroid disorders. Malnutrition or insufficient calcium intake is another risk factor, as well as sedentary lifestyle, long-term steroid use, individuals over the age of 40, menopausal women, and those who consume alcohol and smoke regularly. These groups are all considered at high risk.   Nevertheless, Dr. Virayut emphasized that many people still overlook the importance of osteoporosis and tend to disregard it until it becomes too severe to ignore, prompting them to seek medical attention. Several individuals possess risk factors but are unaware and fail to receive treatment. For instance, even minor accidents or low-impact collisions can lead to bone fractures. Complications arising from such fractures can result in severe disabilities, making it difficult for individuals to walk.   To prevent the silent eruption of osteoporosis within our bodies, it is essential to pay close attention to our physical well-being. If there are any slight signs or indications, it is crucial to consult a bone specialist promptly at the "Bone and Joint Center" of Vibhavadi Hospital by calling 0-2561-1111 ext 1.

See More

Restoring Freshness to the Bones Effortlessly With Vibhavadi Hospital

Restoring Freshness to the Bones Effortlessly With Vibhavadi Hospital   Longevity is desired. Besides staying informed about all the dangers of diseases, don't forget to pay attention to bone health as well. In the recent event "Restoring Freshness to Your Bones" held at the Vibhavadi Bone and Joint Center, there were some excellent discussions about keeping the bones healthy, here are some useful tips that we can all use.   It begins with preventing bone problems before old age. Dr. Piyapan Tharanat, an orthopedic surgeon specializing in bones and joints at Vibhavadi Hospital, explains that bones naturally begin to close and deteriorate for women aged 35 and above, and men aged 45 and above. This occurs because our bodies constantly absorb calcium for daily use. The simplest way to prevent this is by consuming an adequate amount of calcium throughout our lives. Thai meals usually provide around 400-500 milligrams of calcium, but our bodies require 1,200-1,500 milligrams. Therefore, it is recommended to supplement with calcium tablets and engage in regular exercise, such as weightlifting, to strengthen muscles, aerobic exercises to enhance cardiovascular health, jogging, or marathon running to improve endurance, and practicing yoga or tai chi to enhance joint flexibility. It is essential to choose activities that suit each person's age and physical condition.   Merely listening might not paint a clear picture, so we turned to the yoga expert, Auntie Ji, Ajcharaphan Phaiboonsuwan, who demonstrated the impressive "Half Moon" yoga pose to alleviate back pain and “Awkward Pose” to prevent knee problems. These exercises can be easily performed at home. Meanwhile, Associate Professor Dr. Ratree Ruengthai, an expert in aquatic exercise, enthusiastically encouraged aquatic workouts, highlighting their great benefits. The water's pressure reduces muscle strain, improves blood circulation and heart function, and enhances muscle flexibility. It is suitable for individuals with bone and joint issues, and can be easily performed by walking slowly in water, bending the knees at a 45-degree angle, and using the hands to push forward while walking back and forth twice a day. Now let's move on to the topic of nutrition. Dr. Ajjima Suwanchinda advises that proper nutrition is not just about having three complete meals, but also about consuming a well-rounded diet. As we age, it becomes crucial to increase nutrients that strengthen bones, such as calcium found in black sesame and black pepper. It is recommended to consume one tablespoon per day. Additionally, manganese, found in broccoli, helps increase collagen, while drinking one glass of pineapple juice daily, which contains bromelain and magnesium, helps prevent bone loss.   Furthermore, it is advisable to avoid tea, coffee, and salty foods as they contribute to bone fragility. By diligently incorporating these small tips into our daily lives, our bones will undoubtedly remain strong and resilient.

See More

Symptoms of Appendicitis: Which Side of the Stomach Hurts and How? You Need to Know Before It Bursts.

Symptoms of Appendicitis: Which Side of the Stomach Hurts and How? You Need to Know Before It Bursts.   What are the symptoms of appendicitis?   Standard symptoms of appendicitis: Initially, the pain will start generally and it is difficult to pinpoint the exact location. It can be around: The navel area, and can be occasional or constant. However, it is generally constant. After that, about 6-10 hours later, the pain will move to the… Lower right abdomen below the navel. It is constant and may be accompanied by a fever, loss of appetite, nausea, and diarrhea.   Classical symptoms are found in only about 25% of cases.   The remaining symptoms may not be like this, such as there may be no movement of pain, or it may be intermittent (in cases of the early stages or pre-ileal or post-ileal type).   However, the important point is the pain in the lower right abdomen, sensitive to pressure, unable to walk, loss of appetite, and often constant pain. Loss of appetite is a very important symptom, found in almost 100% of cases. Therefore, if there is abdominal pain but no loss of appetite and one can eat rice well, the chance of having appendicitis is almost non-existent.   Ruptured Appendix: If the appendix ruptures, the fever will rise to around 40 degrees Celsius, and the pain will be throughout the entire abdomen on both sides. The abdomen will be stiff, and one will not be able to walk, and have to lie still. The only treatment is surgery, whether it is ruptured or not.   How is the nature of the pain different from other diseases? Generally, the pain from other diseases is intermittent.   Peptic Ulcer: If it is due to a peptic ulcer, the pain is usually below the xyphoid process, associated with food. The stomach feels bloated as if the food is not digested or there is intermittent pain after eating.   Duodenal Ulcer: If it is due to a duodenal ulcer, it may be in the area below the xyphoid process or the right costal arch. There may be intermittent cramping pain before eating, which will improve after eating.   Gallbladder pain: Gallbladder pain usually occurs on the right side of the rib cage. It may radiate to the lower right side of the back or the area between the ribs. There will be a significant symptom, which is discomfort or bloating after eating fatty foods (fat intolerance) or intermittent pain after eating cold food.   Kidney stone pain: Kidney stone pain is often intermittent and located in the lower back. It may radiate down to the groin area, and there may be blood in the urine or urine that appears pink.   Ovarian cyst pain: Pain from the ovary or fallopian tube can cause pain in the lower abdomen, unrelated to food, often accompanied by abnormal bleeding or discharge from the vagina.   It can be difficult to differentiate abdominal pain in the early stages, whether it's from the fallopian tube or other diseases. Therefore, in cases where abdominal pain starts and the cause is unknown, it is recommended to see a doctor for diagnosis before taking pain relievers. This is because taking pain relievers can complicate the diagnosis, making it more difficult for the doctor to determine the cause of the pain.   Doctor: Dr. Thanet Phuwapongpankorn Specializes in Surgery, OB/GYN Surgeon at Vipawadee Hospital.

See More

Find a doctor

Make an appointmen

Jab & Go Clinic