Mar 25, 2012|
By participating in the Own the Bone™ program, the physicians and physicians’ assistants at NWOA strive to improve patient education about fragility fractures, proactively identify patients with osteoporosis, and reduce the odds of patients having another fracture in the near future. As the old saying goes, “an ounce of prevention is worth a pound of cure.”
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Mad men. Good afternoon this is doctor families are welcome to the health and wellness show on any of succeeding WR Julio. I wanted to welcome doctor nick -- In practice and it wasn't -- -- Unix where they have thirteen practicing physicians and -- you're in the thirteenth lucky thirteenth and wanted to thank you for coming here on a Sunday afternoon. Splitting time with us so welcome thanks for having -- -- I hope that all of our listeners around a healthy week in an enjoyable week. Fans. With. Spring here that I hope that you're all going to me making nice healthy choices. Healthy lifestyle changes before we get into the show I just wanted to. Make a couple of personal statements. That. I'm now actively practicing what I preach. And I've been walking regularly. After work a couple of times during a quick lunch break. Cutting out of my portions. And eating healthier. I've lost thirteen pounds and I need to tell all of our listeners. Who anyone who has -- that they need to lose. That thirteen pounds or may not sound like a lot of weight. Makes a huge difference in the way you feel in your activity levels in your energy level in that we use sleep that way you think. And encourage everybody to follow in my footsteps. Hands get out there -- start exercising walking is great eat healthy. And it was shell. Very. Could help. So you know and -- I -- -- welcome -- to the show and as we thought that we would start by speaking about -- in. But densities. Prevention of fractures so nick let's get right into this and speak about bone density. When it's appropriate. The early stage to do it and how we interpret it. North you know. So this is a great topic to talk about because of fractures -- becoming more and more common especially as the population ages. We are living longer now than we used to live and it is much more common to see patients who have a fracture especially. Remote company's problem we in the -- that hip. And the spine. And it's no surprise that as a bone density decreases it's more likely for you to sustain one of these fractures. And these -- we called him fragility fractures by definition there fractures which occur. From about standing height I was very low energy it's not like you got tackled playing football fell off the motorcycle Oregon and a car accident it's just. You're walking -- trip in itself. So generally the patients who have one of these types of fractures are people who have for bone density. And -- you can talk about or bone density and vague terms. These semi scientific way of actually measuring guys you get a bone density scans. Essentially that's an X ray studied. The amount of radiation you get from it probably less than from a chest X ray or from being outside in the sun for fifteen minutes. And -- -- about ten minutes. In his various symbol you really dislike flat and actually table. Very quick you really in and out and we get a lot of information from that very short examination where they -- as you said very little radiation exposure. Yeah that's correct it's an -- of the pelvis and an extra of the Euro lower spine a lot more spine. As -- from standardized tables you. Have your bone density checked against standardized cable stations most of the information collected about standard -- NCs are based on. Women who walk a certain age. However some of that can be extrapolated -- -- another. Some population. -- for women what needs to be be screening. So there -- its various guidelines for when we should do bone density it's not as -- we laid out as other things like chest X rays colonoscopy mammograms. But in general any woman -- postmenopausal. Under the age of 65. Probably should get at least one -- indeed bone density scanned at some point. Any woman over the age of 65 probably should routinely get a bone density -- at some point. And in our practice and you patient who has sustained a fragility fractures no matter what age. Again that's wrist fracture. If fractured spine fracture. From a seemingly low energy mechanism. Could probably get a bone -- -- and the reason is statistically people who have these fractures. There have been done some studies where people. After the fact opponent does care about. Anywhere from sixty to 80% of such patients end up being diagnosed with -- -- osteoporosis or Kenya. The varying grades -- Getting back to when we start screening I know over at -- primary care medicine -- practice that oftentimes. Of a woman we'll ask us. For bone density or when it should be done if she may be of the young age of 404142. She's the demonstrating has not any fractures. Is of a normal body weight and we should tell learn as you said you know to lead to a screening now. We -- really even debacle and how to interpret that data and tell us exactly what that means but debt to wait until postmenopausal. And approach to proceed from there are obviously a woman who's had fractions before. Higher risk to -- discussion but overall would you say that's a proper way of being -- witness. Yeah I -- totally agree with that advice -- management. Certainly at a younger age group somebody who's just patient who is worried and concerned about their health and it's good to have helped him concerned about. Would be and student. Getting that question answered and I would answer that question defects in humans the other seasons that mostly buried there have been answered. With respect to man. We need to also consider man for bone density is and a lot of times in the media in the papers. And we're doing our own research as a patient we don't think that Malia a male should have a bone density. Sometimes when -- when indicated when appropriate soak -- until some of those instances. When a male should consider that. Yet I absolutely agree with theory it is a problem which is not as often recognize the man that is -- a male patient with a -- is not somebody we look at and think osteoporosis right off the bat. But certainly any man in that same age group around age 65. Or any male who seems to have had a fracture from a very trivial injury. And again it's very. Not as well defined in males but I'd probably arbitrarily say anywhere from fifty on words. I who has had one of those three types of fractures. Who seems to not have at a high energy and his injury. You probably considered and -- -- densities and it's not something where we want to bring him back all the time but at least once. Just get an idea of where their bone -- is because it's certainly something where you detected. Things can be done. To reduce the risk of fracture and future. For -- we want to be sure that we screen patients for vitamin. We like the greens to be. Certainly over at thirty a lot of laboratory Rangers will be from. -- -- -- -- -- -- But we certainly want some going to be you know at least of that thirty greens and vitamin. That very low vitamin. And falls in the have you falsely elderly and the M and -- bones again. It's really you know a setting for fractures which we really really wanna avoid so we're going to be sure of the -- and vitamin. Additionally we want to be sure that everyone in their diet. Has adequate calcium. And other and the vitamin. The vote no further than what we've already spoken about. So make sure you get an adequate intake of vitamin. But smoking cigarettes -- an adverse effect on your bone density. Limiting alcohol consumption to a reasonable amount. And you can find that in various ways but I'm also getting enough weight bearing exercise. Is also very important and maintain your -- and the Skelton does respond to constant pressure. People who -- and what program its its pupil spending expensive times based memos -- -- -- that category of people and programs environment. I've been shown to have some loss of bone mineral density after sometimes -- There's definitely some. -- bonus when you load this -- war. And getting into that with -- the weight bearing exercises. It's important to note that appear on the thinner side and you have a lower body mass index. That'd be going for a walk to take a couple little to pound weights three only to view and -- those with the arms. As you're going to really be good because that'll almost mimic. If you were carrying around you know more weight on your frame ends the better that we can mimic those -- during exercises. The better up your bones will be. Let's go go back a step to where we spoke about a steel union. In osteoporosis. In -- that to find them but you know I still Kenya is. A certain degree of bone loss but not so severe that -- into industrial product category. Both -- concerning. And both need attention. So nick -- you'll Kenya -- over patient where they've had a fracture. We do the bone density. Postmenopausal female. And we -- -- to be honest you'll Pina and their vitamin. Is around 1819. We're gonna put my vitamin. Well. If fish have been shown on the density standing TB. A subpoenaed and of items you that in addition to making sure that they take care adequate vitamin. I would want just double check with them that they are doing these other things like limiting smoking. Limiting alcohol. We've got and it probably come back again -- years devoted. Dad. Patient has -- bone density and it's only normal comes in more recent. Yeah yeah it's. -- -- -- -- -- Continuing decline. Especially the setting of pictures of French absolutely. -- -- This is doctor -- blizzard and you listen to the hope that what was showing him succeeding and WR KOR number is 617266. 6868. Again at 6172666868. If you have a question for doctor nick Leon. And -- like to call and someone is standing by your phone call him doctor Leo we'll get back to you whenever staff members tomorrow morning Monday when. Newton was -- the Phoenix's. Open and available for consultations. The practice again as thirteen practicing positions. That -- the fourteen insurgent group. And there's a great website www. NW a wave dot org if they have a cracked. The NW -- dot com dot com and I remember -- and so www. NW only dot com. The phone number is 6179640024. Again 617. 9640024. Again tomorrow morning if you need a consultation. From Newton was -- -- the PX that's the former call. Batting in the number for our station. 617. 2666868. Doctor Leo and I are speaking about -- Bone density is prevention of fractures. Were just speaking about honesty of Pena. And now I'd like to -- -- a step further osteoporosis. -- -- give -- the scenario. Of postmenopausal. Female patients. Adequate vitamin. Does weight bearing exercises. Still the bone density has declined. In osteoporosis was present. A year ago and then we repeated the bone density we've found not only a week still on steel product. But the scores even lower. Stands are patient have instruments into us. I remember this exact same thing for our my mom from ions. In my sister. What's our next step. Wolf patient like that I would strongly consider having that patients. Come back to see your island or. Endocrinologist and for consideration for. Medication in addition to just l.'s movement in these would be things like the best Fossum image this Austin aids drugs. That's great -- the response from the drugs. Have you know really come into play and they really play good -- there's been some controversy. So the best thing has -- is saying is -- your primary care provide -- You should already be having this discussion if you have osteoporosis. And ask is a medication treatments. That should be considered for me. With any medication you need to review side effects. In benefits we look at the risk benefit ratio. If the benefit exceeds the risk and we find it's an appropriate treatment. Then there will be implemented but again osteoporosis there is cheap and available. Even if you have good vitamin. And you're exercising. We don't want someone listening or to think borders on the nose into my bones there is years ago. We never seem to have some options that we have today. Very important to keep in mind. Stands with respect to fractures. Especially patients who suffer hip fractures. In -- -- hip fractures can drastically change your life. We want to be sure that we government prevent this and anyway. Good -- during exercises. Being sure that you're having a nice steady -- -- either you're walking properly. We can minimize fall risk. All important factors here are all part of the discussion. Nick is there anything -- and. -- for a -- of this time. This time. Bone health is an issue which is increasingly. Receiving attention and rightly so. It's becoming a more and more prominent problem again as more and more patients and more more fuel. And a living longer and more healthy productive lives. Nationally -- America north speed association has steps a program called on the bone it's -- cute little creative name. And basically it's in national registry of quality measures that are being established. In institutions. Across country new while we orthopedic associates is the first in Massachusetts. You have registered with on the phone and what that means is that we aren't paying special attention to all of these respective identifying them. In our patients many of who. Do you have -- to Kenya or osteoporosis because it's it's -- fractures which brings him to our attention. But. Many measures such as whether or not we are assessing screening for by -- -- calcium deficiency whether or not there. I'm getting their exercise addressing -- alcohol and back -- and then referring them back if necessary for further medication treatment. If bone density scan reveals that they have lost you know. -- This is doctor -- -- and you listening to the health and wellness so. On Boston's stock station and succeeding WR TO for questions for doctor ineptly on our phone number 617. 2666868. The and that's 617. 2666868. And Newton was you at the PX they have a great website. Www. NW away dot com again that's www. And for Newton. W Wellesley all orthopedics -- associates. Dot com and their phone numbers 6179640024. Again 6179640024. We've been speaking about bone density. Bone health prevention of fractures. That -- measure to take -- points that we'd like you did. I have from today's show. Our -- appropriate. Be sure that you've had that initial bone density. Was speaking about the postmenopausal female. A patient who is at risk who said multiple fractures especially more concerning ways that worried about the bone -- In additionally don't forget about the male patients. Whereupon densities. In certain situations. Are also very appropriate. Be sure that you have your vitamin. He says the -- vitamin. Very little some it is necessary for the proper -- the absorption but you do need a little bit of some Internet. Again be careful in the -- that'll be a separate topic separate show you what's on -- when have you but the point is -- vitamin. A lot of his supplementation. Being out to as a reasonable amount of time -- the proper absorption. Be sure that you're getting adequate calcium. You -- you're exercising. He showed you during the week during exercises. Nick anything else you would add to that little summary. Knows that's all -- -- careful. What -- switch gears and speak about -- hands. About Carpal Tunnel Syndrome. About trigger finger. Hands. Before we get into further details about these particular ailments that could do this. The five million with respect to crumble tunnel syndrome and the structures involved were speaking about that. -- so Carpal Tunnel Syndrome by definition is a compression or -- of a nerve called the median nerve. At the wrist it's one of the most important nerves that -- hand. The supply sensation to the fingertips of the thumb the index. The middle finger and traditionally after the -- although. That being said majority of patients have carpal tunnels and all of their fingers go numb every once in awhile. The reason why the median nerve gets compressed at the carpal tunnel is that there is very limited realistic if you will the wrist. The median nerve and and nine and insect control thumb and finger motion passed through very narrow canal. Which is very tightly bound basically -- three quarters of its. The conference by bone and on the last one quarter by a very thick and unyielding ligament on the transfers -- polygamy. But many different things can cause swelling in the wrist. And whenever there's any swelling all of that stuff the nerves independents have nowhere to go slowly since we've nerve gets pinched and that's what people feel the most. And many of the conditions that caused swelling. Our things like. An injury to the -- from a diabetes. Endocrine disorders. Hormonal changes and I'm just. So there are other conditions give that commitment Carpal Tunnel Syndrome as well there's certainly can be other conditions which can mimic carpal tunnels and however by and large of the various nerve compression syndrome -- almost by far the most common. In this technology computer error where we now live. Much more common then. Twenty years ago would you agree. Yes. But it's certainly one that's being identified more because people are more aware of its existence you can Google carpal tunnel finals -- information. However I worded. Probably not say that increased keyboard and mouse views necessarily cause carpal tunnel. There has been one. Study out there which showed that using a mouse more than thirty hours -- week can be linked to. Higher risk of Carpal Tunnel Syndrome but whether or not keyboard usage every once in awhile. Cause Carpal Tunnel Syndrome is still a matter of controversy. Definitely people who use their hands for vigorous physical activity. Construction workers especially someone operating. -- I read machinery like a jackhammers. Prototypical example. Those patients or at a special risk. For developing -- For keyboard use and others say that in May be exasperating someone symptoms. How would you describe in that it's hard over the -- For someone who's listening but for the best that you can't really describe the best tight -- you're -- should kind of sit. With respect to keyboard. Well no matter how you position your hand of the keyboard the ideal position for the -- -- to have it in neutral position. What that means that the -- history neither -- flexed. Or two expanded. Basically its it's a relaxed position and -- there are many different ways of people try to accomplish this. You can put a little bump in front of your keyboard to -- to risks on the that the fingers. And reached down without your -- having to be two (%expletive) up. There are also all sorts of ergonomic keyboards out there now where the keyboards were broken in the middle and often an -- and raised. So that the risk and sort of come in at a more straight after the keyboard from. Rather than having to try and archery and expanded -- -- -- -- -- -- -- typing position. Could you speak a little bit about this supports. For patience and they're the ones are going to Wear this in the setting of Carpal Tunnel Syndrome and the women and how many hours when he uses as well you know to protect the muscles. Absolutely it's over a supports Lori tried and true treatment for Carpal Tunnel Syndrome especially in mild cases they're much more likely to work and mild cases. We typically recommend their usage at night. I'm mainly because that's the time where you could accidentally fallen to a position where the -- this flexed or extended. For many hours at a time. And just to back up a -- the reason why you don't want to -- reflects our expanded for there along appeared at times because when the -- -- -- on relaxed position. The diameter of carpal tunnel shrinks. It becomes sort of a circle and comes flat. -- but nobles would then it squeezes everything including the meeting serve more. So I'm going back to your question we recommend that typically patients with a wrist support at night they don't have to Wear it all during the day. Mainly tonight and in the early hours of the morning with the symptoms are most severe. That means that I don't make any. Effort to prohibit someone's -- it from wind the support in the daytime there's no harm in doing so. A but it can be somewhat cumbersome it's hard -- and during the day when your way and support. Can be somewhat awkward for some of the -- -- I'll miss. They're similar to where it's 24/7. Or -- recommendations that patient I would say that's not absolutely necessary. I would say you should absolutely where when we. All right that's great. Now let's get to the scenario of a patient where we know they have Carpal Tunnel Syndrome. They wearing this for support as much as they can certainly when they have symptoms. There -- icing on the area the using non startling anti inflammatory medications. Such as Ibuprofen. Of course they -- doing that with the blessing of their primary care provider. Being sure they're taking them with food we noticed different forms of Ibuprofen Wetherbee over the counter but when -- prescription. And that 600 milligrams over the counter is not exactly equal. To 600 milligrams prescription wise as respond to an earlier shows. But what I -- emphasizes that we have a patient now we've done every treatment modality that he can. For carpal tunnel as far as there was support medication -- nice. And their keyboard as -- position away in Reno is not you know. Really the main cause here but there is Sarah and eyes relax position whenever they can as well. What's the step when they go to surgical intervention. Orwell in general if a patient has to have the symptoms going on for a long enough time and arbitrary Leo. Say that's about three to six months. And the symptoms are bothering them not just that night but also during the day patients are losing sleep. And this is just something if they don't wanna go on with and if tribes went saying non steroid pills. Maybe even a cortisone injection and it hasn't really given them sustained relief of their symptoms Bennett and then would be an appropriate time to start having a conversation about surgeries -- the other patient. Who probably would have a discussion about surgery earlier rather than later would be the patient bushels of with actual weakness. And loss of muscle in the base of the -- That patient is at a much more advanced stage of their Carpal Tunnel Syndrome then. Most of the patients we see and those patients we probably won't Warren was -- too much just speak is. At that stage you probably. Are not going to get much relief from justice -- That patient who was very advanced. If they delay medical attention. And they are surgical procedure. Is much certainly in Iran and the patient seeks medical attention. Pretty soon when they need to practicing their primary care provider and say boy you gonna spot now we've tried and needs surgery. How the outcomes in those two different patients the one who went by when he should have to need -- can be associates. Than the one who shows up. Tomorrow morning who says you -- -- they should have come earlier. My my -- just doesn't feel right has been going on for six months house GO commend those scenarios. So the patient who lets the Carpal Tunnel Syndrome go on for a longer time. How will probably not expect to have as all of a return of and -- function as a vision who has taken care of sooner rather than. That's really the main difference. So we want to emphasize to everybody listening. If you know symptoms suggestive of Carpal Tunnel Syndrome. Where doctor -- was defying. The numbness in the unusual sensation. In the the point your finger of the middle finger and part of the ring finger that you want to be sure that you're seeking your medical attention probably. That after you've seen your primary care provider or -- into new -- to a therapeutics. And you've done the treatment modalities and him and recommended. -- and it continues to worsen. Don't wait for you just do next routine -- to get checked himself by the way is still going on not doing a disservice to yourself. And take charge of your -- else. Give -- cause your home your provider. Let them know this isn't any better come. They'll take care the next step. And it surgery is needed as we -- you don't wanna delayed and you wanna be sure you come reserve that nerve function have a good outcome with the surgery. -- This is doctor Alon Glazer. And you listen to help them on this show and it was succeeding double your stereo and my guess is that in -- Leon from new -- to a -- When a thirteen orthopedic physicians there they're -- grade we -- many -- over him have. Very good results. Actually -- as the fourth hand surgeon in the group. There website is www.com. And W 08 dot com -- www. NWA dot com. Their phone number -- for tomorrow morning 6179640024. Against 617. 9640024. Nick let's change gears here and talk more about trigger finger and how will present. And the initial recommendations. And then what we do for the patient when those initial recommendations to work. Focus so trigger finger it's. Sort of like a miniature version of Carpal Tunnel Syndrome well. Trigger fingers -- it and tonight it's of the flex attendance which go to your finger and most of the time people with trigger finger will start out with them in sort of at the base of the finger. On -- -- out of what's happening is that. The flight attendant. Is becoming swollen and inflamed as it answers a little tunnel. Which starts at the base of the finger. If your attention and inflammation go on for long enough. And it can actually develop swelling Republican module. Making it actually difficult for the and in the past into this little at that point the patient will actually -- mechanical some. And this is what's commonly known as triggering. Sometimes -- him at wake up in the morning and the fingers are flexed and an omen can't straighten it without some forcible. Poll. From -- out of their own muscles in the same hand or using the other hand the force of mistreatment. And that usually accompanied by a pop and a lot of pain -- What did you give one moment when the patient -- that pool and here's the pop. What is that. That they're feeling you know what is your reaction -- sure what their feeling is days swollen part of attendant being forced inside of the tunnel at the bases. This tunnel which called flex -- tendencies. So yeah that is what is the -- The pop. In very severe cases its attendant is still swollen. The patient can't even force that's one part of attendant in skews the title. And now it's just stuck outside of the tunnel and the finger stuck in flexed position that's a lot trigger finger that's obviously. A major problem really you almost nothing short of surgery. -- So obviously we want patients to seek medical attention before that sets and and ideally when with the -- ask for medical attention and respect mr. stringer. Or ideally you within a couple of weeks to a month. Developing the onset of their symptoms in that time. Oftentimes trigger finger can just be treated with some. Oral anti inflammatory. Over the counter Ibuprofen. Ice pack to the base of the finger and a brief period just pointing the finger straight. By brief period I mean problem we no longer than two weeks. And it's been shown that patients with trigger -- symptoms of only a couple of weeks ration sometimes we'll have resolution of the symptoms without any further need for treatment. If they catch a very early on us he goes. -- for everybody listening where we're going to splint the finger straight. So we -- that finger I was -- we do it with a bloody finger next to it oh just that finger it's not necessary just went to neighboring. -- with respect to ice. How often you like to tell your patients that they should. Use the -- during the course of a day in how many minutes should be on four. Probably no more than about fifteen minutes at a time and probably three times today. Right that's great. Let's talk -- and other conditions that could mimic Carpal Tunnel Syndrome where trigger finger that you senior practice. So sometimes we get patients to come in I've referred from a primary doctor or because they've just done some. Internet searching on their own and they have some sort of campaign and they come in and have concluded that must be Carpal Tunnel Syndrome or trigger finger. And they will goal. -- -- with reason for it has been carpal tunnels and her finger lot of times conditions that can mimic these problems arthritis is of that and and the fingers. These are things which can cause pain at various points you have. You know depending on what bones are counting has phones anywhere from 26 to thirty bones and hand it. You know between every bone is a joint so you have many different places -- and we can develop swelling. A -- and brightest. And probably the most common problems that received that mimic these problems are hip arthritis of the Angeles. There are also various tendinitis is that can happen. Which people can mistake for Carpal Tunnel Syndrome. -- -- This is doctor -- whizzer and you listen to their health and wellness show on Boston's talk station EM six AB WRKO. Again the phone numbers of the station's 617. 26668686172666868. -- Spiegel a bit further about Carpal Tunnel Syndrome. And trigger finger and other treatment interventions that you'll do it near -- with Phoenix. Yes so we've talked so far about -- very mild symptoms early symptoms and oftentimes you can just sort of manage them on your own. If it's a very early on and he just a couple weeks. If the and I'll talk lectures than -- -- trigger finger has been going on for. More than a couple weeks well first step would be to get in your primary care doctor or see one of us and in -- -- orthopedic associates nature. We get the diagnosis correct. And if splitting and I use an -- -- -- parameters are not making the symptoms of trigger finger no way. A very effective intervention is a cortisone injection to the finger. Where we and inject a very small amount of steroids these are not like these Roger Clemens steroids user. I'm anti inflammatory is it's basically like putting all of the anti inflammatory right in the spot where you needed. It's generally a very low risk intervention. I won't like you it hurts a little bit it's a needle. But it works very well for relieving the clicking and the pain from their finger. Traditionally in -- me if I'm ninth and patience -- belief -- their symptoms after one and sometimes people may have have a second. Even a third. -- Now if that we're not to work. After the second or third -- then we would probably talk about something called -- trigger finger release which is. A very small surgery where we make about a one centimeter incision over the area. At the base's anger and just released the mouth of that tunnel echoes of the finger. Deflects attention to give it anymore. That's a very effective. Little procedures to completely make all the symptoms go away. So there are surgical interventions and hope for everyone listening for advanced Carpal Tunnel Syndrome that's been resistant to more conventional treatment and for trigger finger as well. Correct right. Surgical treatment for carpal tunnel -- is essentially the same principle wise. The surgery for trigger finger. Where it in this case it's a different structure but it's it's a structure that ligament over the top of the carpal tunnel which is just -- Damages a lot of room for the earth do. Expand if there's any swelling for. It'd be no pressure this is again a very highly successful operation if it becomes necessary. -- greater than 95% of patients have excellent relief of their symptoms and which is sustained meaning it doesn't come back. To -- some of the highlights from today's show. Earlier on whispering about bone health bone densities. And prevention of fractures. -- before it went you don't violate. The most important take -- messages and it is to a -- the more about all the bone. And how -- -- MP associates in this area is the only practice. To implement that so -- a little bit more about the program here. As initiative that was set forth by the American orthopedic association. With the goal of expanding awareness both on the level patient as well as on the level of physicians who may encounter these patients. Basically expanding our awareness of osteoporosis and most of Kenya. And see there are ten different measures which the on the -- program seeks to record information about these are. You know how often patients or getting their bone density is when and when this is -- -- health and they're being counseled about lifestyle changes like smoke game you know all. And there's various other measures. And basically -- it is all being compiled and a national registry. So that we can both sort of gets feedback. How good we are doing as physicians. Preventing. Further fractures. As well eyes. Increasing awareness on everybody's part was probably the most important -- increasing awareness and it was part about me any good phone. On the the so on the -- is now being. I guess. On about them. The the program is being executed -- Programs all look at institutions all across the country yeah some of these are large economic -- some of these maybe just individuals. Physician practices. In the state Massachusetts new -- worth it associates is the first to start. Being involved in this. Registry. Although since that time of war. Involvement there have been and probably other institutions in the states that are now participating. I think he's very worthwhile cause could I think you've -- things so. Was to have peace in this area was the first implemented but -- others have followed suit and implementing as well. -- and it would be great if every medical practice an institution could implement descending order. The -- a lot of lives positively. If you could pick. Three messages that are the most important with a respectable and health for all of our listeners what would those three messages being a. Well the first would be to maintain a healthy lifestyle meaning getting your way parent decides. And getting a balanced diet the second would be specifically pay attention to. You -- calcium and vitamin C as you pointed out vitamin. And the third would be to get to bone density scan if you or certainly if you're in one of these risk groups. But it's an fracture it's too late but if -- him -- problem we should still. And now -- three most important messages for Carpal Tunnel Syndrome and trigger finger for all of our listeners. So I think the three most important -- masters regarding. Your fingers enrollment carpal tunnels and would be bad first and foremost. These are benign conditions. Not going to lose and functions from of these loans -- get treated. And in many cases they can be treated on your own if it's just been going on for a couple of days. On the second message I would have is if these have been going on for more than. A couple of days or weeks you really problem we should get and -- the primary doctor or one of our decisions and it -- those. And in the third message is that these conditions are both completely treatable provided you don't. Neglect of the two law. I guess in essence these are all part of the same message but. Both these conditions are very treatable. Whether it's just -- -- shots. Or surgery if that's that's. Nick thank you so much for spending your Sunday afternoon whether it's again. Doctrine that -- and I've been speaking about bone health bone density prevention of fractures Carpal Tunnel Syndrome and trigger finger. -- and as one of thirteen with a Peter positions at new -- orthopedic associates. Their website is www. NW only dot com and their phone numbers 617. 9640024. This is doctor Alon -- you've been listening to the hope there won't show on am succeeding. To a Bjork Leo I look forward to tuning in. To our show next week for more health advice. I wish you well and healthy week. I'm happy week. Be sure you make those good healthy lifestyle choices and with spring here the nicer weather although we had a pretty easy wins -- but with a nicer weather even getting home and more ahead of us. -- sure you take advantage. Great time to implement good choices and it needed lifestyle changes. Stay well and thanks for listening.