3 Exercises to Reduce Anxiety and PTSD

Coping with anxiety and PTSD is not easy, and while professional treatment is welcome, it does not always provide the relief sufferers expect, at least not in daily coping. The truth is that there is no one solution that fits everyone, and each person needs to find their way to deal with the symptoms they experience. That is why we present to you today 3 somatic exercises you can try, which many report help reduce the intensity of the feelings they experience in moments of anxiety and PTSD. These exercises involve the whole body, and before starting any of them, it is recommended to ask yourself: "On a scale of 1 to 10, how anxious am I?" Try the chosen exercise, ask yourself again, and check if that number has decreased—this way, you'll know you found the exercise that suits you.

1. Joint activation 

 

 

When your mind is preoccupied with something, it’s hard to stop the automatic thoughts that come. Any attempt to do so will fail, but what can help is occupying the mind with something else, and it’s easiest to focus on the physical sensation in your body. For this, you will activate your body slowly and calmly, starting from the bottom and gradually moving upwards until you significantly reduce the symptoms you’re experiencing.

Start with one leg—slowly move your foot in circular motions 10 times in one direction and focus on the sensation created in the joint. Then do the same in the other direction, and after that, repeat with the other leg. If you are lying on your back, you can do the same with your knees while your thighs are in the air. If you’re standing, you can place your hands on your knees and rotate them together in circular motions. Also, rotate your pelvis to both sides, and then pause and try to notice the sensation in your lower body compared to the upper body—do you feel a difference? 

 

Now do the same with your wrists—one at a time or both together—then with your elbows and shoulders. Finally, rotate your head to one side and then to the other. Throughout the exercise, remember to focus on the sensation created in the joint during the rotations—this will help your mind focus on something else and move the energy around your body instead of trapping it inside.

2. Deep breathing and "voo" exhalations 

 

The respiratory and cardiovascular systems are interconnected and influence each other—when one operates faster, so does the other. While we cannot directly control our heartbeat, we can definitely control our breathing. Some people find that deep breaths help restore calm to their body and bring their heart rate to a relaxed pace. If you have tried breathing exercises in the past and found them helpful, you might want to try the "voo" exhalation exercise.

To begin the exercise, place one hand on your chest and the other on your abdomen, and take a deep, slow breath. Then exhale the air while making a "voo" sound—try to make the sound come as much as possible from your abdomen and not your throat. This is an ancient breathing exercise that calms the vagus nerve, which runs from the brain to the diaphragm, and supports the parasympathetic nervous system responsible for relaxation when the body is at rest. Do this 10 times and see how you feel. 

 

3. Focusing on observing something calming 

 

There are many things that can be calming, like the support of another person, a warm bath, or even a thick, heavy blanket resting on your body. However, such things can also be found through sight alone, and that is the goal of this exercise. Look around for something that can calm you—some people find it helpful to gaze at something sparkling and beautiful, while others prefer a natural element like a leaf swaying on a branch in the wind. 

 

For some people, focusing on something distant works even better—the farther away it is, the more calming its effect can be. However, you might find it helpful to concentrate on something close to you, to which you can direct your entire gaze and examine closely. Try the exercise both ways to discover what works better for you, and focus your gaze until you feel its calming effect—this might take a few minutes. If you like, you can even combine this exercise with one of the previous ones and perform them simultaneously.

To sum up 

 

When we suffer from PTSD or anxiety, the symptoms can be severe and exhausting. The recovery process is long and not easy, but don’t let the symptoms make you think it’s impossible. Try the exercises we suggested when you feel overwhelmed, and give yourself a chance to relax and regain functionality in moments when you feel like you’re falling apart. They will help balance your body and mind, providing quick relief when you need it most.

This is only for your information, kindly take the advice of your doctor for medicines, exercises and so on.   

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This is How You Cure Insomnia Once and For All

We spend over a third of our time sleeping. But unfortunately for many of us, sleep isn't a simple ON/OFF switch we can just activate at a moment's notice. Do you struggle to sleep even though you feel tired and sleepy? Do you wake up in the middle of the night anxiously watching the clock, calculating how much time you've got left to sleep? If you've answered yes to any of these questions, you're not alone. About 2 out of 5 people share your problem.

Insomnia is a common, devastating problem that can cost us our energy, our good mood, our ability to function and ultimately our health. If the situation becomes chronic, it can lead to more serious health problems and even a shortening of our life span, according to experts. 

 

Insomnia in itself is not the problem but is usually a symptom of a variety of other potential problems. The trick is identifying the underlying cause of our insomnia and finding the right treatment for that problem. Sometimes insomnia hides more serious medical or psychological issues, and sometimes there is no easy cure for it, and one must take special supplements or pills to sleep.

Common Symptoms of Insomnia: 

Difficulty falling asleep despite being tired 

Waking up frequently during the night 

Trouble getting back to sleep when awakened 

Exhausting sleep 

Relying on alcohol to fall asleep 

Waking up too early in the morning 

 Daytime drowsiness, fatigue, or irritability 

Difficulty concentrating during the day 

 

Causes of Insomnia: Figuring out why you can’t sleep  

Let's put on our detective hat and try to find the reasons for our insomnia. Sleep detectives like ourselves take note of factors such as stress, anxiety, and depression, which are responsible for about half of all insomnia cases. In addition, they note the daytime habits, the sleep routine and the actual physical health of the person to understand their impact on the quality of their sleep.

Psychological issues that may cause insomnia: 

Depression, anxiety, chronic stress, bipolar disorder, post-traumatic stress disorder. 

 

People who suffer from these mental stresses have a hard time sleeping, not only because of their inner turmoil but because the body is physically preventing sleep because of these issues. Unfortunately, the lack of sleep tends to make these problems worse, and thus a vicious cycle is made, where we are constantly tired, cranky, anxious and depressed, and can't sleep to boot. 

 

Medications that may cause insomnia:  

Antidepressants; cold and flu medications that contain alcohol; pain relievers that contain caffeine (Midol, Excedrin); diuretics, corticosteroids, thyroid hormone, high blood pressure medications. Make sure to always check with your doctor, and research the medication you're taking to make sure that one of the side effects is not insomnia.

Medical problems that can cause insomnia: Asthma, allergies, Parkinson’s disease, hyperthyroidism, acid reflux, kidney disease, cancer, chronic pain. 

 

Sleep disorders that can cause insomnia: Sleep apnea (trouble breathing during the night that results in the person not breathing, then waking up many times in the night without knowing why), narcolepsy, restless legs syndrome. 

 

How to cure your insomnia: 

Some of the things we do to cope with our lack of sleep may actually do us harm, such as drinking a lot of coffee during the day to wake up or alcohol (red wine for example) at night to fall asleep. Often, changing the habits that are reinforcing sleeplessness is enough to overcome insomnia altogether. It may take a few days for your body to get used to the change, but once you do, you will sleep better. 

 

That is the easy solution half the time. If a change of habits and relaxation really don't do the trick, there are remedies on the market that can help. 

 

Adopting new habits to help you sleep 

 

 Make sure your bedroom is quiet, dark, and cool. Noise, light, and heat can interfere with sleep. Try using a sound machine or earplugs to block outside noise, an open window or fan to keep the room cool, and blackout curtains or a sleep mask to block out light. 

 

Stick to a regular sleep schedule. Support your biological clock by going to bed and getting up at the same time every day, including weekends, even if you’re tired. This will help you get back in a regular sleep rhythm. 

 

Avoid naps. Napping during the day can make it more difficult to sleep at night. If you feel like you have to take a nap, limit it to 30 minutes before 3 p.m. 

 

Limit caffeine, alcohol, and nicotine. Stop drinking caffeinated beverages at least eight hours before bed. Avoid drinking alcohol in the evening; while alcohol can make you feel sleepy, it interferes with the quality of your sleep. Quit smoking or avoid it at night, as nicotine is a stimulant.

Preparing your brain for sleep  

Your brain produces the hormone melatonin to help regulate your sleep-wake cycle. As melatonin is controlled by light exposure, not enough natural light during the day can make your brain feel sleepy, while too much artificial light at night can suppress the production of melatonin and make it harder to sleep. 

 

To boost melatonin production, use low-wattage bulbs, cover windows and electrical displays in your bedroom, avoid bright light and turn off the television, smartphone, and computer screens at least one hour before bed.

Learn to associate your bed with sleeping, not sleeplessness 

Use the bedroom only for sleeping. Don’t work, watch TV, or use your computer or smartphone. The goal is to associate the bedroom with sleep so that when you get into bed your brain and body get a strong signal that it’s time to nod off. 

 

Get out of bed when you can’t sleep. Don’t try to force yourself to sleep. Tossing and turning only increases anxiety. Get up, leave the bedroom, and do something relaxing, such as reading or listening to soothing music. When you’re sleepy, go back to bed. 

 

Breathing from your belly. Most of us don’t breathe as deeply as we should. When we breathe deeply and fully, involving not only the chest, but also the belly, lower back, and ribcage, it can help relaxation. Close your eyes and take deep, slow breaths, making each breath even deeper than the last. Breathe in through your nose and out through your mouth. 

 

Progressive muscle relaxation. Lie down or make yourself comfortable. Starting with your feet, tense the muscles as tightly as you can. Hold for a count of 10, and then relax. Continue to do this for every muscle group in your body, working your way up from your feet to the top of your head.

The New Tech Solution of Insomnia  

This device combines the powerful effects of relaxation techniques with the ability to distract you from stressful thoughts and outside noises. It's called a Hoom Band, and it might become the easy solution for you if you experience trouble sleeping. 

 

This device is a lightweight, comfortable, and washable headband with a special light, the flickering of which is suggested to help with the normalization of circadian rhythms, and a set of sleek headphones that won't disrupt your sleep. It comes with a free app downloadable on your smartphone, which contains stories, guided meditations, and calming sounds, all carefully curated by sleep experts. 

 

When you're in bed and ready to fall asleep, put the band on, select one of the stories, and let the sound distract you from the noisy world and busy mind while the stress-disrupting light slowly lulls you to sleep. The calming effect is almost instant, you will feel your body relax and mind focus on the journey you're listening to instead of stressed out inner voice that doesn't let you fall asleep at night. To put it simply, the Hoom Band is an effortless choice for those of you who just want a have a good night's sleep every night, effort and fuss free.

This is only for your information, kindly take the advice of your doctor for medicines, exercises and so on.   

https://gscrochetdesigns.blogspot.com. one can see my crochet creations  
https://gseasyrecipes.blogspot.com. feel free to view for easy, simple and healthy recipes    
https://kneereplacement-stickclub.blogspot.com. for info on knee replacement
https://GSiyers home remedies.blogspot.com   is the latest addition to my blogs

What’s the Difference Between Impulsive vs. Intrusive Thoughts?

Too often, people say they “let their intrusive thoughts win” after spontaneously dyeing their hair or making a late-night purchase. There’s a difference between impulsive and intrusive thoughts, however—and mixing the two up is a common mistake worth clearing up for a few reasons.

At first glance, it might seem like a matter of semantics. “But misusing [these terms] can be extremely invalidating to people who actually suffer from intrusive thoughts,” which she says can be “overwhelming and anxiety-inducing.” Kaylee Bullen, LCSW, a therapist who treats obsessive-compulsive disorder (OCD) based in Encinatas, California, tells SELF. Beyond simply getting your language right, understanding the nuances between the two experiences can also help you manage these unexpected intrusions and impulses more effectively.

So what exactly are intrusive thoughts? And how do they differ from impulsive ones? Below, we asked experts to break down the biggest distinctions.

 

1. Intrusive thoughts are a clinical symptom of conditions like OCD.

According to Jon Abramowitz, PhD, a psychologist specializing in OCD treatment and professor of psychology and neuroscience at the University of North Carolina, Chapel Hill, intrusive thoughts are more than just in-the-moment, random ideas—they’re a legit clinical term used to describe unwelcome repetitive thoughts. Technically, anyone can experience them, but Dr. Abramowitz tells SELF that they’re much more persistent, recurring, and difficult to dismiss for folks with mental health conditions like OCD, post-traumatic stress disorder (PTSD), and generalized anxiety disorder.

Impulsive thoughts, on the other hand, aren’t actually a recognized psychological term. Instead, people throw it around casually to describe spontaneous, slightly chaotic ideas or actions—like cutting your bangs in your bathroom at 1 a.m., say, or licking your delicious, cookie butter-scented body lotion just because.

2. Simply having an intrusive thought can be distressing and anxiety-inducing.

Intrusive and impulsive thoughts are both involuntary and unexpected. But the way they affect someone can be very different, Alyssa Faro, PhD, director of clinical services at the Child and Adolescent OCD Institute at McLean Hospital, tells SELF.

Usually, intrusive thoughts are ego-dystonic, Bullen says, meaning they conflict with your true values and identity. For example, What if I drop this baby I’m holding? What if I just cut my finger off with this kitchen knife? What if I jump in front of this moving car? Because they’re so at odds with who you are (and what you want), “people can feel tormented by the presence of these ideas,” Dr. Faro explains, leading to strong reactions like fear, disgust, guilt, and shame. (For the record, though, having intrusive thoughts does not mean you want to act on them. More on that later.)

Impulsive thoughts, on the other hand, resemble sudden urges. While they can also be random, disruptive, and “intrude” on your mental space, they don’t carry the same emotional weight, Dr. Faro points out. In fact, these thoughts (which sound more like, Blow out that person’s birthday cake before they do! Quit your job on the spot! Sure, make that questionably inappropriate joke!) can even be tempting or momentarily appealing.

3. People will rarely act on intrusive thoughts.

All three experts agree that following through on intrusive thoughts is pretty unlikely. “I would never want to say never just because it’s a really strong word,” Dr. Abramowitz says. But because they’re unwanted by definition, most people won’t end up pushing someone in front of a train, say, or sticking their hand in a pot of boiling water.

This differs from impulsive thoughts, which are “more compelling and tend to be followed by a sudden urge to act on them without necessarily taking into consideration the consequences,” Bullen says. That’s why you might spontaneously book a weekend trip with zero planning, for instance, or randomly sing out loud in a quiet library—both of which are reckless and unplanned, sure, but not disturbing or “intrusive.”

However, saying something like, “My intrusive thoughts got the best of me” in these situations (when you’re really referring to impulsive behaviors) can unintentionally reinforce the harmful narrative that having unsettling thoughts means you’ll follow through with them, according to all three experts. “When, in fact, they fear acting on them,” Dr. Faro says.

4. Distractions work best for impulsive thoughts, but not intrusive ones.

When dealing with impulsive thoughts, distracting yourself or delaying them can be pretty effective, Dr. Faro says. For instance, if you suddenly experience the urge to get a tattoo as you walk past a parlor, waiting until the next day will likely make the temptation fade—or at least give you time to think it through and make a more intentional decision.

But for intrusive thoughts, forcing yourself to ignore them can backfire, according to every expert we spoke with. “If you try to make them go away, they’ll only come back,” Dr. Abramowitz says, comparing it to what happens when you tell yourself not to think of a pink elephant—suddenly, that’s all you picture. And with conditions like OCD, suppressing anxiety can lead to compulsive behaviors—such as repeating certain phrases or avoiding specific people or places—in an attempt to neutralize fear, which often backfires and worsens it.

Rather than pretending they don’t exist, a more effective approach is accepting intrusive thoughts for what they are: just thoughts. This might mean practicing mindfulness and reminding yourself, This is just a thought, not a reflection of who I am or what I’ll do. Or continuing with whatever you were doing before it popped up uninvited. In more serious cases, it’s also recommended to enlist the help of a therapist, who can assist you in identifying these thoughts as they arise and recommend cognitive strategies to reduce their power.

Ultimately, though, even recognizing the subtle differences between intrusive thoughts and impulsive thoughts can be a great first step in effectively managing them—and preventing them from taking up more space in your head than they deserve.

 

 

This is only for your information, kindly take the advice of your doctor for medicines, exercises and so on.   

https://gscrochetdesigns.blogspot.com. one can see my crochet creations  
https://gseasyrecipes.blogspot.com. feel free to view for easy, simple and healthy recipes    
https://kneereplacement-stickclub.blogspot.com. for info on knee replacement
https://GSiyers home remedies.blogspot.com   is the latest addition to my blogs

 

Psychodynamic therapy helped me overcome trauma when CBT couldn’t

The first time I saw my therapist, she was standing in front of a room full of people, talking about William Golding’s novel Lord of the Flies (1954). It was part of a series of book events on the theme of psychoanalysis and literature, and my therapist was dissecting the emotional and psychodynamic contours of the book, in particular the ending.

The novel concerns a group of English schoolboys whose plane is downed while they are being evacuated from a war that is raging at home: after being stranded on an island for weeks and brought to the brink of murderous despair, they are rescued by a British naval officer on the novel’s final page. But… my therapist was saying, the man represents rescue in only the least meaningful sense of the word. He would save the boys, yes. They would survive. But sometimes that is not enough. When the boys begin to cry, breaking down in front of the adults as they process what happened to them on the island, the naval officer turns away while they compose themselves. He will save them, but he cannot bear to witness their suffering. What does that kind of survival mean?

As soon as my therapist explained why the ending of the book was not a meaningful rescue, I thought: I know what that’s like – the worst effects of my own traumatic history were brought about by my mortal fear of allowing anyone to witness them. I know what it’s like to survive without being seen. To survive, but live forever in hiding. In that moment, I knew that she would not turn away. I emailed her every week following until an appointment slot opened up in her diary.

My therapist practises psychodynamic psychotherapy. That means she specialises in so-called talk therapy, in which the patient guides the conversation. It derives from the Freudian model of psychoanalysis, but it has an extra element, too. Psychodynamic therapists believe that relationships hold the key to many people’s psychological suffering, and so the way the patient relates to others is key to healing. That work begins with the relationship between patient and therapist.

Psychodynamic therapy differs from other talk therapies in using the patient-therapist relationship to explore the patient’s unconscious thoughts and fears, and in allowing the therapist to interject, feeding back how they feel about what the patient is and isn’t saying. A psychodynamic therapist enables the patient to renegotiate their relationships using the therapeutic dynamic as a safe testing ground. This is why, I believe, psychodynamic therapy is often so useful for people who suffer from post-traumatic stress disorder (PTSD). It can help the patient recognise hidden memories associated with the original trauma by showing them how those memories play out inside the patient-therapist relationship.

Abuse survivors are left with a sense that there is something toxic about them that caused another person to treat them badly

Trauma is not cognitive. It is not a set of thoughts, but a set of instincts. The US psychiatrist Robert Jay Lifton writes in Death in Life: Survivors of Hiroshima (1968) that PTSD occurs when a traumatic event leaves a ‘death imprint’ or an ‘indelible imprint’ on the brain. When traumatic memories get stuck in this way, they cannot be rearranged into logical narratives. Instead, they remain trapped in the brain as flashes of an unbearable experience that leak out at the mind’s weakest moments. The part of the brain responsible for separating the past from the present – the hippocampus – becomes dysfunctional and the brain re-enters fight, flight or freeze mode every time it is reminded of the experience, even though there is no longer any danger present.

I suffered from PTSD for 10 years without knowing it, after I was violently raped by a stranger in an abandoned bathroom stall, following years of being sexually abused by a mentor as a young elite gymnast. I never spoke about my rape or my abuse. I thought that, in not telling anyone, I could pretend it hadn’t happened. But it doesn’t work like that. At 17, I started having panic attacks; I stopped sleeping, fell prey to severe bouts of depression. Looking back now, I understand that this was connected to my rape. But at the time, I was committed to ignoring it. I was referred to a cognitive behavioural therapist – a type of talk therapy that tries to identify the person’s unhelpful thought patterns and re-arrange them. I tried CBT for years, but it never helped me, because my conscious thoughts weren’t the problem. What was troubling me was much deeper, more unconscious, than that. What was troubling me was hidden from everyone – even me.

Abuse survivors are left, often without realising it, with a sense that there is something toxic or bad about them, something rotten that caused another person to treat them badly. This was never something I thought. It was something I felt; something pre-rational that I knew in my bones to be true. Because these assumptions are unconscious, they play out in every relationship we form without us knowing it. And because of the intense connection between trauma and shame, we find it very hard to identify the feelings that are symptoms of PTSD because they are, so often, unspeakable.

Until I met my therapist, I had never been able to articulate the worst things I believed about myself. I didn’t think anyone would be able to tolerate how much I hated myself. So instead of articulating these feelings, I spent years and years dissociating from relationships, avoiding intimacy and sabotaging closeness, imagining I’d be abandoned as soon as the other person found out how rotten I truly was. But while dissociation protects us from feeling the overwhelming emotions connected to the traumatic memory – panic, fear, pain – if it is never processed, it numbs all the other emotions, too: connection, love, joy, safety. It is the naval officer in Lord of the Flies, offering rescue but not compassion. Offering survival, but not living.

Feeling ashamed and dissociated often leads PTSD sufferers to develop intense people-pleasing behaviour. The fear of being exposed as inherently bad addicts us to finding ways to win the approval of others, as if that approval might neutralise the toxic thing inside of us. I have always been this way, people-pleasing my way into what I thought were meaningful relationships. But when you believe you’ve tricked people into liking you by doing things for them, you rob yourself of the ability to feel close to anyone. Every relationship becomes conditional.

Without realising it, I have spent most of my life believing that I have to hide parts of myself in order to be loved. That I have to pretend to be more than I am – more successful, more wanted, more beautiful – because of a deep-seated belief that I am unworthy. Until I met my therapist.

One afternoon in June last year, my therapist brought up the fact that I find an excuse to cancel our session every other week. ‘Something always comes up that you are willing to put our session off for,’ she said.

I stayed silent for a moment, unsure what to say.

‘I think there is a part of you that is still so afraid to be seen clearly by anyone,’ she said.

‘Sustained contact is terrifying to you because it is the most intense form of exposure. The idea that I might catch you on a bad day really frightens you, because it means I will see that sometimes you are grumpy or underslept or resentful.

‘Or,’ she said after a pause, ‘worst of all – when you are unhelpful. When you are angry.

‘You are willing to be seen by me, but only when you feel able to curate yourself first. When you can say smart things and dutifully recount your week and encourage me when I make an observation that is accurate: only when you can be helpful, pliant, pleasant.

‘This way, you are always in control. On the other days, you find an excuse to hide from me. You can’t bear it.’

She was absolutely right. I’ve worked so hard at expelling my shame, but its grip is still suffocating. This woman, the person who knows more about me than anyone ever has, was still being presented with a false version of me. I was still curating myself for her in order to hide the things I’m ashamed of.

At first, I panicked when my therapist said this. I felt exposed, which in my mind is linked to danger. But being seen and being bad are not the same thing. My therapist was not criticising me for cancelling our sessions – she was accepting this avoidance as part of my suffering and she was trying to help me. In that room – and only in that room – I believed that I did not have to be perfect to be worthy of love.

Another of my dissociative symptoms is a desperate need to repress feelings of anger. If anger is weaponised against you, you fear it. My rapist was somehow so, so angry with me, even though we had never met before that night, and so he bequeathed me a fear of my own anger; as if, in feeling anger, I might become him, and he me, and I might carry him inside me forever. When anger is adjoined to abuse, it’s frightening. But healthy anger is productive. Anger says: This isn’t working for me. Anger says: I need more than this. Expressing anger requires being willing to be seen, which is why you can express it only when you feel confident that a relationship can contain its emotion and move forward. Since I’d always assumed that my relationships were fragile and weak, and that any moment the other person saw me clearly, they’d leave, I couldn’t risk expressing anger. So I dissociated.

More and more frequently, I was describing situations to my therapist and casting them in the light I’d perfected so well: always framing myself as relatively helpless, anxious, grateful for any scrap of love offered me, and guilty for asking too much. And slowly, she started saying: ‘I don’t actually think you feel grateful, or anxious to please this person. I think you feel angry.’

She was right. At the heart of what I was voicing, somewhere I couldn’t reach, was a story about someone letting me down. Somewhere, buried beneath all my shame, was anger.

‘How did you know?’ I said.

She said: ‘I know because I feel angry. And I think that feeling is coming from you.’

In this moment – which we’ve now repeated many times – is the true beauty of psychodynamic therapy. What my therapist was describing is transference – when the therapist is so intimately attuned to the patient that they can sense an emotion that the patient is unable to consciously express.

I can’t tell you how much that one phrase has changed me: I know because I feel angry. For the first time in my life, my anger could be expressed, because I felt safe enough to feel it in her presence. The idea that someone cares about me enough to see me clearly, and to feel genuine anger on my behalf, has been life-changing. The shift wasn’t about the ways my therapist encouraged me to think. It was about the way she made me feel. She made me feel real. Made me feel safe. Made me feel alive.

 

This is only for your information, kindly take the advice of your doctor for medicines, exercises and so on.   

https://gscrochetdesigns.blogspot.com. one can see my crochet creations  
https://gseasyrecipes.blogspot.com. feel free to view for easy, simple and healthy recipes    
https://kneereplacement-stickclub.blogspot.com. for info on knee replacement