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Reduced patient restrictions following total hip arthroplasty: study protocol for a randomized controlled trial
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1 Peters et al. Trials (2015) 16:360 DOI /s TRIALS STUDY PROTOCOL Open Access Reduced patient restrictions following total hip arthroplasty: study protocol for a randomized controlled trial Anil Peters *, Miranda Tijink, Anne Veldhuijzen and Rianne Huis in t Veld Abstract Background: Total hip arthroplasty (THA) is a very common procedure in orthopedic surgery. In the Netherlands, 25,642 primary THAs were performed in Postoperative hip dislocation is one of the major complications and has been reported in 0.5 to 10.6 % of patients after primary THA. Several reports regarding the use of an anterolateral surgical approach have shown that a non-restriction or reduced restriction protocol does not increase the dislocation rate. For the posterolateral surgical approach it has been suggested that patient restrictions might be unnecessary but the amount of available literature is scarce. As such, randomized controlled trials aimed at investigating restrictions following THA using a posterior approach are strongly recommended. The aim of this prospective randomized controlled trial is to investigate the non-inferiority hypothesis concerning the early dislocation rate after THA in patients with and without the use of a reduced restriction protocol. Methods/Design: After providing informed consent a group of 456 patients with symptomatic coxarthrosis will be randomized to receive a THA either with care as usual, i.e. receiving postoperative restrictions including the advice to sleep in a supine position for the first 8 weeks postoperatively, or reduced restrictions with no recommendations regarding the position during sleeping. Primary outcome measure will be the percentage of early dislocations within the first 8 weeks after THA. Secondary outcome measures will be patient satisfaction, time to functional recovery, quality of sleep and patient s self-reported compliance with postoperative instructions. Discussion: To our knowledge this will be the first randomized controlled trial that compares a reduced restriction protocol with a restricted protocol following THA using a posterolateral surgical approach. Our hypothesis is that a reduced restriction protocol following THA with use of a posterolateral surgical approach has no influence on the early dislocation rate compared to a restricted protocol. Instead, embracing a reduced restriction protocol might even contribute to a higher quality of sleep, thereby facilitating a faster uptake and return to daily functions in patients after THA. Trial registration: ClinicalTrials.gov NCT , registration date 3 April Keywords: Arthroplasty, Replacement, Hip, Posterolateral surgery, Precautions * Correspondence: Center for Orthopedic Surgery OCON, Geerdinksweg 141, 7555 DL, Hengelo, The Netherlands 2015 Peters et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
2 Peters et al. Trials (2015) 16:360 Page 2 of 6 Background Total hip arthoplasty (THA) is a very common procedure in orthopedic surgery [1]. In the Netherlands, 25,642 primary THA implants were performed in 2013 [2]. Postoperative hip dislocation is one of the major complications and has been reported in 0.5 to 10.6 % of patient after primary THA [3, 4]. Surgical technique and approach as well as implant selection, implant positioning, patient education and patient-related factors have an impact on the incidence of dislocations [5 7]. Traditionally, patient restrictions following THA are prescribed in order to prevent early dislocation by limiting the flexion of the hip (<90 degrees) as well as adduction and internal rotation [8]. In modern orthopedic surgery, less invasive, tissue-sparing techniques have been introduced and patients are operated upon using shorter acting anesthetics. Nowadays, surgery duration is shorter and patients are being mobilized early after surgery. These factors possibly contribute to less loss of muscle strength after surgery, resulting in a more stable hip joint immediately postoperative. Postoperative joint stability is further enhanced by the use of larger diameter femoral head components. Patients are also better educated and managed with clinical pathways which include detailed protocols, thereby reducing the risk of an early dislocation [6, 9]. However, the aspect of evidence-based application of restrictions after THA has attracted less attention, with long-standing protocols continuing to be routinely used in most hospitals. Several studies have shown that no or reduced restriction protocols do not result in increased dislocation rates [10 12]. Moreover, Talbot et al. have documented that patients had difficulties sleeping and felt discouraged during the time of restricted postoperative hip precautions [12]. Likewise, faster return to normal activities, higher patient satisfaction and earlier return to work are the benefits that have been shown when using no or reduced restrictions following THA, making it a cost-effective and patient-friendly alternative to the restricted protocol [10, 13]. Nowadays, most of the available knowledge on the effects of reduced postoperative precautions and restrictions after THA has been obtained utilizing an anterior surgical approach [10 12, 14]. This might be explained by the fact that THA utilizing a posterior approach without repair of the posterior capsule and external rotators is associated with an increased risk for dislocation when compared to patients undergoing an anterior or anterolateral approach [15]. However, when conducting a posterior soft tissue repair this increased dislocation rate through the posterior approach is reduced [16]. As such, further research on applying a reduced restriction protocol in this group of patients is warranted [17]. To our knowledge this will be the first randomized controlled trial (RCT) that investigates use of a reduced restriction protocol following THA with use of a posterolateral surgical approach. Our hypothesis is that a reduced restriction protocol following THA with use of a posterolateral surgical approach has no influence on the early dislocation rate compared to a restricted protocol. Methods/Design Study design The study design is a single-center, parallel-group, stratified, randomized trial with a planned duration of 3 years in which 456 primary THA patients will be allocated to either a care-as-usual group receiving postoperative restrictions including the advice to sleep in a supine position for the first 8 weeks postoperatively or an experimental group, receiving postoperative instructions without restrictions on sleeping position after THA surgery. The experimental group does not use a pillow between the legs in any sleeping position and the care-asusual group, that is only allowed to sleep in a supine position, is advised to use a pillow between the legs while doing so. A non-inferiority design was chosen as a standard approach to assess similarity of results of the experimental as opposed to the care-as-usual treatment. In order to avoid an imbalance in treatment assignments and to reduce the opportunity for bias and confounders, a stratified blocked randomization technique will be applied with random sequences of varying block sizes (varying from n =2, n =4 or n = 6). Among the stratification factors are operating surgeon and the preferred selfreported sleeping position (supine, prone, on the side, combination/no clear preference) of the patient. Measurements will be taken at baseline (preoperatively), 8 weeks (at regular polyclinic visit) 6, 12 and 24 months after surgery (postoperatively). Setting Written informed consent, from patients who meet the inclusion criteria for participation in the trial, having verified that the candidate fully understands what is involved, will be obtained by the research nurse. Patients will be recruited by the Center for Orthopedic Surgery OCON, Hengelo, The Netherlands. All THAs will be performed by one of OCON s four orthopedic surgeons specialized in hip surgery and with at least 5 years experience in THA. Time, duration and type of anesthesia will be recorded in our patient database. The surgical approach is standard posterolateral with use of a capsular repair. The soft-tissue tension is optimized through neck-length adjustments until an axial force with the leg in extension produces 1 to 2 mm of soft-
3 Peters et al. Trials (2015) 16:360 Page 3 of 6 tissue laxity for male patients and 2 to 3 mm of softtissue laxity for female patients. During trial reduction, stability of the hip is tested in full flexion; 90 degrees of flexion and 45 degrees of internal rotation; full extension; 0 degrees of extension and 45 degrees of external rotation; and with and without knee flexion (up to 90 degrees). Such stability testing is routine in our practice and was not modified for the present study. The implants that will be used are: Exceed ABT Ringloc-XShell, Biomet Orthopedics, E-Poly Hi-Wall Liner Biomet Orthopedics, Modular Taperloc complete femoral stem Biomet Orthopedics, Biolox Delta Modular Ceramic Head 32 mm (Dordrecht, The Netherlands). The postoperative protocol is full weight bearing to tolerance from day 1. The first radiologic assessment, to control prosthetic positioning occurs on the day of the operation, with an anteroposterior (AP) and lateral view of the hip. The second radiographic assessment is at 8 weeks postoperative with an AP pelvic view and a lateral view of the hip. Implant position including cup inclination angle, acetabular component anteversion, hip offset, and leg length will be measured on the 8 weeks postoperative AP pelvic view. The target zones for anteversion and inclination are defined as degrees and degrees, respectively. The local Medical Ethical Committee approves the study design, procedures, protocols and informed consent. The trial is registered at ClinicalTrials.gov NCT Study population Patients with symptomatic osteoarthritis of the hip who are planned for THA are included if they meet the following criteria: ASA-classification I or II (American Society of Anesthesiologists); written informed consent provided by the patient. Exclusion criteria are: blindness, scheduled second THA within 6 months, mental incapacity, or inability to fill in the questionnaires in Dutch, infection involvement, wheelchair-dependency, alcohol abuse, and neurological disorders such as Parkinson s disease, or stroke and hypermobility syndromes such as Ehlers- Danlos syndrome. Interventions After randomization, patients will receive either careas-usual; postoperative instructions with the advice to sleep in a supine position for the first 8 weeks postoperatively or reduced restrictions; postoperative instructions without any restriction on sleeping position. All patients are instructed by the physiotherapist by oral and written guidelines which include the following: Not to cross the legs Not to squat Not to internally rotate the hip more than 45 degrees Not to flex the hip more than 90 degrees and Not to make a combination of these two movements When sitting not to use a very low chair that makes the hip flex more than 90 degrees When sleeping only to sleep in the supine position and to use a pillow between their legs during sleep When bending move the operated leg backward so the operated hip will not flex more than 90 degrees Care-as-usual/restricted group In the restricted group patients have to sleep in a supine position during the first 8 weeks. Hip flexion over 90 degrees and internal or external hip rotation more than 45 is not allowed for the first 8 weeks. Patient will be mobilized by the physiotherapist at the day of the operation or the first postoperative day with full weight bearing to tolerance. Experimental/reduced restricted group In the reduced restricted group patients are allowed to sleep in any position they find comfortable. Hip flexion over 90 degrees and internal or external hip rotation more than 45 degrees is not allowed for the first 8 weeks. Patient will be mobilized by the physiotherapist on the day of the operation or the first postoperative day. Patient will be mobilized by the physiotherapist at the day of the operation or the first postoperative day with full weight bearing to tolerance. Patients are instructed by the physiotherapist how to lie in bed and how to prevent more than 90 degrees of hip flexion and 45 degrees of rotation. Next to the general instructions as stated earlier, patients in this experimental group receive additional instructions on how to lie and turn in bed by preventing more than 90 degrees of hip flexion and 45 degrees of rotation. Main study parameters/endpoints Primary outcome measure is the difference in dislocation rate, expressed as a percentage, within the first 8 weeks between the group that receives postoperative instructions with the advice to sleep in a supine position for the first 8 weeks postoperatively and the group that receives postoperative instructions without any restriction on sleeping position. The diagnosis of a dislocated hip will be confirmed by clinical examination and X-ray findings. Secondary study parameters/endpoints Secondary outcome measures are patient s compliance with postoperative instructions, the influence of sleeping position restrictions on quality of sleep [18], the influence
4 Peters et al. Trials (2015) 16:360 Page 4 of 6 of sleeping position restrictions on patient satisfaction (anchor questions rating the degree of perceived quality of sleep and burden of the restrictions prescribed, the Client Satisfaction Questionnaire) and the effects of the advice to sleep in a supine position for the first 8 weeks on functional recovery. Other study parameters These parameters include: 1. Resumption of specific activities following THA such as driving a car. 2. The use of assistive devices (e.g. pillow between the legs during sleep, crutches). 3. The self-reported compliance of patients with the restrictions prescribed. 4. Satisfaction with received quality of care (Client Satisfaction Questionnaire). Study procedures After inclusion and prior to surgery, subject patients will complete the baseline questionnaire at the outpatient clinic during the intake by the nurse practitioner. The physiotherapist will mobilize patients on the day of the operation or the first postoperative day. During this mobilization patients are instructed how turn in bed and how to prevent more than 90 degrees of hip flexion and 45 degrees of rotation. The only difference in instruction between the two study arms is the sleeping position. When discharged to home or nursing home, patients receive a booklet describing the instructions relevant to the study arm they are assigned to. This booklet serves as an enchiridion for partners, physiotherapists, and other persons involved in the care of the patient. In addition, patients are handed a standardized diary booklet in which they are asked to document their sleeping position, exercise activities, experience of pain and any further comments they may want to convey. Patient will visit the outpatient clinic preoperatively and then at 8 postoperative weeks. Routine physical examination will be performed by the orthopedic surgeon. All scores and measurements will be recorded by the nurse practitioner who will also collect the diary booklet from the patients. Preoperative functional assessment will be done by pain severity (Visual Analogue Scale: range 0 10), hip function (Hip Disability and Osteoarthritis Outcome Score) and quality of life (EQ-5D). At 8 weeks follow-up the same functional assessment will be recorded by the nurse practitioner. This visit is combined with the regular postoperative control by the orthopedic surgeon. At 6, 12 and 24 months there will be follow-up questionnaires by , paper or telephone depending upon the availability of the patients addresses. The primary outcome: dislocations within the first 8 weeks, will be recorded in the patient s file when visiting the emergency department. Sample size calculation The maximum allowable difference in proportion in which there is still equality in the effect is not known in the literature. Previous studies suggested a threefold difference in dislocation rate to be a clinically relevant difference [4]. Since the literature is suggesting an average dislocation rate of 2.03 % [8] in the posterolateral surgical approach, a dislocation percentage between 2.03 and 6.09 % is considered to be equal. Hence, the planned sample size is n = 456 THA patients. (One-sided, α =0.025, β =0.80, missing data 20 %). Statistics Populations Primary analyses will be performed for both the intention-to-treat (ITT) and per-protocol (PP) populations. The PP population of patients will comprise those who completed all measurements and did not have any reasons for exclusion from this population, including no baseline data, no data at 8 weeks and/or 6 months or major protocol violations (e.g. position compliance < 80 %). Additional analysis will be based on an ITT (All Patients Treated) population that consists of all randomized patients who had both a baseline and at least one postbaseline measurement. Primary analysis Descriptive statistics were calculated for all variables. Depending on the type of data were compared between the groups using either a t test (continuous) or chisquare (categorical). The intervention group that receives postoperative instructions without any restriction on sleeping position will be declared non-inferior to the group that receives postoperative instructions with the advice to sleep in a supine position for the first 8 weeks postoperatively in case it can be demonstrated that the difference between these 2 groups does not exceed a 3-fold difference in dislocation rate in favor of the supine sleeping position group. This margin corresponds to the definition of clinically relevant difference in dislocation rate by Peak et al. The secondary analysis A repeated measure analysis of (co)variance (ANOVA; group and time) will be applied in order to investigate differences between the groups satisfaction, functional recovery (HOOS) and quality of life (EQ-5D) at 8 weeks, 6 months, 1 and 2 years postoperatively. In addition, correlation coefficients will be calculated between quality
5 Peters et al. Trials (2015) 16:360 Page 5 of 6 of sleep and functional recovery and quality of life. ANCOVA will be conducted dependent upon the analysis of differences in baseline characteristics between groups (e.g. preoperative values, age, radiographic analysis). Subgroup analysis will be directed towards identifying differences in functional recovery between patients with and without compliance and patients who were and were not satisfied. Missing data Missing values (<30 %) in the APT analysis will be handled by multiple imputation techniques. It will be assumed that any missing data will occur at random and missing values will be imputed for the ITT population using multiple imputation by chained equations. The imputation models will be specified to include the individual scores observed at 8 weeks, 6 months, 1 and 2 years and any available variable that has a statistical association with the outcome to be imputed or with missingness, as identified in a logistic regression analysis with missingness as the dependent variable. Corresponding to the percentage of missing values (with a minimum of 25) datasets with imputed plausible values will obtained, with iterations between datasets. Predictive mean matching will be employed to obtain pooled parameter estimates and their associated standard errors for all analyses. The results of the analysis of the primary study hypothesis using the pooled results will be compared to the results obtained on the observed (PP) data alone. Ethical considerations This study is approved by the medical research ethics committee. The Medical Ethics Committee Twente acts as central ethics committee for this trial (Number P13-.31, NL ). An insurance which is in accordance with the legal requirements in the Netherlands (Article 7 WMO and the Measure regarding Compulsory Insurance for Clinical Research in Humans of 23 June 2003) has been obtained. This insurance provides cover for damage to research subjects through injury or death caused by the study. Once a year, information will be provided to the medical research ethics committee on the numbers of subjects included and numbers of subjects that have completed the trial, serious adverse events/serious adverse reactions, and other problems. Discussion Various postoperative restrictions have been proposed for patients undergoing THA to prevent early hip dislocation by emphasizing the importance of avoiding extremes of motion as well as to protect the soft tissue repair [8]. However, the scientific rationale for the effectiveness of these postoperative restrictions in the prevention of early dislocations is limited. Moreover, there are indications that applying a reduced restriction protocol has several benefits. In a prospective, randomized study, with use of an anterolateral surgical approach, Peak et al. reported that patients were much more satisfied when they were given fewer restrictions [10]. Furthermore, these patients achieved a faster return to daily functions and were able to return to work faster [9]. In addition, sleep was positively affected by the reduced precautions [10]. Ververeli et al. demonstrated that reduced hip precautions can facilitate recovery and are more cost-effective [14]. Today the available knowledge is mainly directed at analyzing the anterior or anterolateral surgical approach. However, there are two cohort studies that have investigated the effectiveness of a reduced restriction protocol in primary THA following a posterolateral instead of an anterolateral approach but these studies lack a randomization procedure. For example, Mikkelson et al. found no difference in dislocation rate comparing two cohorts with and without restrictive motion [13]. The study did not show any beneficial effect of rehabilitation without movement restrictions on patient evaluated function. Schmidt-Braekling et al. showed, in a retrospective analysis, that shortening standard posterior hip precautions from 6 to 4 weeks after primary THA utilizing a posterior approach does not increase the risk for postoperative dislocation within the first year after surgery [7]. In the present study we will compare two postoperative protocols that differ in the restriction of sleeping position following THA via the posterolateral surgical approach. Based on the study of Talbot et al., who found that patients had difficulties sleeping following a restricted protocol, our intervention group will not be restricted to sleep in a supine position [12]. In previous studies only the duration of the restrictions was shorted or the reduced restriction protocol was directed towards movement restrictions and use of assistive devices [7, 13]. Another interestingly aspect of the current study compared to the existing literature is that fact that it incorporates an analysis of the patient self-reported compliance to postoperative restrictions. Our study plans to assess patient compliance to the sleeping position instructions in relation to their preferred sleeping position. In summary, the aim of this RCT is to show that a reduced restriction protocol following THA with use of a posterolateral surgical approach has no influence on the early dislocation rate. By omitting the postoperative sleeping restriction patients might have a better quality of sleep, higher patient satisfaction and a faster functional recovery. To our knowledge this will be the first
6 Peters et al. Trials (2015) 16:360 Page 6 of 6 RCT that investigates use of a reduced restriction protocol following THA with use of a posterolateral surgical approach. Trial status Recruiting as of April Abbreviation APT: All patients treated. Competing interests The authors declare that they have no competing interests. 14. Ververeli PA, Lebby EB, Tyler C, Fouad C. Evaluation of reducing postoperative hip precautions in total hip replacement: a randomized prospective study. Orthopedics. 2009;32(12): Robinson RP, Robinson Jr HJ, Salvati EA. Comparison of the transtrochanteric and posterior approaches for total hip replacement. Clin Orthop Relat Res. 1980;147: Bottner F, Delgado S, Sculco TP. Minimally invasive total hip replacement: the posterolateral approach. Am J Orthop. 2006;35(5): Husted H, Gromov K, Malchau H, Freiberg A, Gebuhr P, Troelsen A. Traditions and myths in hip and knee arthroplasty. A narrative review. Acta Orthop. 2014;85(6): Snyder-Halpern R, Verran JA. Instrumentation to describe subjective sleep characteristics in healthy subjects. Res Nurs Health. 1987;10(3): Authors contributions AP, MT and RH originated the idea for the study, contributed to its design and developed the intervention protocol. MT and AV are responsible for the data collection. AP, AV and RH drafted the manuscript. All authors read, edited and approved the final manuscript. Acknowledgments No funding has been and will be received for the present trial. We thank the participating surgeons: Hans Andre Schuppers, Christiaan Rompen and Dean Pakvis. Joe Thachankery is thanked for editing the manuscript. Received: 1 March 2015 Accepted: 4 August 2015 References 1. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet. 2012;380(9855): Landelijke Registratie Orthopedische Implantaten. LROI-Rapportage 2013, meer inzicht in kwaliteit van orthopedische zorg. Eindhoven: Landelijke Registratie Orthopedische Implantaten; Hummel MT, Malkani AL, Yakkanti MR, Baker DL. Decreased dislocation after revision total hip arthroplasty using larger femoral head size and posterior capsular repair. J Arthroplasty. 2009;24(6 Suppl): Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res. 1998;355: Hailer NP, Weiss RJ, Stark A, Karrholm J. The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis. An analysis of 78,098 operations in the Swedish Hip Arthroplasty Register. Acta Orthop. 2012;83(5): Lubbeke A, Suva D, Perneger T, Hoffmeyer P. Influence of preoperative patient education on the risk of dislocation after primary total hip arthroplasty. Arthritis Rheum. 2009;61(4): Schmidt-Braekling T, Waldstein W, Akalin E, Benavente P, Frykberg B, Boettner F. Minimal invasive posterior total hip arthroplasty: are 6 weeks of hip precautions really necessary? Arch Orthop Trauma Surg. 2015;135: Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop. 1970;72: Sharma V, Morgan PM, Cheng EY. Factors influencing early rehabilitation after THA: a systematic review. Clin Orthop Relat Res. 2009;467(6): Peak EL, Parvizi J, Ciminiello M, Purtill JJ, Sharkey PF, Hozack WJ, et al. The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study. J Bone Joint Surg Am. 2005;87(2): Restrepo C, Mortazavi SM, Brothers J, Parvizi J, Rothman RH. Hip dislocation: are hip precautions necessary in anterior approaches? Clin Orthop Relat Res. 2011;469: Talbot NJ, Brown JH, Treble NJ. Early dislocation after total hip arthroplasty: are postoperative restrictions necessary? J Arthroplasty. 2002;17(8): doi: /arth Mikkelsen LR, Petersen MK, Søballe K, Mikkelsen S, Mechlenburg I. Does reduced movement restrictions and use of assistive devices affect rehabilitation outcome after total hip replacement? A non-randomized, controlled study. Eur J Phys Rehabil Med. 2014;50(4): Submit your next manuscript to BioMed Central and take full advantage of: Convenient online submission Thorough peer review No space constraints or color figure charges Immediate publication on acceptance Inclusion in PubMed, CAS, Scopus and Google Scholar Research which is freely available for redistribution Submit your manuscript at
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text:
Separate names with a comma.
Discussion in 'Lawn Mowing' started by Caddyshack Lawn Care, Jul 16, 2013.
Why not use Free Shipping.
That all sounds wonderful....roller skating with a customer and all.....but I generally try to avoid my customers at all costs because the results are usually bad: 1) they waste my time talking about stuff i could care less about....2) they cost me money while my crew sits out in the truck doing nothing.... Or 3) complain and/or ask me to do additional services for free....usually starting out with a "would you mind...(fill in the blank)"...). Don't get me wrong, I'm a friendly guy and I would never do or say anything intentionally rude but personally I'd rather spend time with my wife and kids than on their front porch talking about their abusive ex- husband, about the weather or how their car is in the shop. Sorry I don't care.
If only every LCO had this same outlook. It's unrealistic to expect all of your customers to be happy all the time. I have worked in various service industries and can tell you, great work = great customers. When I ran a pest control route back in the early 2000's, I only had complaints from customers whose problems weren't resolved, and was always willing to listen to their needs to get the job done, it was very gratifying knowing that when I left a service that I had met their needs. The lawn care industry is no different, and a lot of the services I provided then are carried over today. Get in and get the job done right the first time and 99% of the time you won't be getting a call back from them. Customers remember even the smallest mannerisms, and facial expressions, it means a lot to them at the end of the day that they have a professional working on their property.
Excellent customer service allows you to charge a premium price for an average product.
Until they find out their neighbor pays $10 less per week -- $40 less per month. Then all bets are off. I believe the best customer service/job security = showing up every week like you're supposed to and cutting their lawn nicely for a fair price. Anything over and above that will either take money out of your pocket, waste your time, keeping you away from your home and family, or both. I realize there are two schools of thought on this...so I'm not saying I'm right regarding the mow-and-get-the-heck-outta-there philosophy -- different strokes for different folks. My type of service will appeal to a certain kind of customer while yours will appeal to another kind. In general though, the laws of economics say that the higher your price is, everything else being equal,
the fewer customers you will have.
And, the attitude will be easily noticed by the customer.
LS is populated with threads with LCOs complaining dealers "not caring." If LCOs are savvy enough to pick up the "don't care" attitude, why won't a customer pick up the "don't care" attitude as well? The "don't care" isn't constrained to the latest social party, the latest achievement of their student, or the loss of a loved one. It extends into the work scope as well. We don't work in isolation.
Like I said...
As I'm out working, I see a lot - and I mean a LOT of "professionals" out there.
There are very few that I'd ever allow to set foot on my property though based on simple observation.
The way they act, look, work, talk...
Those HAVE to be the guys with all the complaints.
I agree. Just go to a gas station when a typical landscaping crew is getting fuel/snacks and listen to the way they talk. F-bombs while wearing company shirts is a no-no.
Customers don't dictate my schedule--I dictate my schedule. If a client tells me that I need to be present for work on a certain day, I usually respond with, "I would really like to be there but already have made commitments for that day." Remember, YOU own your business, not your clients.
Tom-n-Texas . . . . Amen!
I'm 64 and physically cannot do a lot of things anymore.
Most misery in life is optional.

subset: commoncrawl


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Hebe and Biba(45 Posts)
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Breaking Hair News: Kristin Chenoweth Goes Brunette
Kristin Chenoweth has gone to the dark side!
No, the actress isn't switching roles in Wicked. Rather, she's decided to trade in her normally platinum blonde locks for a completely different 'do!
Chenoweth took to Twitter over the long weekend to share her new hair, which is an ombre style with extensions–much different than her blonde bob she was previously sporting earlier this summer.
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I'm Cid. Really love the beach and all its potential it offers for photography. I'm the kind of guy that will stop doing whatever he's doing to take a really nice pic. Nature photography is something that I enjoy and find peace in, so here I am!
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CHARLOTTE N.C. —The power of prevention was repeatedly lauded during the fourth annual Food Safety Symposium, held recently in this city.
In presentations and panel discussions throughout the three-day event, which was produced by Nation's Restaurant News and sponsored by Ecolab, operators, consultants and attorneys stressed the importance of taking pre-emptive steps to reduce incidences of foodborne outbreak, the s
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What does it mean when u see a blue vein in your breast I'm scare I don't know what to say about it
I will make an appointment to see my doctor and I been having tender breasts it also Itch
If you are concerned please call your doctor. Blue veins can be normal...as can itching... but they can also be a cause for concern if they are abnormal in size or color... when in doubt consult a physician! please keep us posted on what the doc says!
Definitely talk to your doctor. It's probably nothing to worry about but having the peace of mind to hear it from a professional is a good thing!
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About Antoinette
Current: Houston, Texas
Birth: November 30
On Moms.com since: Mar 17, 2014
Hi Ladies I'm mother of 4 boys enjoying my kids having fun with my family n friends I also enjoying life.... I love movies music books shopping shooting pool bowling go to the park with the kids
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AHG 2014 National Leadership Conference June 26-28th
Check-out the details and comments https://www.facebook.com/AmericanHeritageGirls
AHG made history at Arlington National Cemetery
Sunday, June 29 at 1:15pm ET.
Stars & Stripes recipient Marta Tverberg and
AHG Executive Director and Founder Patti Garibay
laid a wreath at the Tomb of the Unknown Soldier.
Welcome AHG MD1412 – June 17thPlease welcome this to the AHG Maryland family!
St Paul's Catholic Church
They'd appreciate our prayers for a successful launch and great impact!
Click graphic to see our Maryland Troops
together for the first time at the AHG NLC
Thanks to all who attended this first gathering of Maryland AHG Troop leaders!
For more information about future group outings contact
Gretchen Magnos Troop Coordinator
AHG MD1208 email@example.com
AHG MD0413 – Court of Award Ceremony
St. Louis Roman Catholic Church
Welcome our new Central Maryland
Ministry Expansion Lead (MEL)
|Sheila Bisson
Professionally, Sheila works part time as a nurse, a ministry she also loves. She is active in her local church St. Mary of the Mills where her daughter's AHG troop is chartered. In her spare time, she loves to go camping, go rock climbing, and read a good book in a hammock.


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Let us know when your receive great advice so we can thank our lawyers and point others with similar questions in the right direction.Got it!
Police came to my home to question me about 2 checks deposited to my checking account, they wanted information about the person who wrote me the check, I advise the police that the person they were looking for was my ex boyfriend and that I was aware of the situation. I deposited two checks from ex, and both checks came back as account closed. I already made two payments towards the negative balance of my account. Can the police pursue criminal charges against me and my boyfriend if both already started to pay money back to the bank? It seems like the police think we are into some check fraud activity because we know each other and he once lived with me. The whole situation is messy, but I am making payments towards the negative balance.
Sure they can but there is always a cost/benefit analysis they do to justify the cost of a criminal prosecution. If restitution is being quickly made the chances of a prosecution is less. Be sure you are not implicating yourself by answering questions while unrepresented.
Good luck.Ask a similar question
Your ex has criminal exposure. I don't think you do unless you were part of the scam.
Feel free to contact me at (212) 577-9797 or by email at: firstname.lastname@example.com. I am a former federal and State prosecutor and have been doing criminal defense work for over 17 years. I was named to the Super Lawyers list as one of the top attorneys in New York for 2012 and 2013. No more than 5 percent of the lawyers in the state are selected by Super Lawyers. Martindale-Hubbell has given me its highest rating - AV Preeminent - in the areas of Criminal Law, Personal Injury, and Litigation. According to Martindale-Hubbell"AV Preeminent is a significant rating accomplishment - a testament to the fact that a lawyer's peers rank him or her at the highest level of professional excellence." Fewer than 8% of attorneys achieve an AV Preeminent rating. I also have the highest ranking – "superb" – on Avvo. The above answer, and any follow up comments or emails is for informational purposes only and not meant as legal advice.Ask a similar question
Your ex boyfriend has criminal exposure. Assuming you were not part of the scheme you will be OK.Ask a similar question
Post a free question on our public forum.Ask a Question
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Patrice Vecchione
Patrice Vecchione's new book "Step into Nature: Nurturing Imagination and Spirit in Everyday Life" (Simon & Schuster/Beyond Words) is available wherever books are sold. Workshop info: www.patricevecchione.com.
Recent articles
A Walk About Town: Moving in music
The first thing Scott Seward, the director of marketing and communications for the Carmel Bach Festival, said to me after we shook hands, is "Music is movement!" Actually, he didn't say it; rather he exclaimed it. His words were a crescendo that splurged from his mouth to my eager ears. "A Walk About Town" is usually about actual walks you might enjoy taking. This month I'm giving it a little twist. Inspired by the upcoming Carmel Bach...
A Walk About Town: Exploring the Carmel River with artist Paola Berthoin
If you get close to the Carmel River this spring, you're certain to hear music. Water music, that is. Standing at the riverbank, I heard the water say, "Listen! There is so much to sing about." Every moment of each day and night, the river water gurgles and splashes, rushing to the Pacific. Its music is unmistakable. Though I didn't grow up near a river, the recognition of its sound and the calm it provides feel primal.At each turn, water plunges...
A Walk About Town: Losing (and finding) the way along the Pfeiffer Canyon trail
email@example.com For many years, I've been the poetry teacher at Captain Cooper Elementary School. I've gotten to know not only the children but parents and others in the Big Sur community. They are caring, stalwart people who look after each other. One poetry writing day, shortly after the instability of Pfeiffer Canyon Bridge had become evident, 6-year-old Dodge wrote this poem:My sadnessis the rainbreaking the bridges.Writing the poem,...
A Walk About Town: Meadows painted with delight
April is National Poetry Month. It's also the unofficial start of wildflower season, at least outside my door. Since poetry and flowers fit so nicely together, I thought I'd welcome them both into this story. Shakespeare included more than 100 wild plants in his work. Violets and pansies represented love. Mismanagement could be expressed through thistles, and oh, what a thistly time we're living in these days. Mustard lit up January. In February, the...
A Walk About Town: Women walking together between rainstorms
A small group of smart and curious local women accepted my invitation to take a walk. "A walk and talk," I said, "in honor of Women's History Month."We were Sharon and Sheila, Judy and Camille, Pat, Debbie, and me, gathered at Jacks Peak Park — that easy-to-get-to park, at least somewhat familiar to all of us."What's it like to be a woman now, both at the point you are in your life and where we're at as a...
Visual arts
A Walk About Town: A tree is something worthy of love
It came as a surprise, loving a tree. That a person could love a tree or would love one or potentially even love a whole bunch of trees was not something I'd considered before it began, gradually, to happen to me. As a child, the way I saw things, love was reserved for a select number of people, favorite books, particular paintings that hung on museum walls, and eating well. That was it for love, and that was fine by me. In 1967, when I was 11, much to my dismay, my...
A Walk About Town: The magic of Mission San Antonio
Long, solitary drives can be fruitful times for contemplation. On a cold winter morning heading south on Highway 101, on my way to Mission San Antonio, my mind was alert and my imagination engaged, and the wide, open road was mine. "You can take the girl out the Church," begins an old saying, "but you can't take the Church out of the girl." That's certainly true for this girl. The lasting value of having been brought up Catholic far...
A Walk About Town: Of seabirds and solace
"Busy old fool, unruly sun, Why dost thou thus, Through windows and through curtains call on us?"— John DonneNeither the chaparral nor the pine forest had succeeded in doing the job I'd assigned first to one wild place and then to the other — not with all their birds, trees, and miles of winding paths, not with their settled stones, bobcats and darting lizards.Since the presidential election results came in...
A Walk in the Park: A nature walker's love of place
In line at the post office the other day, a young couple was at the window being waited on. Oddly, the man crouched down on the floor. Had he dropped a postage stamp? "Oh, come here," he crooned, seemingly to no one. "Let's get you right side up. Now I'll take you outside." Who was he talking to? I edged closer. A bee. The guy was talking to a bee. Clearly, though we'd never met, that man was a kindred spirit, a member of my tribe. I...
Recreation and leisure
A Walk About Town: Looking for inspiration at Palo Corona Regional Park
When a walk in nature is called for (and when isn't one?), I usually get myself to Jacks Peak or to the area affectionately called Happy Trails, an endangered place that many are doing their best to preserve from development, near the Ft. Ord Monument. However, on days that I want to go where the views are so stunning that I forget myself entirely, until recently, my one and only go-to place has been Pt. Lobos, and never have I been disappointed. Why just the other day, leaning into...


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As I understand it, you can only follow up to a certain amount of people based on a ratio. 110% of your followers or 2,000 people -- whichever is greater.
But I thought it would be cool to create a list of people on Twitter who will try to follow back all the people who follow them.
Right now I don't recommend auto-follow or unfollow scripts and programs on Twitter......because I'm reading testimonies from people who say using them has gotten their Twitter account banned and suspended.
So leave a link to your clean Twitter account in the comments section, and if the comment is approved, we can start building a nice little manual follow Twitter list.
Follow me via the link above to Twitter -- and I'll try my best to follow you back. If I don't timely enough, feel free to unfollow me and follow others.
Twitter love!


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Mac Power Users
Learn about getting the most from your Apple technology with focused topics and workflow guests. Creating Mac Power Users, one geek at a time since 2009.
This show broadcasts live. Check the schedule.
#261: MPU Live: My Machine Just Kernel Panicked
June 11th, 2015 · 105 minutes
Jeff Richardson of iPhone JD joins David and Katie to chat about the Apple Watch, we follow-up on Dropbox,Photos.app and photo workflows meal planning, DevonThink, DevonThink, storing items locally without sacrificing drive space and travel tips.
This episode of Mac Power Users is sponsored by:
The Omni Group We're passionate about productivity for Mac, iPhone and iPad.
Squarespace Everything you need to create an amazing website.
Fujitsu ScanSnap
ScanSnap Helps You Live a More Productive, Efficient, Paperless Life
A new way to share, access and protect files.
Download: MP3 (60.35 MB)


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Go batty at Radipole Lake with the RSPB. Guided night walks will be taking place every Friday from July 11 to July 25.
The walk starts at 9pm and finishes at 11pm, bat detecting equipment will be provided.
Booking is essential and the walk costs £4 for RSPB members, £6 for non-members and £3 for children.
For more information or to book your place call 01305 778313.


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FitPinUp Model
Carl Blum PhotographyPhotographer Male Las Vegas, Nevada, US
My Website: FaceBookMy MM URL: http://www.modelmayhem.com/carlblum
Mayhem # 370370
About Me
Welcome to my Profile and Portfolio.
Email: firstname.lastname@example.com
Phone Number: 702.350.2586 ( If you need something done short notice, CALL)
I am always up for shooting you for a publication, get a hold me!
A lot of the photos in my Portfolio on here, done for fun and thru the facebook. Want to shoot, YOU have to get a hold of me or respond to one of my random shoot requests on my Facebook Page.
I shoot just about anything, from Product Shots to Full Blown Magazine Pictorials. Have some Idea what you want before you get a hold of me.
If you are looking to shoot with me, be pro-active. I am not the kind of Photographer who hunts down models to shoot... Be Active, Ask and ACT..
You will be surprised as to what I might say YES too..
I DO NOT provide unedited photos.
If you are looking for a TFP shoot, please use my Facebook link and contact me through there (above). I am not on here enough to give you a decent response.
https://www.facebook.com/CarlBlum.Photo … tos_stream
I shoot Anything and everything, just ask. I shoot studio and location.
If you wish to hire me, $1,200 is my Daily Rate.
A Bit about me
20 years professional experience. My First Billboard (Las Vegas) was in May of 1993. First Magazine shoot, 1994. First Digital camera shoot 1997, Last film camera shoot 2003. Professional in Graphics/photoshop/airbrushing since 1989 (yep I am that old)
Have you worked with Carl Blum Photography? Add Credits for Carl Blum Photography! >>
Tasha Ann Marie
See Sample Worked together 2-10 times; Most recent: November 2016
Credit Notes
Clients and Publications:
FemmExposure Magazine • CoEd Magazine • Playboy • KaBoom Magazine • MatureModel.com • In the Wind • Silver Nugget • Casino Cannery Group • Stations Casinos • Paradise Casino • Esquire Inc • Dynamic Choppers • Count's Kustoms • Sunset Lanes • Iron Horse •Street Bikes • Broken Leash • Ed Hardy • Harley Davidson • Head Blade • Choppers Quarterly • Ol' School Ridz • Rio Hotel •Tropicana Hotel • Lucky Exhibits • Stonehedge • Ed Roman Guitars • Cooper Tire • Bridgestone USA • Paradise Peaks Mine • Emerald Gardens • 702Weddings • Leftridge Entertainment • Girls of Vegas • Napoli Pizza • Renata's Diner • Sin City Choppers • Noble Sports • A.D.A.• State of Nevada • Inked • Rolling Stone • Easy Rider • Speed • Classic Cruzin • Mochten Magazine • and so many more I have just forgotten…… I been at it a long time. <br> Now just curious, who noticed my listed experience level .....
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As the Wicker Park neighborhood has evolved over the past decade, it's become a place where families are abundant everywhere you look. The recently opened The Chop Shop and 1st Ward Events intends to become an integral part of that community.
Whether you are looking for a local butcher, a new lunch spot, a bar to grab a drink, a restaurant for a delicious meal or a venue for a private event, The Chop Shop has managed to accommodate them all in one massive space.
"The vision started out as a traditional Italian salumeria, and then evolved into something more expansive with the inclusion of the bar and restaurant," says Matt Woodburn, co-owner and principal of The Chop Shop.
At the forefront of The Chop Shop is the butcher division with an abundant assortment of meats and cheeses on display.
"The butcher shop has introduced a new lunch offering to Wicker Park with quality, quick-service, deli-style offerings and offers an alternative to the big box supermarkets for high quality, locally sourced custom cut meat," he says.
Whether guests are stopping in to grab a signature handmade sausage or sitting down for a meal, The Chop Shop intends to be a welcoming environment for families. There is even a reserved area for stroller parking.
"We've always felt that it was important to be inclusive, open and comfortable when it comes to the environment at The Chop Shop," says Woodburn. "Plus as a Wicker Park resident for years and now a father of two young girls myself, it's nice to see families eating together inside the restaurant and downstairs shopping at the butcher."
See more of Megan's stories here.
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Hey guys :)
Kaiser here with another blog.
I'm pretty sure most (if not all of you) have your own ideas for your own custom champions and/or champion skins. I'm no exception to that. I've had lots of ideas and drew them on paper. But recently, I have been running out of ideas. And I thought about this LoL community here, which should be full of fun and creative ideas for champions and skins. I'm pretty decent with a pencil so I'll be taking a few requests every now and then :)
How it will work
I'll be accepting two types of requests: Custom Champions and Custom Skins. I'll be only accepting two of each at a time. This will be a first-come-first-serve system. Basically, whoever asks first will be entertained first. I'll be updating this blog with completed requests and the usernames of the ones who requested them.
I will change the number of requests at a time from 2 to 1 each type.
Custom Champions
Custom Skins
I am not entirely sure how long it will take for me to finish a request because of my duties as a college student, but I will assure it gets finished as soon as possible :)


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PDT Photon Photodynamics Light Therapy Skin Rejuvenation LED Light Therapy Facial Mask
Item: PDT Photon Photodynamics Light Therapy Skin Rejuvenation LED Light Therapy Facial Mask
Item ID: PE165
Color: White
Voltage: 110V / 220V
Weight: 0.385 kg
Treatment Area: Face
1. LED Light Masks (Red & Blue) X 1
2. Control Panel X 1
3. Goggles X 1
4. Mask Holder X 1
- Clear, lighten, smooth the skin
- Firm and enhance skin texture
- Reduce and prevent wrinkles, helps fight fatty areas
- Improve skin elasticity
- Minimize Pores
- Balance skin tone
- Enhance circulation
- Inhibit the formation of melanin pigment
- Fight acne
- Accelerate blood circulation
- Natural light waves improving the look of skin
- Each color of light shows beneficial effects on particular skin conditions.
- Easy to operate
- Portable
- Warranty
The Photon Beauty Device, designed for facial beautification, uses natural light waves, which are transmitted by LEDs into the skin. The light activates photoreceptors in skin cells, producing energy for absorption by skin components, to beautify your complexion.
Studies show that light enters the body as photons (energy) and is absorbed by the photoreceptors within cells. Massaging with the Photon Beauty balances skin tone and enhances circulation. Light is known for helping with some beauty problems, for instance, inhibiting the formation of melanin pigment, fighting acne and dermatitis, and improving the look of pockmarks, scars and wrinkles.
Functions of different light color:
a. Blue(463 nm)---Excellent effect of curing acne, kill bacteria, improve sensitive skin
The blue light penetrating about 0.5mm has the function of calming against skin rashes; suitable for the skin which is sensitive, oily and with skin rashes. It can adjust skin sebum secretion, effectively get rid of acne and whelk to reach the aim of beautification. Besides, the blue light can astringe and tighten loosened skin.
b. Red(650 nm)--- One of the most powerful colors to increase blood circulation. Stimulate skin cells to excrete collagen to achieve firm and smooth texture.
The red light penetrating 8-10mm is suitable for any type of skin; it can reach derma to stimulate fibre cells. Heating can improve blood circulation and collagen albumen hyperplasia to reduce wrinkles and make skin more elastic and smooth. The mild wave length is suitable for surrounding eyes and forehead.
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