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Total Knee Replacement Rehabilitation

Total Knee Replacement Rehabilitation aims at preventing hazards of bedrest, assist with adequate functional ROM and strengthening knee musculature to obtain independent activities of daily living.

Indications for Total Knee Arthoplasty

disabling knee pain with functional impairment radiographic evidence of significant arthritic involvement failed conservative measures including ambulatory aids (canes), NSAIDS, and lifestyle modification.

Contraindications for Total Knee Replacement Absolute

Relative

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Goals Of Total Knee Replacement Rehabilitation Prevent hazards of bedrest like DVT, pulmonary embolism, pressure ulcers. Assist with adequate and functional range of motion. Strengthen the knee musculature. Assist patient in achieving functional independent activities of daily living.

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joint infection sepsis or systemic infection neuropathic arthropathy painful solid knee fusion (usually due to RSD. RSD is not helped by additional surgery)

severe osteoporosis debilitated poor health nonfunctioning extensor mechanism significant peripheral vascular disease

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A total knee replacement (TKR) is usually done as the surgical treatment option for advanced osteoarthritis of the knee joint.During the surgery, the knee joint is replaced with artificial material. The knee joint is made up of the femur (thigh bone), the tibia (shin bone), the patella (knee cap) and cartilage (usually worn out because of OA).The end of the femur is removed and replaced with a metal surface and the top of the tibia is removed and replaced with a plastic piece that has a metal stem. If the knee cap has also degenerated, a plastic piece may be added to the back surface to create a smoother joint surface.

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Independent ambulation with an assistive device.

Perioperative considerations for Total Knee Replacement Rehabilitation Component design, fixation method, operative technique (osteotomy, extensor mechanism technique), bone quality will all affect perioperative rehabilitation. Implant can be posterior cruciate ligament (PCL) retaining, PCL sacrificing, or PCL sacrificing with substitution. Rehabilitation of Patients with Hybrid Ingrowth Implant versus those with Cemented knee Implant Cemented Total Knee Arthroplasty

Hybrid or Ingrowth Total Knee Arthroplasty

Touch down weight bearing (TDWB) only with walker for first 6 weeks. Next 6 weeks, begin crutch walking with weight bearing as tolerated. Surgeon's preferences may be different. Total Knee Replacement Rehabilitation Outline Preoperative Physical Therapy

Review bed to chair transfers, bathroom transfers, tub transfers with tub chair at home. Teach postoperative knee exercises and give patient handout. Teach ambulation with assistive devices TDWB or WBAT at the discretion of the surgeon. Review precautions.

Inpatient Total Knee Replacement Rehabilitation Goals

Day 1

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FOLLOW THE VIDEOS FOR BETTER UNDERSTANDING OF THE EXERCISES IN Total Knee Replacement Rehabilitation Ankle pump

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Initiate isometric exercises.

0-90 degree ROM in the first 2 weeks before discharge from an inpatient setting. Rapid return of quadriceps control and strength to enable patient to ambulate without knee immobiliser. Rapid mobilisation to minimize risk of bedrest.

Quads sets Lie on your back with legs straight, together, and flat on the bed, arms by your side. Perform this exercise one leg at a time. Tighten the muscles on the top of one of your thighs. At the same time, push the back of your knee downward into the bed. The

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Ability for weight bearing as tolerated (WBAT) with walker from 1 day postoperative.

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3 result should be straightening of your leg. Hold for 5 seconds, relax 5 seconds; repeat 10 times for each leg.

SLRThis exercise helps strengthen the quadriceps muscle also. Bend the uninvolved leg by raising the knee and keeping the foot flat on the bed. Keeping your involved leg straight, raise the straight leg about 6 to 10 inches. Hold for 5 seconds. Lower the leg slowly to the bed and repeat 10-20 times. Once you can do 20 repetitions without any problems, you can add resistance (ie. sand bags) at the ankle to further strengthen the muscles. The amount of weight is increased in one pound increments.

Ice: Ice may be used during your hospital stay and at home to help reduce the pain and swelling in your knee. Pain and swelling will slow your progress with your exercises. A bag of crushed ice may be placed in a towel over your knee for 15-20 minutes. Your sensation may be decreased after surgery, so use extra care. Day 2-2 weeks

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2-3 weeks

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Continue isometric exercises throughout Total Knee Replacement Rehabilitation. Perform vastus medialis oblique (VMO) strengthening by terminal knee extension-Lie on your back with a blanket roll under your involved knee so that the knee bends about 3040 degrees. Tighten your quadriceps and straighten your knee by lifting your heel off the bed. Hold 5 seconds, then slowly your heel to the bed. You may repeat 10-20 times. Begin gentle passive ROM exercises for knee- knee extension, knee flexion, heel slides, wall slides. Begin patellar mobilization techniques when incision stable to avoid contracture. Perform active hip abduction and adduction exercises. Continue active and active assisted knee ROM exercises. Continue and progress these exercises until 6 weeks after surgery. Give home exercises with outpatient physical therapist following patient 2-3 times per week. Plan discharge when ROM of involved knee is from 0-90 degrees and patient can independently execute transfers and ambulation.

Continue previous exercises.

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Ambulate twice a day with knee immobilizer, assistance, and walker. Cemented prosthesis: Weight bearing as tolerated (WBAT) with walker. Noncemented prosthesis: TDWB with walker. Transfer out of bed and into the chair twice a day with leg in full extension on stool or another chair. CPM machine- Do not allow more than 40 degrees of flexion on settings until after 3 days. Usually 1 cycle per minute. Progress 5-10 degrees a day as tolerated. Initiate active ROM and active assisted ROM exercises. During sleep place a pillow under the ankle to help passive knee extension.

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Continue walking with walker until otherwise instructed by surgeon. Prescribe prophylactic antibiotics for possible eventual dental or urological procedures. Driving is not allowed for 4-6 weeks. Orient family to patient's needs, abilities, and limitations.

Review tub transfers in Total Knee Replacement Rehabilitation

6 weeks onwards in Total Knee Replacement Rehabilitation

Hip Replacement Rehabilitation

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Hip Replacement Rehabilitation might also have to be adjusted because ofstability. Abduction brace may be used to prevent adduction and flexion of more than 80 degrees for upto 6 months in case of recurrent dislocations. Similarly, leg shortening through a hip at the time of revision with or without a constrained socket should be protected with an abduction brace until the soft tissues tighen up. Hip Replacement Rehabilitation Protocol- Posterior Approach Goals of Hip Replacement Rehabilitation Guard against dislocation of the implant. Obtain pain free range of motion within safe limits. Gain functional strength.

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The Hip Replacement Rehabilitation protocols mentioned here for are general and should be tailored to specific patients. For example, weight bearing should be limited to toe touch in osteotomy of the femur. Expansion osteotomies allow the insertion of a larger prosthesis, and reduction osteotomies allow narrowing of the proximal femur normally. In patients with these osteotomies, weight-bearing should be delayed until some union is present. These patients should avoid SLR (straight leg raise) and side-leg-lifting until, surgeon agrees that it is safe to do so.Treatment may also have to be adjusted according to difficulty of initial fixation. In revision surgery, a stable press-fit acetabular component may be difficult to achieve and multiple-screw fixation may be required. Caution should be exercised in rehabilitation in these circumstanses.

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Begin weight bearing as tolerated with ambulatory aid, if this has not already begun. Perform wall slides and lunges. Perform step ups. Begin closed chain knee exercises on total gym and progress over 4-5 weeks for bilateral lower extremities. Perform cone walking with progression. Progress to stationary bicycling.

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Many patients lack sufficient strength, ROM, or agility to step over tub for showering. Place tub chair as far back in tub as possible, facing the faucets. Patient backs up to the tub, sits on the chair, and then lifts the leg over. Tub mats and nonslip stickers for tub floor traction also are recommended.

Strengthen hip and knee musculature. Teach transfers and ambulation independently or with assistive devices. Prevent bedrest hazards (eg. pneumonia, decubitus ulcer, pulmonary embolism, thrombophlebitis).

Rehabilitation Considerations in Cemented and Cementless Techniques > In cemented total hip Weight Bearing To Toleranance (WBTT) with walker should be started immediately after surgery. Preoperative Instructions

Postoperative Hip Replacement Rehabilitation Regimen

Patient should be made to come out of bed in stroke chair twice a day with assistance within 1 or 2 days postoperatively. Chair should not be of low height. Begin ambulation with assistive device (walker) twice a day. > Weight bearing recomendations in Hip Replacement Rehabilitation Cemented Prosthesis: Weight bearing as tolerated with walker for atleast 6 weeks, then use cane in the contralateral hand for 4-6 months. Cementeless Prosthesis: Touch down weight bearing with walker for 6-8 weeks, then use a cane in contralateral hand for 6 months. Wheelchair must be used for long distances with careful avoidance of excessive hip flexion greater than 80 degrees while in wheelchair, this can be achieved by placing a cushion in the wheelchair seat with highest cushion point posterior. Isometric and bed Exercises (Hip Replacement Rehabilitation)

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Straight Leg Raise (SLR)- Tighten knee and lift leg off the bed, keeping the knee straight. Flex the opposite knee to aid this exercise. Ankle Pumps- Pump ankle up and down repeatedly. Quadriceps Sets- Tighten quadriceps muscles by pushing knee down and holding for a count of 5. Gluteal Sets- Squeeze buttocks together and hold for a count of 5. Isometric hip abduction with self resistance while lying. Hip abduction adduction- (Prevent initially if patient had a trochanteric osteotomy). While lying on the back patient can slide the leg to the side. In standing this can be done by moving the leg out to the side and back. Perform this exercise while lying on one side (56 weeks postoperatively). The patient should be turned 30 degree towards prone to

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Instruct on precautions for hip dislocation (mentioned later). Provide instructions for transfers in and out of bed and chair. Avoid deep chairs. Also instruct the patient to look at the ceiling as they sit down to minimize trunk flexion. Avoid crossing legs while sitting. While rising from a chair scoot to the edge of the chair and then rise. Use elevated commode seat. Elevated seat is placed on commode at a slant, with higher part at the back, to aid in rising. For ambulation instruct on use of anticipated assistive device.

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6 utilize gluteus maximus and medius muscles. Most patients would otherwise tend to rotate towards the supine position, thus abducting with the tensor fascia femoris. ROM and Stretching Exercises (Hip Replacement Rehabilitation)

Abduction Pillow

Keep an abduction pillow between the legs while in bed. Use the abductor pillow while asleep or resting in bed for 5-6 weeks, it may then be safely discontinued. Bathroom Rehabilitation : Permit bathroom privileges with assistance and an elevated commode seat. Teach bathroom transfers when the patient is ambulating 10-20 feet outside of room. Always use elevated commode seats. >Assistive devices used in Hip Replacement Rehabilitation

Transfer Guidances

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Stair training in Hip Replacement Rehabilitation Going up stairs- Step up first with the uninvolved leg, keeping crutches on the step below until both feets are on the step above, then bring both crutches up on the step. If available hold the handrail.

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>Use "reacher" or "grabber" to help retrieve objects on the floor. Do not bend to put on slippers. Shoe horn and loosely fittings shoes or loafers.

Bed to Chair- Avoid leaning forward to get out of chair or off bed. Slide hips forward to the edge of the chair first, then come to standing. Do not cross legs when pivoting from supine to bedside position. Therapist or nurse assists until able to perform safe, secure transfers. Bathroom- Use elevated toilet seat with assistance. Continue assistance until able to perform safe, secure transfers.

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1 to 2 days postoperative, begin Thomas stretch to avoid flexion contracture of the hip. Pull the uninvolved leg to the chest while lying supine on the bed. At the same time, push the involved leg against the bed. This stretches the anterior capsule and the hip flexors of the involved leg. Perform this stretch 5 times per session, 5-6 times a day. Patient may start with exercising on stationary bicycle depending on trunk stability with a high seat 4-7 day postoperative. Until successful completion of a full arc on the bicycle, the seat should be set as high as possible. The seat may be progressively lowered to increase hip flexion within safe parameters. Perform extension stretching of the anterior capsule in standing by extending the involved leg while the uninvolved leg is mildly flexed at the hip and knee, supported by the walker. Slowly thrust the pelvis forward and the shoulders backward for a sustained stretch of the anterior capsule.

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Going down stairs- Place crutches on the step below, then step down with the involved leg, and then with the uninvolved leg. If possible, hold the rail.

Exercise Progression in Hip Replacement Rehabilitation :

Instructions for Home in Hip Replacement Rehabilitation

Managing Problems After Total Hip Replacement : 1-Trendelenburg Gait(weak hip abductors)

2-Flexion Contracture of the Hip

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The above mention Hip Replacement Rehabilitation Protocol should be tailored to individual patients need and performed in guidance of a physical therapist. Precautions After Total Hip Replacement Following points must be explained clearly during Hip Replacement Rehabilitation. AVOID

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Concentrate on hip abduction exercises to strengthen abductors. Evaluate leg-length discrepancy. Make the patient stand on involved leg with flexed opposite knee. If opposite hip drops, have patient try to lift and hold in an effort to reeducate and work gluteus medius muscle.

Avoid placing pillow under the knee after surgery. Walking backward helps stretch flexion contracture. Perform Thomas Stretch 30 times a days.

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Continue with the previous exercises and ambulation activities. Continue to observe precautions. Install elevated toilet seat at home. Supply walker for home. Review rehab specific for home situation, like- steps, stairways, narrow doorways. Ensure home physical therapy has been arranged. Avoid driving for minimum 6 weeks. Patient should have prescription of prophylactic antibiotics that may be needed eventually for dental or urologic procedures.

At 5-6 week, begin standing hip abduction exercises with pullys, sports cords or weights. Also may perform side stepping with a sports cord around the hips, as well as lateral step ups with a low step, if clinically safe. Progress hip abduction exercises until the patient exhibits a normal gait with good abductor strength. Perform prone lying extension exercises of the hip to strengthen the gluteus maximus. These may be performed with the knee flexed (to isolate the hamstrings and gluteus maximus) and with the knee extended to strengthen the hamstrings and gluteus maximus. Initiate general strengthening exercises, develop endurance and perform cardiovascular exercises.

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Crossing your legs or bringing them together(adduction). Bringing the knee too close to your chest- extreme hip flexion ( you can bend until your hand gets to your knee).

Frozen Shoulder Exercises Frozen Shoulder Exercises aim to reduce pain, increase extensibility of the capsule, and improve strength of the rotator cuff muscles. Restorative Programme : The basic aim of frozen shoulder exercises are:

i) Relaxation ii) Passive mobilization technique iii) Specific frozen shoulder exercises to offer graduated stretching.

Shoulder Rehab Exercises You Can Do with The Rotater - These bloopers are hilarious Relaxation

Relaxed Passive Mobilization

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The patient is placed in supine position with the affected shoulder in maximum possible abduction and neutral rotation and elbow in 90 degree of flexion. The physiotherapist grasping the arm above the shoulder joint carries out relaxed passive gliding movement of head of humerus on glenoid. Axial traction and approximation is carried out along with antero-posterior glide and abduction- adduction glide. To induce relaxation, always begin with slow rhythmic movement. Slow and rhythmic circumduction at the glenohumeral joint, in forward stoop position effectively induces relaxation and promotes mobility. Gentle relaxed passive movements reduces pain and pathologic limits of motion. The reduction in pain occurs because of the neuro-modulation effect on the mechanoreceptors with in the joint.

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Though prior heating of the joint has been found to facilitate relaxation and mobilization, one may use the heat modality suitable to the patient's response. However ultrasound, beside deep heating, has the added advantages of increasing excitability of the contracted soft tissue and is therefore performed.

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Mobilization is attained by 3 basic approaches:

To reduce pain. To increase extensibility of the thickened and contracted capsule of the joint at the anteroinferior border and at the attachment of the capsule to the anatomical neck of humerus. To improve mobility of the shoulder. To improve strength of the muscle. However it may be remembered that strengthening of muscle is secondary to mobilization.

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9 Mobilization by accessory movements of acromio-clavicular, sterno-clavicular and/or scapulothoracic joint articulation is also extremely helpful.

Shoulder Pain Pendulum Exercise - Click here for more amazing videos Exercise Programme Frozen shoulder exercises plays an important role in management of the condition. While planning the frozen shoulder exercises one must give due importance to the fact that contracted soft tissue when objected to repeated prolong mild tension show extensibility and plastic elongation.

Shoulder elevation with flexion, abduction and external rotation. Shoulder internal rotation with extension, adduction and elbow flexion i.e attaining "hand to lumbar position".

The above mentioned Frozen shoulder exercises can be done in two ways:

Passive Mobilization Technique

For this, manipulation and mobilising techniques are given by "MAITLAND". By this patient respond very well for acquiring full range by properly guided simple and specific Frozen shoulder exercises which ensures relaxed graduated stretching of the contracted capsule. Frozen Shoulder Exercises for Home and Cautions:

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By weight and pully- Tolerable weight must be used. This may be done in supine or sitting position. By self assisted stretching- Method of performing is, the patient uses his normal or contralateral arm for gradually stretching the affected shoulder.

The importance or necessity of regular stretching must be explained to the patient even after he had recovered from stiffness and pain to avoid the recurrence of periarthritis or stiffness. Patient having diabetes responds very slow to the treatment and also feel much more pain as compared to those who are non-diabetic. Patient who are complaining of pain in the night (nocturnal pain) should be treated by heat therapy or thermo therapy.

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The specific Frozen shoulder exercises should include the maximum number of combination of various movement by minimising the number of exercises. Graduated relaxed sustained stretching based on the PNF pattern are following types:

An increase in the movement following the session of prolonged stretching was usually associated with a corresponding increase in the other movements too. However improvement in the range of other movements is not always at the same rate.

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The contralateral or normal shoulder should always be examined and given regular stretching exercise programme as a precautionary measure to maintain its functional capacity.

Frozen Shoulder Introduction: Codman introduced the term "frozen shoulder" in 1934 to describe patients who had a painful loss of shoulder motion with normal radiographic studies. In 1946, Neviasernamed the condition "adhesive capsulitis" based on the radiographic appearance with arthrography, which suggested "adhesion" of the capsule of th GH joint limiting overall joint space volume. Patients with adhesive capsulitis have a painful restriction of both active and passive GH joint motion in all planes, or a global loss of GH joint motion.

Adhesive Capsulitis is characterized by 3 stages:

Length of each stage is variable, but typically the first stage lasts for 3-6 months, the second stage from 3-18 months, and the final stage from 3-6 months. The first stage is the freezing phase, characterized by onset of an aching pain in the shoulder. The pain is usually more severe at night and with activities, and may be associated with a sense of discomfort that radiates down the arm. Often, a specific traumatic event is difficult for the patient to recall. As symptoms progress, there are fewer arm positions that are comfortable. Most patients will position the arm in adduction and internal rotation. This position represents the "neutral isometric position of relaxed tension for the inflamed glenohumeral capsule, biceps, and rotator cuff." The second stage is the progressive stiffness or frozen phase. Pain at rest usually diminishes during this stage, leaving the patient with a shoulder that has restricted motion in all planes Activities of daily become severely restricted. When performing activities, a sharp acute discomfort can occur as the patient reaches the restraint of the tight capsule. Pain at night is a common complaint and is not easily treated with medications or physical modalities. The stage can last from 3-18 months. The final stage is the resolution or thawing phase. This stage is characterized by a slow recovery of motion. Aggressive treatment with physical therapy frozen shoulder exercises, closed manipulation or surgical release may accelerate recovery, moving the patient from the frozen stage into the thawing phase. Diagnosis:

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Not every stiff or painful shoulder is a frozen shoulder, and indeed there is some controversy over the criteria for diagnosing "frozen shoulder". Stiffness occurs in a variety of conditions-

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The condition is common in people of 40-60 years age group, with a higher incidence in females. The onset of an idiopathic frozen shoulder has been associated with extended immobilization, relatively mild trauma, and surgical trauma, especially breast and chest wall procedures. Adhesive capsulitis is associated with medical conditions such as diabetes, hyperthyroidism, ischemic heart disease, inflammatory arthritis and cervical spondylosis. Most significant association is with Insulin dependent diabetes.

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11 arthritic, rheumatic, post-traumatic, and post operative. The diagnosis of frozen shoulder is clinical resting on two characteristic features.

Painful restriction of movement in the presence of normal x-rays, and a natural progression through three successive phases.

In general, a global loss of active and passive motion is present; the loss of external rotation with the arm at the patient's side is a hallmark of this condition. The loss of passive external rotation is the single most important finding on physical examination that helps to differentiate the diagnosis from a rotator cuff problem because problems of the rotator cuff generally do not result in a loss of passive external rotation. Frozen Shoulder Treatment:

Operative intervention is indicated in patients who show no improvement after a three month course of aggressive management that includes medications, corticosteroid injection and physical therapy.

Phase 1: Weeks 0-8 Goals

No restriction or immobilization. Pain Control

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Relieve pain Restore Motion

Frozen Shoulder Exercises (Rehabilitation Protocol):

Medications NSAIDS- first line medication for pain control GH joint injection: corticosteroid/local anesthetic combination Oral steroid taper- for patients with refractive or symptomatic frozen shoulder. Therapeutic modalities Ice, ultrasound, HVGS Apply moist heat before therapy and ice pack at the end of session.

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Even though adhesive capsulitis is believed to be a "self limiting" process, it can be severely disabling for months to years and, as a result, requires aggressive treatment once the diagnosis is made. Initial treatment should include an aggressive frozen shoulder exercises to help regain shoulder motion. For patients in the initial painful or freezing phase, pain relief may be obtained with a course of anti-inflammatory medications, the judicious use of GH joint corticosteroid injections, or therapeutic modality treatments. Intra-articular corticosteroid injections help to abort the abnormal inflammatory process often associated with this condition.

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When the patient is seen first, a number of conditions should be excluded: infection, post traumatic stiffness, diffuse stiffness and reflex sympathetic dystrophy.

12 Motion: Frozen Shoulder Exercises

Phase 1: Weeks 8-16 Criteria for progression to Phase 2

Improvement in shoulder discomfort. Improvement in shoulder motion. Satisfactory physical examination.

Improve shoulder motion in all plane Improve strength and endurance of rotator cuff and scapular stabilizers

Pain Control by same means as used in 1st 8 weeks. Motion: Frozen Shoulder Exercises

Muscle strengthening

Start with rotator cuff strengthening exercises 3 times per week, 8-12 repetitions for three sets.

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Phase 3: 4 months and beyond Criteria for progression to Phase 3

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Perform active, active assisted and passive range of motion exercises to obtain around 140 degree of forward flexion, 45 degree of external rotation and internal rotation to twelfth thoracic spinous process.

Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion. Progress to open chain strengthening exercises with theraband for same greoup of muscles. Progress to light weight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors. Perform strengthening of scapular stabilizers. Deltoid strengthening.

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Goals

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Initially focus on forward flexion and internal and external rotation with the arm at the side, and the elbow at 90 degrees. Active ROM exercises. Active assisted ROM exercises. Passive ROM exercises. In home these Frozen Shoulder Exercises should be performed 3-5 times per day. A sustained stretch, of 15-30 seconds, at the end ROMs should be part of all ROM routines.

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Significant functional recovery of shoulder motion. Successful participation in activities of daily living. Resolution of painful shoulder. Satisfactory physical examination.

Goals

Please check with your Physical Therapist before starting with this frozen shoulder exercises. Warning Signs:

Loss of motion Continued Pain

These patients may need to move back to earlier routines May require increased utilization of pain control modalities as outlined above If loss of motion is persistent and pain continues, patients may require surgical intervention Manipulation under anesthesia Arthroscopic release

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Treatment of Complications:

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Home maintenance frozen shoulder exercises. ROM exercises 2 times a day. Rotator cuff strengthening 3 times a week. Scapular stabilizer strengthening 3 times a week.

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cervical spondylosis,
Treatment of cervical spondylosis, also known as Cervical Osteoarthritis by physical therapy modalities. Cervical Osteoarthritis can be treated in physiotherapy department by various means like:

Aims of Cervical Spondylosis Treatment

Cervical Osteoarthritis refers to the degenerative condition of the cervical spine including the intervertebral joints in between the vertebral bodies and the vertebral discs. The other terms used for this condition are

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It is very common in persons above 50 years of age and those who have got to do work like typing or persons who have to keep the neck in one position as in reading, writing and other table works. It starts with degeneration of disc resulting in, reduced space in between two vertebrae, later osteophytes are formed in the periphery. This is followed by involvement of the posterior intervertebral joints resulting in pain in the posterior part of the upper limb. Generally, this pain is along with tingling, numbness and radiating in nature.

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Degenerative disc disease Degenerative spondylosis Osteopytosis Spondylitis deformans

Cervical Osteoarthritis Introduction

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To relieve pain To provide support to the neck To restore the neck movements in full range To re-educate the patient for posture correction To strengthen the cervical muscles To analyse the basic precipitating causes of the patient's problem and aim at alleviating those causative factors.

Heat Modalities Neck Exercises Manipulative Therapy Hydrotherapy Postural Awareness Relaxation cervical traction neck support

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15 The osteophytes formed may also compress the cord which will produce weakness of whole of the limb. Predisposing Factors For Cervical Osteoarthritis Faulty posture adapted is associated with wrong habits, anxiety and mental tension.

The segments commonly affected in the cervical region are C4 to T1. Along with these sites, other parts of spine are also affected due to compensatory adjustments. Clinical Feature Of Cervical Osteoarthritis

1)Onset: The condition gets precipitated by fatigue, mental tensions, worries, anxiety or depression. It occurs gradually due to faulty posture.

3)Muscle weakness: Depending on which nerve root gets compressed, the concerned muscles that are supplied by that nerve root gets affected and weakened. Usually, the postural muscles of the neck are weak. They are: upper cervical spine flexors, lower cervical spine extensors and side flexors. 4)Sensation: There occurs paraesthesia that means, pins and needles or altered sensation of the particular dermatome which is supplied by the impinged nerve root. 5)Nature of pain: Usually described as dull, aching pain, sometimes gets exaggerated as sharp, stabbing pain and frequently occurs as cramping type.

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2)Pain: The region of pain depends on the site where the cervical spine is affected by the pathology. a) Upper cervical spine- Headache b) Mid cervical spine- Neck pain c) Region from C4 to T2- Radiating pain; pain in shoulder girdle, shoulder and arm, either unilateral or bilateral.

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Occupational stresses causes continous pressure on the cervical segments. The sections of society prone to stress and strain area) Officers, typists and others working on poorly and wrongly positioned desks and tables. b) Drivers prone to prolonged driving. c) Coal miners and divers. d) Persons involved in occupations including lifting and carrying things on their head. e) Habit of holding phone on one shoulder while talking. f) Sleeping in awkward positions, using inappropriate pilows. Built of the body Persons having thick neck with a Dowager's Humpand long backs are much prone to spondylosis.

16 6)Limitation of movement: All the neck movements get limited, often bilateral but is unilateral in case of acute onset of pain. The movement which gets very much limited is flexion of the upper cervical spine and extension of the lower cervical spine. 7)On palpation: It is detected that there is loss of mobility of soft tissues along with loss of movements of the accessory intervertebral structures.

9)Postural disturbance: The posture gets disturbed in cervical osteoarthritis as follows

10) Cervical spondylosis is usually associated with headache, vertigo and loss of balance which is due to postural changes. Investigations The only investigation which can easily confirm the diagnosis apart from the symptoms of the patient is radiograph. Early and proper diagnosis is necessary for Treatment Of Cervical Spondylosis/Cervical Osteoarthritis. The X-ray finding reveals that there is:

Treatment for Cervical Spondylosis Heat Modalities

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Heat is an effective mean of reducing and relieving pain in cervical osteoarthritis. The modalities that can be used are:a)Hot packs for moist heat. b)SWD (pulsed or continous) for dry heat. Once the pain subside to a tolerable limit, then exercises should be started and progressed gradually according to the conditions and requirements of the patient.

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Osteophyte formation at the margin of the apophyseal joints Reduced space between the vertebral bodies Lipping of the vertebral bodies

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Stress at C5,C6, so tightness of upper cervical spine extensors. Chin placed forward. Kyphosis of thoracic spine. Tight pectorals. Flattened, sometimes lordotic lumbar spine. Flexion of elbows and hand. Backward tilt of pelvis. Hip flexed and knee flexed. Ankles dorsiflexed.

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8)Muscle spasm: There is spasm mostly of the scalene muscle usually unilaterally. As the middle and lower fibres of trapezius get lengthened and reduced in tone. Imbalance results causing the upper trapezius to bear increased tone and hence there occurs muscle spasm and muscle tightness.

17 Static Contractions and Strengthening Exercises Isometric contractions of the cervical muscles improve the muscle endurance and tone as the contractions improve the blood supply thereby the nutrition to the muscle is increased and hence muscle strengthening is done. The basic technique of this exercise is that both Physiotherapist and patient exert equal pressure so that static; non dynamic action takes place in the cervical muscles. During all the movements, shoulder girdle should be stabilised so as to avoid trick movements. The pressure can be applied by the physiotherapist or by the patient himself after teaching him the technique properly. Soft tissue technique

Kneading helps to release tightness of upper fibre of trapezius. Picking up, wringing and skin rolling also helps in relieving the tightness of scalene muscles, interspinous ligaments, paravertebral muscles and trapezius. Traction

Oscillatory traction is considered to be effective in mobilizing the stiff neck.Continuous traction is used to relieve nerve root pressure. Traction is always given in comfortable position with minimum weight which should be graduated slowly as for the patient's recovery. This depends on the frequency of remissions and exacerbations of the condition. It can be given in sitting or lying position. The traction can be given either in the form of manual traction or positional traction. Hydrotherapy Float support lying in warm water is best for total relaxation and hence gain relief of muscle spasm. To relax the upper fibres of trapezius, patient is taught to push one hand then the other towards the feet in the float support lying position. For the lower fibres of trapezius and serratus anterior, sitting on the float with both hands holding down the float is the preferred position. This also stimulates the muscles and the receptors of the neck and shoulder joint to hold the head in a good position. Postural Awareness

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As the condition progresses, the abnormality of posture also increases, thus from the initial stage itself, postural awareness through proper advice and education should be planned and initiated by the physiotherapist. The ideal posture is straight neck with chin tucked in and back straight with no compensatory actions or any trick movements. While sitting a high backed chair is provided to the patient with head, neck and shoulder supported; a small pillow in the lumbar spine, feet properly supported and arms resting on a pillow over the lap or on the arms of the chair.

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18 While sleeping, side lying is the most preffered position, supine lying is also adviced. A single pillow under head for head support is allowed. A Butterfly pillow is the best support for a patient of cervical osteoarthritis, as it is flattened in the middle where the head rests and the elevated ends support the head on the sides. Support

Relaxation

Due to pain and spasm of cervical muscle, patient is always in discomfort and uneasiness. So to alleviate these undesirable situations, relaxation techniques are taught in various positions that is during rest, work or play. While lying on bed, patient is adviced to loosen his entire body and stretch for few times so as to reduce the muscular tension to a minimum. While relaxing the whole body should be fully supported by pillows. He is then encouraged to think of something pleasent which will facilitate comfortable and relaxed sleep. Surgery may be necessary for a patient suffering from cervical osteoarthritis if he/she has severe pain that does not improve from other conservative treatments. It should be the last resort as there is always a risk factor involved.

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Heel Spur Causes

Heel Spur or Calcaneal Spur is one of the most common causes of heel pain. Continued overstrain of plantar fascia results in stripping of periosteum from its origin at the calcaneus. The gap thus formed is filled by the proliferation of bone resulting in formation of a bony spur to secure the detached attachment.

Thus calcaneal spur is a late sequale of plantar fascitis. Heel spurs and plantar fasciitis can occur alone or be related to underlying diseases which cause arthritis (inflammation of the joints) such as Reiter's disease, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis.

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Calcaneal Spur

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Support for the neck are of great importance to keep the neck steady and to relieve the pain. A firm neck collar is very beneficial especially during activities or during travelling. While patient is resting or sitting, the collar should be removed but then also the neck should be supported by pillows or head rest.

19 Heel Spur Symptoms

Heel Spur Diagnosis

Once formed, this spur is permanent and attempts to remove it results in its recurrence. Heel Spur Treatment

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Rest: The intensity and duration of activity and weight bearing should be reduced. Staying off the feet can help a lot ( For example- heel raise walking while getting down from bed in morning or after long sitting ). Relieve pain and inflammation: Use of ultrasound and contrast bath help reduce pain and inflammation. Avoid walking barefoot: Shoes are a must to support the arch of the foot even when at home. Arch Supports and heel cups cushion to the heel, and reduce the weight bearing on the foot during activities. Stimulation: Faradism can be an effective measure to induce contractions in the intrinsic muscles improving their tone, power and circulation. Exercises: The workout regimen should consist of mild stretches for strengthening of foot and calf muscles so as to reduce the tension on the heel mechanically. Exercises to the intrinsic muscles in warm water in the morning before initiating weight bearing. Strengthening exercises to the intrinsic muscles as sustained toe curling, performed even with shoes on provide an excellent technique of resistive exercises. Resting on lateral border of the foot with cupping of the foot by curling of toes is effective in moulding longitudinal arch. Weight loss: Losing weight can reduce the extra pressure that plantar fascia bears with every step. Medications: Pain Relief Medications like analgesics and anti-inflammatory are advisable in acute as well as chronic cases. For chronic heel pain management or surgical advice consult a podiatrist. Steroids and anesthetic injectables at the site of spur may be advised in severe ceases.

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Heel bone spurs can be diagnosed with an X-ray foot where a bony outgrowth can be seen at the calcaneal bone near the attachment of plantar fascia. Radiological proof helps exclude other conditions like arthritis, stress fractures etc.

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The calcaneal spur may not be always painful.When painful a sharp, stabbing pain under or on the inside of the heel. The pain is typically relieved during rest, but is worse after getting up again. As a rule of thumb, it is most painful first thing in the morning. The pain is made worse by walking on a hard surface or carrying something heavy, such as a suitcase. The pain can become so severe that it becomes difficult to continue your daily work.

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Genu Varum
Genu Varum is also known as Bow Leg. It is a deformity wherein there is lateral bowing of the legs at the knee. This is usually due to defective growth of the medial side of the epiphyseal plate. It is commonly seen unilaterally and seen in conditions such asRickets, Paget's disease and severe degree osteoarthritis of the knee. The degree of deformity is measured by the distance between the two medial femoral condyles when the patient is lying. Treatment of Bow legs

Generally, no treatment is required for idiopathic presentation as it is a normal anatomical variant in young children. Treatment is indicated when its persists beyond 3 and half years old, Unilateral presentation, or progressive worsening of the curvature. During childhood, assure the proper intake ofvitamin D to prevent rickets.

Post operative Physiotherapy

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Gradual knee mobilization is the main part of the treatment. Some heat modalities may be given for relief of pain. Strengthening exercises for quadriceps, hamstrings and gluteus muscles are given. When the patient is able to walk, he is given correct training for standing, balancing, weight transferring and walking.

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Mild degree of deformity can be treated by wearing surgical shoes with 3/8" outer raised and with a long inner rod extending to the groin and leather straps across the tibia and the knee. Corrective operations can also be performed, if necessary. The person would need to wear casts or braces following the operation.

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De Quervain Tenosynovitis
What is De Quervain tenosynovitis? : De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist. It is an inflammatory condition affecting the tendon sheaths (tenosynovitis) that pass over the wrist joint. The inflammatory response occurs following injury and leads to the symptoms of pain, heat, redness, swelling and loss of function. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist. Also known as:

.Etiology of De Quervain tenosynovitis

De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should. Tendinitis may be caused by overuse. It can be seen in association with pregnancy. It may be found in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged women.

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The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the handso called radial abduction (as opposed to movement of the thumb away from the hand, out of the plane of the hand -palmar abduction). The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. Evaluation of histological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process. The pathology is identical in de Quervain seen in new mothers. De Quervain is potentially more common in women; the speculative rationale for this is that women have a greater styloid process angle of the radius. Signs and symptoms of De Quervain tenosynovitis Patients with De Quervain tenosynovitis note pain resulting from thumb and wrist motion, along with tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Signs of De Quervain's tendinitis:

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Pathology of De Quervain tenosynovitis

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The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath.

Radial styloid tenosynovitis de Quervain disease de Quervain's stenosing tenosynovitis mother's wrist and mommy thumb washerwoman's sprain

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Examination

Tenderness is absent over the muscle bellies proximal to the first dorsal compartment. Tenderness and pain on axial loading are absent at the carpometacarpal (CMC) joint unless the patient has arthritis in that joint. Treatment of De Quervain tenosynovitis Rest, ice and NSAIDs may provide relief and reversal of this condition, especially if it is caught early enough. Splinting with a thumb-spica splint may be necessary to reduce the movement of the wrist and lower joints of the thumb. If these interventions do not work, then a cortisone shot into the irritated area may be the next course of action. Physical therapy may also be used to retrain movements to avoid or change the method of those daily actions that caused the inflammation. The final step, if all other interventions fail, is surgery to release the tendons and provide more space for them to move. Following the surgery physical therapy may still be required to retrain the movements that caused the injury. What can a physical therapist do to help in De Quervain tenosynovitis? In acute stage

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Provide a variety of hand splints to support the thumb and the wrist Help identify aggravating activities and suggest alternative postures Massage cryotherapy (eg, cold packs, ice massage) to reduce the inflammation and edema ultrasound (ie, phonophoresis) or electrically charged ions (ie, iontophoresis)

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Finkelstein's test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the examining physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs during Finkelstein test along the distal radius (top of forearm, about an in inch below the wrist), DeQuervain's syndrome is likely.

The first dorsal compartment over the radial styloid becomes thickened and feels bone hard; the area becomes tender. Usually, the compartment's thickening so distorts the sparsely padded skin in this area that a visible fusiform mass is created.

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Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist. Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region. Pain and swelling may make it difficult to move the thumb and wrist. A "catching" or "snapping" sensation may be felt when moving the thumb. Numbness may be experienced on the back of the thumb and index finger. This is caused as the nerve lying on top of the tendon sheath is irritated.

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suggest activity modifications

In chronic stage

Surgical Treatment for De Quervain tenosynovitis

Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons.

Complications

Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, or adhesions in the scar can cause neuritis in this high-contact area, greatly limiting hand and wrist function. This complication is best avoided through careful blunt dissection of the subcutaneous tissue and gentle traction. Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis. In such a case, the extensor pollicis brevis tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgical re-exploration may allow a previously overlooked tendon to be released. Subluxation of released tendons is possible. With wrist flexion and extension, the tendons of a widely released first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the release to the thickest mid 2 cm of the first dorsal compartment or by reconstructing a loose roof to the released sheath. Reconstruction of the sheath with a slip of local tissue may relieve symptoms. Preventive measures for De Quervain tenosynovitis

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Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment is quick and straightforward, complications can be profound and permanent. Careful attention to surgical technique at the initial release is paramount to avoiding complications.

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Thermal modalities Transverse friction massage Cold laser treatments are becoming more common with a high success rate for reducing localized swelling of tendons (tendonitis). More and more physical therapy and hand centers are finding this modality to be useful for De Quervain's syndrome. Splinting Sensory evaluation Therapeutic exercisesstarting with ROM exercises, and as the patient progresses, adding strengthening exercises Ergonomic workstation assessment as needed Educating the patient to either avoid or decrease repetitive hand motions, such as pinching, wringing, turning, twisting or grasping and A home-exercise program

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24 Prevention of overuse injuries commonly requires breaking up sessions of work or practice involving a particular area into shorter periods with more frequent breaks to allow that area to rest and avoid the overuse.:>>A proper warm up before doing any lifting, grasping or holding for extended periods may prepare the tendons for the task and prevent some of the strain placed on them.>:Avoidance of activities that cause pain is a common sense prevention method that often gets ignored. If a movement causes pain, find another activity or action that accomplishes the same task without the pain.

Pinched Nerve In Shoulder

What is a pinched nerve?

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The neck is a complex place when it comes to nerves, and neck pain can stem from all manner of things, including a pinched nerve in the shoulder. Nerves can become trapped in the shoulder itself, due to the cramped conditions in an area called the brachial plexus. The brachial plexus has a number of cervical nerves travelling through it to the upper limbs. These nerves exit the spinal column and then branch off and rejoin in various patterns to innervate the musculature of the chest, shoulder, arms, and hands. Disc herniation in the cervical spine can also cause pinched nerves leading to shoulder and neck pain. Causes of pinched nerve in shoulder Usually, people who work in construction, factories, delivering packages, and others are the ones who are having pinch nerve in shoulder. People working in constructions carry heavy loads like hollow blocks, sand, rocks, wood are the once having pinch nerve in their shoulder.

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A pinched nerve is a term that is quite common to hear, but most of us dont really know what it means. A pinched nerve in the shoulder is a complaint that you will hear often, a very painful one at that, however not totally correct. Nerve compressions can be caused by muscles, tendons, bones and cartilage that surround the nerve and branches of it. Often people can get a pinched nerve in the shoulder region when they have tight muscles, however, generally the nerve is not actually being pinched by a muscle in the shoulder. Typically it comes from the disc area in your neck. It usually happens around C6 and C7. This is typically where problems can occur and result in symptoms like a pinched nerve in the shoulder. The nerves that run through C6 and C7 travel down through your shoulder blades, and can cause chronic pain and muscles spasms. A pinched nerve in the shoulder that originates in the neck is not always the actual diagnosis, but it is something you need to look out for, as it is quite typically disguised as a shoulder problem.

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A pinched nerve in shoulder can cause debilitating pain. It can seemingly come from out of nowhere, waking you up from a night's sleep, or it can be the result of an accident or sports injury. In many cases, a pinched nerve results in severe pain and disability in the shoulder and upper arm. After treating the pain with moist heat, consult your physician. Exercise therapy is one of the first courses of treatment.

Typically, pinched nerve in shoulder occurs when too much pressure is applied to the shoulder nerve by the surrounding tissue, such as cartilage, tendons, bones and muscles.Symptoms include muscle weakness, numbness, pain and a tingling sensation that radiates along the shoulders and into the neck or spine. While pinched nerves may occur anywhere in the body, they most commonly affect the neck, shoulder and lower back.

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25 Same for factory workers and delivery men carry heavy loads of their products. They have been putting pressure on their bodies, especially their shoulders. Other causes of pinch nerve are due to swelling of some parts of your body because of pregnancy,arthritis, diabetes, family history and many more. So even though were careful, we can still have pinch nerves. The problem may also stem from poor posture that causes tissue surrounding the nerve to "push" into the nerve. In obese people, the sheer mass of excessive tissue surrounding a nerve can be the cause. The trouble could be rooted in another medical problem, such as a herniated spinal disc. If you have an extra cervical rib this can put more stress on an already cramped area, and any minor trauma to the shoulder can result in neck pain, arm pain, and even coldness and weakness in the fingers, depending on which nerves have been impacted. Sometimes a fairly innocuous repetitive motion which taps on the front of the shoulder can lead to inflammation in the area and cause a pinched nerve in the shoulder. Pinched Nerve In Shoulder Symptoms

Numbing: Numbness or tingling can occur due to a pinched nerve in shoulder. You might get a feeling that your shoulder is dead, or when you touch it you dont feel as much, there is less sensation. Pins and needles is another common complaint. It may occur any place between your hand to your neck and depends on where the nerve is being compressed. Weakness: Since the nerve are what activates muscles, if one is being compressed, the signal to your muscle will be weak. You will therefore experience muscle weakness as a result of a pinched nerve in shoulder. You may experience it when you are reaching above your head to try to grab something, and occurs in different parts of the arm depending on the nerve location. Muscle Spasms: Muscles spasms and twitching can occur as a result of a pinched nerve, especially one that is originating in the neck area.

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Diagnosis Of A Pinched Nerve In Shoulder In the majority of cases a pinched nerve in the neck happens at C6 or C7, and your physician will isolate the problem by assessing your symptoms and then, most often, sending you for an

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C5 - The main result of a pinched C5 nerve root is shoulder pain, weakness in the deltoid muscles, along with the possibility of a numb sensation in the shoulder area. C6 - The main result of a pinched C6 nerve is pain radiating down your arm and into your thumb. Other less common symptoms include weakness in the biceps and wrist muscles. C7 - The main result of a pinched C7 nerve is pain and numbness radiating down the arm and into the middle finger. C8 - The main result of a pinched C8 nerve is a numb sensation or pain felt in the outside of the hand.

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Pain: Pain is a common symptom of a pinched nerve in shoulder. It might be sharp or burning, it could cover the whole shoulder area, or a specific spot. This depends on the location of the nerve. If it is close to the spinal cord and originating from the neck then neck movements may agitate it as well.

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26 X-Ray, MRI or CT scan. If the nerve at C5 is pinched, however, you are likely to develop shoulder pain, numbness, and weakness in the deltoids and bicep muscles. Pain can be both sharp and acute, or a dull aching pain in the neck or shoulder. Some patients may experience a widespread pain, whereas for others it is isolated to a smaller spot and can produce a burning sensation. Numbness, and a feeling of pins and needles in the shoulder can indicate a trapped nerve and lead to muscle weakness and, over time, muscle atrophy (wasting). Treatment for Pinched Nerve In Shoulder Stuff To Do At Home

3. Apply a heat pack onto your shoulders and neck. One of the reasons you have pain is because your shoulder muscles might be too tight and therefore compressing the underlying nerve. Heat can greatly relieve the muscular tension and therefore apply less pressure on the nerve. 4. Massage the neck and shoulder. Make sure that you dont apply too much pressure. The massage should be light and gentle. Dont try to massage yourself and get a health professional like a chiropractor, physical therapist or massage therapist to treat you. 5. Use anti-inflammatory drugs (NSAID Non-Steriod Anti-inflammatory drugs). These can give you a bit of relief but be sure that you know the possible side effects are. They do not remove the cause of the pain. 6. Apply heat cream or herbs onto the affected area. Again, this doesnt remove the cause of the problem but can give you plenty of relief. After about 10 -12 days, you can start physiotherapy. It helps strengthen and stretch the muscles, relieve pain and pressure, alleviate stiffness and improve the range of motion. Also, the doctor may prescribe over the counter analgesics to allay pain quickly. Cases that do not respond to conservative treatment need surgery. Useful Tips to overcome Pinched nerve in shoulder There are many factors that contribute to pinch nerve in shoulder but they can be prevented to. Do not carry heavy loads using your back but use your legs to carry it. Obesity is also one cause because it increases the pressure on the nerves with the heavy weight in your body, so try to loose weight. Exercising regularly is a big help, try swimming, jogging or biking. Then let your body rest after a long work. One cause of pinch nerve is over working.

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2. Rest your arms and shoulder in a relax position. Put your arms on a pillow and try not to stretch your shoulder out. Moving your arms can stretch the nerve and therefore aggravate the condition.

1. Correct your shoulder and back posture. The way that you are sitting now can cause more compression of the nerves. If you are hunching forward, this can cut the blood flow to the nerve so it is best to keep your shoulders back. To correct your shoulder posture, you can buy a shoulder posture shoulder brace online or if you want immediately, go buy it for your pharmacist or any other health equipment shop.

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27 Try doing stretches; it can help after a long day of work. And lastly, always have proper posture. Stand up straight and sit down properly. Try to avoid slouching, keep your stomach in and chest out, and try to lessen the use of very high heeled shoes. These are some tips that can help in improving pinched nerve in shoulder. But take note that you should always ask your doctor about these especially when your pinch nerve is severe.

Myositis Ossificans
Prodyut Das

localized non neoplastic bone myositis ossificans traumatica myo-osteosis myositis ossificans circumscripta traumatic ossifying myositis ossifying haematoma

Most people if not all, have a history of trauma, simple severe blow or series of repeated minor traumas. Condition may be classified according to its location as extra osseous, periosteal or parosteal. Haematoma seems to be necessary prerequisite. Muscles most often involved are brachialis, quadriceps femoris and adductor muscles of thigh. It is significant that these muscles gain attachment to bone over a wide surface area, suggesting that periosteum participates to some extent in the process. Commonly young athletic men are predisposed with Myositis. Region of elbow is a favorite site, and when the process appears to restrict elbow motion progressively, ill advised forcible manipulation will cause a widespread involvement. What causes myositis ossificans?

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It is characterized by fibrous, osseous and cartilaginous proliferation and by metaplasia. The term myo and itis is a misnomer because skeletal muscle is often not involved and inflammatory changes are rarely evident. Also in early phase of evolution, formation of bone may not be observed, so term ossificans is not always applicable.

Not applying cold therapy and compression immediately after the injury. Having intensive physiotherapy or massage too soon after the injury. Use someone who is properly qualified and insured.

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Also known as

Myositis Ossificans is extra-skeletal ossification that occurs in muscles & other soft tissues. If you have a bad muscle strain or contusion (dead leg!) and it is neglected then you could be unlucky enough to get Myositis. It is usually as a result of impact which causes damage to the sheath that surrounds a bone (periostium) as well as to the muscle. Bone will grow within the muscle (called calcification) which is painful. The bone will grow 2 to 4 weeks after the injury and be mature bone within 3 to 6 months.

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Returning too soon to training after exercise.

If the ossification is located in the adductor muscles, it is known as "Prussian's disease". Pathogenesis of Myositis Ossificans Muscle is commonly but not invariably involved, and fascia, tendon and periosteum can also be the site. Process is peculiar alteration within the ground substance of connective tissue, associated with striking proliferation of undifferentiated mesenchymal cells. Initially there is degeneration and necrosis, in case of muscle, disrupted muscle fibers retract. In 3 to 4 days, fibroblasts from endomysium invade damaged area and rapidly form broad sheets of immature fibroblasts. At the same time, primitive mesenchymal cells proliferate within injured connective tissue. Intense cellular proliferation of fibroblasts and mesenchymal cells produces a histological picture that may be erroneously diagnosed as fibrosarcoma or myosarcoma. Ground substance becomes homogeneous or glassy or waxy, suggesting some type of edema. It increases in amount and encloses some of mesenchymal cells, which then assume the morphological characteristic of osteoblasts. Mineralization follows and bone is formed. This events typically takes place first within least damaged part i.e. periphery. As the process of osteoid formation and mineralization changing in mature bone evolves, it progressively extends towards the central, severely damaged area. When myositis is not removed and is allowed to mature, it becomes oriented and covered by a cartilaginous cap, because of muscle action over the lesion. This is called post traumatic osteochondroma and is common in region of knee joint. Pathophysiology of myositis ossificans traumatica

Myositis Type

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Symptoms of Myositis include Restricted range of movement Pain in the muscle when you use it

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The specific cause and pathophysiology are unclear - it may be caused by an interaction between local factors (e.g., a reserve of available calcium in adjacent skeletal tissue or soft tissue edema, vascular stasis tissue hypoxia or mesenchymal cells with osteoblastic activity) and unknown systemic factors. The basic mechanism is the inappropriate differentiation of fibroblasts into bone-forming cells (osteoblasts). Early edema of connective tissue proceeds to tissue with foci of calcification and then to maturation of calcification and ossification.

In the first, and by far most common type, nonhereditary myositis ossificans (commonly referred to simply as "myositis ossificans"), calcifications occur at the site of injured muscle, most commonly in the arms or in the quadriceps of the thighs. The term myositis ossificans traumatica is sometimes used when the condition is due to trauma. It is passive stretching then active exercise, is responsible for bone formation. The second condition, myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva) is an inherited affliction, autosomal dominant pattern, in which the ossification can occur without injury, and typically grows in a predictable pattern.IP joint of thumb, large toe and spine are liable to fuse. All joint motion is finally lost and patient dies of inter current infection. This condition is very rare.

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A hard lump in the muscle An X-ray can show bone growth

Radiographs:

Bone Scan: active myositis appears as intense para-osseous accumulation of tracer activity in acutely damaged muscle on delayed images; Prognosis: over time, the volume of heterotopic bone will diminish; Treatment of myositis :

Radiation therapy subsequent to the injury or as a preventive measure of recurrence may be applied but its usefulness is inconclusive. Treatment is initially conservative, as some patients' calcifications will spontaneously be reabsorbed, and others will have minimal symptoms. In occasional cases, surgical debridement of the abnormal tissue is required, although success of such therapy is limited. physiotherapy management of myositis ossificans includes

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Surgical Management

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Rest Immobilization Anti-inflammatory drugs physiotherapy management surgical debridement

Rest Immobilization pulsed Ultra sound and phonophoresis Maintain available range of motion but avoid stretching and massage, until maturation. iontophoresis with 2 % acetic acid solution. extra corporeal shock wave therapy

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CT Scan: calcification of the heterotopic ossification proceeds from the outer margin and progresses centrally

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soft tissue ossification not attached to bone is common x-rays show round mass w/ distinct peripheral margin of mature ossification & a radiolucent center of immature osteoid & primitive mesenchymal tissue this peripheral maturation, reverse of that seen in a malignant tumor, is characteristic of myositis

30 Growth should not be removed in premature stage as it will likely reoccur. The ossification becomes exuberant, infiltrates beyond the original site, and compresses the soft tissues around beyond hope of repair. When after serial x-rays the mass is dense, well delineated, and at a stand still, it may be safely removed. It may be possible to prevent myositis by aspirating the original haematoma.

Ganglion Cyst Treatment

Ganglion Cyst Treatment include ultrasonic therapy,immobilization using splint, aspiration and surgery.

What is ganglion cyst: A Ganglion cyst is a localised, tense cystic swelling in connection with the joint capsule or tendon sheath. It contains clear gelatinous fluid. Causes for Ganglion Cyst: The aetiology is yet to be known. Myxoid degeneration of fibrous tissue of capsule, ligaments and retinaculae has been suggested. This is sometimes initiated or excited by injury. According to some, ganglion arrises from small bursa within the substance of the joint capsule or the fibrous tendon sheath. This bursa becomes distended possibly following trauma giving rise to a ganglion. Synovial herniation is the probable cause of ganglion has been rejected. Pathology: Ganglion is a cystic swelling containing clear gelatinous fluid or viscious fluid. It is surrounded by fibrous capsule and it posseses small pseudopodia.

The tendons on the dorsum of the wrist from lateral to medial are

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Sites:

The commonest site is on the dorsum of the wrist. Other probable sites are Front of the wrist, when it may compress a nerve causing numbness or weakness Dorsum of the foot Palmer aspect of the hand Flexor aspect of the fingers, where small ganglions may develop.

abductor pollicis longus and extensor pollicis brevis (surrounded by a common sheath) extensor carpi radialis longus and extensor carpi radialis brevis (surrounded by a common sheath) extensor pollicis longus extensor indicis extensor digitorum extensor digiti minimi extensor carpi ulnaris

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31 Clinical features of Ganglion Cyst: The patient often is a young adult. The most common presenting symptom is a painless lump. Occasionally there may be considerable pain, which is often seen in case of ganglion on the flexor aspect of the finger. On Examination: the lump is well defined , cystic swelling, but is often felt firm or even hard (as the cyst is very tense). Mobility is not much, though it can be moved with great difficulty sideways. It is immobilise along the axis of the tendon. When it arrises from the fibrous sheath of a tendon, the swelling becomes fixed as the tendon is made taut. Ganglion Cyst Treatment: Consevative Ganglion Cyst treatment

Complete excision is the best ganglion cyst treatment. This is usually done by using a tourniquet. The ganglion is removed completely. Care must be taken to remove all the pseudopodia and the fibrous layer from which they arrise. The excised specimen should be sent for biopsy as very occasionally there may be some neoplastic change, particularly synovioma. After surgery

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Operative Ganglion Cyst treatment

Keep the affected limb elevated for up to 48 hours to help reduce swelling. You may experience discomfort, swelling and tenderness for two to six weeks. Your doctor may recommend analgesics, such as acetaminophen (Tylenol, others), or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, Naprosyn, others), for pain relief. Change your bandages (dressings) as directed. Depending on the location of the cyst, your doctor may recommend temporarily wearing a splint or brace to help minimize postoperative pain. In most cases, however, moving the affected area soon after surgery is recommended. As the incision heals, it's important to watch for signs of infection, including redness, swelling or discharge.

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Ultrasonic therapy helps to reduce swelling and inflammation Immobilization" Because activity can make the ganglion cyst grow larger, your doctor may recommend wearing a wrist brace or splint to immobilize the area. This helps your hand and wrist to rest, which may help shrink the cyst. As the cyst shrinks, it may release the pressure on your nerves, relieving pain. A strike on the cyst will cause rupture on the cyst with apparent belief of cure (previously it was done with the holy bible in the west). But with this ganglion cyst treatment recurrence is common. Massaging the ganglion. Rubbing the ganglion gently but often during the day may help move the fluid out of the sac. Do not smash a ganglion with a book or other heavy object. You may break a bone or otherwise injure your wrist by trying this folk remedy, and the ganglion may return anyway. Aspiration of the cyst and injection of sclerosing solution ( 3% sodium murrhuate or 5% phenol in almond oil) or hydrocortisone is another well known treatment of this condition. This injection may be repeated followed by crepe bandaging. This has also not succeeded to claim cure in majority of the cases

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Managing Fibromyalgia an urban ache

What is Fibromyalgia?

Fibromyalgia (FMS) refers to a condition with a constellation of symptoms that include widespread aching, stiffness, fatigue, and the presence of specific body tender points. The presence of pain originates in the muscles and connective tissues of the body. It is a syndrome of unknown etiology characterized by chronic wide spread pain, increased tenderness to palpation and additional symptoms such as disturbed sleep, stiffness, fatigue and psychological distress. While medication mainly focus on pain reduction, physical therapy is aimed at managing fibromyalgia consequences such as pain, fatigue, deconditioning, muscle weakness and sleep disturbances and other disease consequences. Connective tissues contain fibrocytes, or fiber cells, muscles contain myocytes, or muscle cells, and together with the Latin word for pain, algia, the word fibromyalgia is constructed. The exact physiological process has not been determined, but it is likely many factors, including those beyond the muscles and fibrous tissues, play a role. Since many patients with joint and ligament pain have been referred to rheumatologists, to check whether inflammation is present that would respond to antiinflammatory drugs, this medical specialty developed criteria for the diagnosis of this illness. The American College of Rheumatologists (ACR) defined fibromyalgia (FMS) in 1990 as the presence of

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Patients most often have associated fatigue, sleep disorders, irritable bowel syndrome, migraine headaches, immune system or endocrine system disorders. When the joints and ligaments are

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1) body or joint pain above and below the waist, and on the right and left side of the body, 2) axial pain (most often neck or low back pain), and 3) 11 out of 18 possible tender points.

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Therapy is sometimes utilized after surgical and non-surgical treatment. Your therapist will teach you exercises to mobilize your joints. This may be helpful for reducing swelling and discomfort. You will also learn exercises to increase your hand strength, flexibility, and coordination. The goal of therapy is to restore maximum function to the wrist and hand. Unfortunately, there's no guarantee that a ganglion cyst won't recur, even after surgery. And as with all surgeries, there are risks to be considered. Though rare, injury to nerves, blood vessels or tendons may occur. These could result in weakness, numbness or restricted motion. Your doctor can help you decide the best treatment for you

33 examined by clinicians, there is surprisingly little inflammation present for the amount of pain that is experienced. In fact, muscle and ligament examinations from biopsy samples characteristically show no unusual patterns of disease or inflammation. About 2-5% of the general population is considered to have FMS. FMS is a common disorder characterized by multiple tender points, widespread deep muscle pain, fatigue, and depression. What are tender points? Tender points are pain points or localized areas of tenderness around joints, but not the joints themselves. These tender points hurt when pressed with a finger. Tender points are often not deep areas of pain. Instead, they are superficial areas seemingly under the surface of the skin, such as the area over the elbow or shoulder. How many tender points are important for FMS?

There are 18 tender points important for the diagnosis of fibromyalgia (see picture below). These tender point are located at various places on your body. To get a medical diagnosis of FMS, 11 of 18 tender point sites must be painful when pressed. In addition, for a diagnosis of fibromyalgia, the symptom of widespread pain must have been present for three months. FMS trigger points exist at these nine bilateral muscle locations:

Is there a prescription medication that help managing fibromyalgia pain ? Managing Fibromyalgia Pain for tender points with involves a multifaceted treatment program that employs both conventional and alternative therapies. While the reason is not entirely clear, FMS pain and fatigue sometimes respond to low doses of antidepressants. However, the standard treatment for managing fibromyalgia (Chronic fatigue syndrome) and tender points involves medications, daily stress management, exercise, physiotherapy, hydrotherapy using heat and ice, and rest. Other remedies for symptoms may also be used in managing fibromyalgia. What at-home treatments might help in managing fibromyalgia tender point pain? Alternative treatments or home remedies are important in managing fibromyalgia and the pain of tender points. As an example, therapeutic massage can manipulate the muscles and soft tissues of the body to help ease pain, muscle tension, spasms, and stress.

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Low cervical region: (front neck area) at anterior aspect of the interspaces between the transverse processes of C5-C7. Second rib: (front chest area) at second costochondral junctions. Occiput: (back of the neck) at suboccipital muscle insertions. Trapezius muscle: (back shoulder area) at midpoint of the upper border. Supraspinatus muscle: (shoulder blade area) above the medial border of the scapular spine. Lateral epicondyle: (elbow area) 2 cm distal to the lateral epicondyle. Gluteal: (rear end) at upper outer quadrant of the buttocks. Greater trochanter: (rear hip) posterior to the greater trochanteric prominence. Knee: (knee area) at the medial fat pad proximal to the joint line.

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34 Twice daily moist heat applications are also helpful in easing the deep muscle pain and stiffness. To benefit from moist heat, you can use a moist heating pad, warm shower, or a heat "cozy" that you warm in the microwave. With chronic fatigue syndrome, it's extremely important to manage your schedule and to control your level of stress. Be sure to block time each day to rest and relax. Avoid making too many commitments that can increase stress and fatigue. In addition, you can do relaxation exercises such as guided imagery, deep-breathing exercises, or the relaxation response to manage how you respond to stress. Staying on a regular bedtime routine is also important. Doing so allows your body to rest and repair itself. In addition, regular exercise is vital to managing fibromyalgia pain, depression, and other symptoms of fibromyalgia. A number of factors can make FMS symptoms worse. They include:

What Are the Symptoms of Fibromyalgia? Symptoms of FMS include:

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Chronic muscle pain, muscle spasms or tightness, and leg cramps Moderate or severe fatigue and decreased energy Insomnia or waking up feeling just as tired as when you went to sleep Stiffness upon waking or after staying in one position for too long Difficulty remembering, concentrating, and performing simple mental tasks Abdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome) Tension or migraine headaches Jaw and facial tenderness Sensitivity to one or more of the following: odors, noise, bright lights, medications, certain foods, and cold Feeling anxious or depressed Numbness or tingling in the face, arms, hands, legs, or feet Increase in urinary urgency or frequency (irritable bladder) Reduced tolerance for exercise and muscle pain after exercise A feeling of swelling (without actual swelling) in the hands and feet Painful menstrual periods Dizziness

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Anxiety Changes in weather -- for example, cold or humidity Depression Fatigue Hormonal fluctuations such as PMS or menopause Infections Lack of sleep or restless sleep Periods of emotional stress Physical exhaustion Sedentary lifestyle

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35 FMS symptoms may intensify depending on the time of day -- morning, late afternoon, and evening tend to be the worst times, while 11 a.m. to 3 p.m. tends to be the best time. They may also get worse with fatigue, tension, inactivity, changes in the weather, cold or drafty conditions, overexertion, hormonal fluctuations (such as just before your period or during menopause), stress, depression, or other emotional factors. If the condition is not diagnosed and treated early, symptoms can go on indefinitely, or they may disappear for months and then recur. What causes fibromyalgia?

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Diagnosis

Fibromyalgia is considered a controversial diagnosis, with some authors contending that the disorder is a non-disease, due in part to a lack of abnormalities on physical examination,

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Doctors don't know what causes fibromyalgia, but it most likely involves a variety of factors working together. These may include: Genetics. Because FMS tends to run in families, there may be certain genetic mutations that may make you more susceptible to developing the disorder. Infections. Some illnesses appear to trigger or aggravate FMS. Physical or emotional trauma. Post-traumatic stress disorder has been linked to FMS. Stress-induced pathophysiology Consequence of sleep disturbance Central dopamine dysfunction (hypodopaminergia) Deficient human growth hormone (HGH) secretion Other hypotheses-Other hypotheses have been proposed related to various toxins from the patient's environment, viral causes such as the Epstein-Barr Virus, an aberrant immune response to intestinal bacteria, and erosion of the protective chemical coating around sensory nerves. Still another hypothesis regarding the cause of fibromyalgia symptoms proposes that affected individuals suffer from vasomotor dysregulation resulting in sluggish or improper vascular flow.

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Other researchers believe fibromyalgia is caused by a lack of deep sleep. It is during stage 4 sleep that muscles recover from the prior day's activity, and the body refreshes itself. Sleep studies show that as people with FMS enter stage 4 sleep, they become more aroused and stay in a lighter form of sleep. Even though they may sleep for a long period of time, they get poor quality sleep. Also, patients with fibromyalgia have impaired non-Rapid-Eye-Movement, or nonREM, sleep phase (which likely explains the common feature of waking up fatigued and unrefreshed in these patients). The onset of FMS has been associated with psychological distress, trauma, and infection.

The exact cause is not known. Patients experience pain in response to stimuli that are normally not perceived as painful. Researchers have found elevated levels of a nerve chemical signal, called substance P, and nerve growth factor in the spinal fluid of fibromyalgia patients. The brain nerve chemical serotonin is also relatively low in patients with chronic fatigue syndrome. Studies of pain in fibromyalgia have suggested that the central nervous system (brain) may be somehow supersensitive. Scientists note that there seems to be a diffuse disturbance of pain perception in patients with FMS.

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36 objective laboratory tests or medical imaging studies to confirm the diagnosis. While historically considered either a musculoskeletal disease or neuropsychiatric condition, evidence from research conducted in the last three decades has revealed abnormalities within the central nervous system affecting brain regions that may be linked both to clinical symptoms and research phenomena. Although there is as yet no generally accepted cure for fibromyalgia, there are treatments that have been demonstrated by controlled clinical trials to be effective in managing fibromyalgia symptoms, including medications, patient education, exercise, and behavioral interventions. Diagnostic Criteria

A proper history and physical exam coupled with blood work and/or x-rays may be done to rule out:

Electrical nerve and muscle testing, known as electromyography (EMG) or nerve conduction velocity (NCV), may also be done to check the muscles and nerves. Discussion

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Although the pathophysiology of fibromyalgia is unknown it is a very real syndrome. Treatment may provide only partial symptomatic relief. True FMS is a chronic condition requiring long term effort in managing fibromyalgia that may include physical therapy, exercise, patient education and reassurance along with sleep-enhancing medications like low dose tricyclic antidepressants. Emergency physicians often see trigger points associated with simple self-limiting regional myofascial pain syndromes which appear to arise from muscles, muscle-tendon junctions, or tendon-bone junctions. Myofascial disease can result in severe pain, but typically in a limited distribution and without the systemic feature of fatigue. When symptoms recur or persist after

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Hormonal imbalance Anemia Infection Muscle disease Bone disease Nerve disease Joint disease Cancer Rheumatoid arthritis Hypothyroidism (including primary hypothyroidism, secondary hypothyroidism, Hashimotos thyroiditis, iodine deficiency goiter, and genetic thyroid enzyme defects). Thyroid-stimulating hormone levels should be checked routinely because this condition can mimic many of the symptoms of Chronic fatigue syndrome Polymyalgia rheumatica

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The difficulty with diagnosing FMS lies in the fact that, in most cases, laboratory testing appears normal and that many of the symptoms mimic those of other disorders. A definite diagnosis of fibromyalgia syndrome should only be made when no other medical disease can explain the symptoms. This is to say, FMS is a diagnosis of exclusion.

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37 the basic therapy above, or are accompanied by generalized complaints, refer the patient to a rheumatologist or primary care physician. When the quadratus lumborum muscle is involved there is often confusion as to whether or not the patient has a renal, abdominal, or pulmonary ailment. The reason for this is the muscle's proximity to the flank and abdomen as well as its attachment to the 12th rib, which when tender, can create pleuritic symptoms. A careful physical exam, with palpation, active contraction, and passive stretching of this muscle reproducing symptoms, can save this patient from a multitude of laboratory and x ray studies. Managing Fibromyalgia

In general, treatments for fibromyalgia include both medication and self-care. The emphasis is on minimizing symptoms and improving general health. Medications

Medications can help managing fibromyalgia pain and improve sleep. Common choices include:

Therapy

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Physical therapy. Specific exercises can help restore muscle balance and may reduce pain. Stretching techniques and the application of hot or cold also may help. Counseling. Cognitive behavioral therapy seeks to strengthen your belief in your abilities and teaches you methods for dealing with stressful situations. Therapy is provided through individual counseling, classes, and with tapes,and may help managing fibromyalgia. Trigger point injections with lidocaine. Acupuncture/acupressure. Relaxation/biofeedback techniques Osteopathic manipulation. Chiropractic care. Therapeutic massage.

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Analgesics. Acetaminophen (Tylenol, others) may ease the pain and stiffness caused by fibromyalgia. However, its effectiveness varies. Tramadol (Ultram) is a prescription pain reliever that may be taken with or without acetaminophen. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen sodium (Aleve, others) in conjunction with other medications. NSAIDs haven't proved to be as effective in managing fibromyalgia pain when taken by themselves. Antidepressants. Your doctor may prescribe amitriptyline to help promote sleep. Fluoxetine (Prozac) in combination with amitriptyline is effective in some people. Duloxetine (Cymbalta) may help ease the pain and fatigue associated with FMS. And milnacipran (Savella) was recently approved by the Food and Drug Administration for managing fibromyalgia symptoms. Anti-seizure drugs. Medications designed to treat epilepsy are often useful in reducing certain types of pain. Gabapentin (Neurontin) is sometimes helpful in reducing FMS symptoms, while pregabalin (Lyrica) is the first drug approved by the Food and Drug Administration for managing fibromyalgia.

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Gentle exercise program.

The most important therapy for muscle pain is regular, low-impact exercise. Keeping muscles conditioned and healthy by exercising three times a week decreases the amount of discomfort. It is important to try low-stress exercises such as walking, swimming, water aerobics, and biking rather than muscle-straining exercises such as weight training. Besides helping with tenderness, regular exercises can also boost energy levels and help with sleep. Other home-care techniques that can help managing fibromyalgia include these:

heat applied to sore muscles, stretching exercises (Pilates is one form of exercise that may be beneficial), and massage.

Exercising With Fibromyalgia

Exercise Can Help, it is crucial to get your muscles healthy which can offer some relief. Healthy muscles are flexible, which can increase your range of motion and the stronger you are, the more you can move around each day. Other benefits include:

Better sleep Reduced stress and depression Improved your energy levels More endurance Weight control

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Cardio is important, and so is strength training. But, before you do anything check with your doctor and get a referral to a physical therapist so you know exactly what to do. In general, strength training exercises for managing fibromyalgia can include: Pushups-Do them against a wall instead of on the floor Lifting weights-Use very light weights or even canned food for resistance Resistance Bands-Use a light resistance and take your time. Machines-Make sure you get instructions on how to use them and start with NO weight.

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Your first order of business is to start SLOWLY. Your goal should be to improve your health (so forget about weight loss for now). Even walking feels like a chore so you may only be able to exercise for minutes at a time. That's normal! Setting small goals (i.e., walk two minutes today and add a minute every day after) can help you slowly increase your exercise time. Other activities you might enjoy are: Swimming - This is a great way to condition your heart and body while getting full and gentle support from the water. No impact means your joints are protected. Yoga - Increase your flexibility and de-stress by learning how to relax and breathe. Take care to keep movements easy...some postures may be too difficult so talk to your instructor about modifications. Tai Chi - This 'moving meditation' helps you get back in touch with your body and stay active without impact or jarring movements.

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39 Condition your body slowly and only do as much as you can. Give yourself at least one day (preferably two) of rest before going back to weights. The hardest part of exercising with FM is the frustration--knowing that you used to be able to do more and now you can barely get out of bed. Try channeling that frustration into your workouts, reminding yourself that every time you move around you are improving. Taking control of your health can provide tremendous relief, not only physically but emotionally. PHYSIOTHERAPY FOR MANAGING FIBROMYALGIA

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According to the American Physical Therapy Association, physical therapists teach selfmanagement skills to people with all types of conditions. That includes people with fibromyalgia. Physical therapists can help managing fibromyalgia by relieving symptoms of pain and stiffness in everyday life. These health care professionals teach people with FMS how to build strength and improve their range of motion. They show them ways to get relief from deep muscle pain. And they can help in managing fibromyalgia by teaching people how to make sensible decisions about daily activities that will prevent painful flare-ups. Proper posture, which your physical therapist will help you with, allows efficient muscle function. That results in your being able to avoid undue fatigue and pain. In addition, the

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Numerous modalities, including electrotherapy (transcutaneous electrical nerve stimulation), cryotherapy, and therapeutic heat, can reduce pain. Teach patients how and when to use therapeutic modalities as part of their maintenance program. One investigator recommends muscle energy treatments, positional release methods, and massage as part of the rehabilitation program to decrease stiffness and pain. Some investigators have found that daily aerobic and flexibility exercises are an essential component of the rehabilitation program. Subsequent clinical trials have confirmed the benefits of aerobic exercise and muscle strengthening on mood and physical functioning. Patients should begin with gentle warm-up, flexibility exercises and progress to stretching all of the major muscle groups. Low-impact aerobic exercise is necessary at least 3 times weekly. Patients should always start at low levels of exercise and progress slowly. The goal is to exercise safely without increased pain. The patients' target exercise regimen is 4-5 times a week for at least 20-30 minutes each time; this may take the patient months to achieve. Some patients with fibromyalgia may never be able to achieve this level of exercise; encourage them to exercise at the highest level possible without worsening their symptoms. Some investigators believe that aquatic exercise may be the safest and gentlest aerobic conditioning exercise available for this group. Aquatic therapy enables aerobic conditioning and also flexibility, strengthening, and stretching exercise. Aquatic exercise is well tolerated and is especially helpful for some patients.

The goal of physical therapy is to maximize function and reduce impairment to limit disability in patients with musculoskeletal conditions. (1) Based on a British study, physical therapists most commonly use exercise, education about correct posture and functional activity, relaxation, and energy conservation and fatigue management. (2) For this review, physical therapy is defined as a treatment program that includes patient education and supervised exercise.

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40 therapist may use slow stretching exercises to help you improve muscle flexibility. Relaxation exercises that the therapist will show you will help you reduce muscle tension. While there is no known cure for fibromyalgia, physical therapy may help in managing fibromyalgia pain. It can also help reduce stiffness and fatigue. Physical therapists use a wide range of resources to support exercise. These resources range from deep tissue massage to ice and heat packs for hydrotherapy. With these tools, physical therapists can help people with FMS use their muscles, stretch for flexibility, and move their joints through range-of-motion exercises. The benefit of physical therapy is that it allows a person with fibromyalgia to work closely with a trained professional who can design a fibromyalgia-specific treatment program. The therapist documents your progress and gauges whether you're practicing good therapy habits, alignments, and movement patterns when doing "homework" or exercises at home. Hydrotherapy with moist heat or cold packs works by stimulating your body's own healing force. For instance, cold compresses reduce swelling by constricting blood vessels. That helps control minor internal bleeding. Conversely, warm, moist compresses on painful areas dilate blood vessels. That increases the flow of blood, oxygen and other nutrients and speeds the elimination of toxins. Thus hydrotherapy also helps in managing fibromyalgia.

vascular Necrosis of Femoral Head

A Patient's Guide to Avascular Necrosis of Femoral Head : Avascular Necrosis of femoral head can cause hip joint pain. It is defined as,death of the femoral head following partial or complete obliteration of its blood supply. Anatomy : Avascular necrosis of the hip occurs when blood flow to the top portion of the thigh bone (femur) is interrupted. The affected portion of the bone consists of the head (the ballshaped piece of bone that fits into the socket of the hip) and neck (the portion of the thighbone just below the head). When its deprived of blood, this part of the bone begins to die, breaking down and causing the cartilage on top of it to collapse. Classification of Avascular Necrosis of Femoral Head It can be classified into two types

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1.Primary or Idiopathic: in which no cause can be established. 2.Secondary: due to some underlying cause which may include alcohol abuse. radiation therapy. Gouchers disease. Gout. renal osteodystrophy.

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injectable steroid use. sickle cell anaemia. Caisson disease.

Primary disease is more common in men, between the age of 40 to 60 years. In up to 60% of cases both the hips may be involved.

There are many causes of AVN. Anything that damages the blood supply to the hip can cause AVN.

A clear link exists between AVN and alcoholism. Excessive alcohol intake somehow damages the blood vessels and leads to AVN. Deep sea divers and miners who work under great atmospheric pressures also are at risk for damage to the blood vessels. The pressure causes tiny bubbles to form in the blood stream which can block the blood vessels to the hip, damaging the blood supply.

Symptoms of Avascular Necrosis of femoral head Although avascular necrosis often affects both hips, you may feel pain in only one. Or you may feel groin pain that radiates down your thigh. At first, the pain will be slight. Then, as it becomes more intense, youll probably develop a limp and start to lose mobility. Next, hip pain at nightdevelops. Eventually, pain accompanies any movement or activity and joint motion becomes restricted. Diagnosis for Avascular Necrosis of femoral head The diagnosis of AVN begins with a history and physical examination. Your doctor will want to know about your occupation, what other medical problems you have, and your medication use. You'll be asked whether you drink alcohol. A physical examination will be done to determine how much stiffness you have in the hip and whether you have a limp. Once this is done, X-rays will most likely be ordered.

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Some medications are known to cause AVN. Cortisone is the most common drug known to lead to AVN. This is usually only a problem in patients who must take cortisone every day due to other diseases, such as advanced arthritis, or to prevent rejection of an organ transplant. Sometimes there is no choice, and cortisone has to be prescribed to treat a condition, knowing full well that AVN could occur. AVN has not been proven to be caused by short courses of treatment with cortisone, such as one or two injections into joints to treat arthritis or bursitis.

Injury to the hip itself can damage the blood vessels. Fractures of the femoral neck (the area connecting the ball of the hip joint) can damage the blood vessels. A dislocation of the hip out of the socket can tear the blood vessels. It usually takes several months for AVN to show up, and it can even become a problem up to two years following this type of injury.

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Causes for Avascular Necrosis of femoral head

42 X-rays will usually show AVN if it has been present for long enough. In the very early stages, it may not show up on X-rays even though you are having pain. In the advanced stages, the hip joint will be very arthritic, and it may be hard to tell whether the main problem is AVN or advanced osteoarthritis of the hip. Either way, the treatment is basically the same. Prognosis

This means that the dead bone in the head of femur becomes weak and breaks down. This causes the the hip joint to become incongruous. This causes osteoarthritis of the hip joint.

Although rest and exercise can sometimes heal the affected portion of bone, surgery is usually needed. In as many as 80% of patients with early disease, an operation called core decompression can spark regeneration of the bone. In this procedure, the surgeon drills out the damaged section of bone up to the head of the femur. This opens up channels for blood vessels to reach the diseased area and foster the production of new bone. Hip pain is relieved, and as many as 75% of patients avoid joint replacement later on. Early in the disease, osteotomy has been used to redistribute weight and prevent collapse and deformation of the femoral head. In patients with large areas of dead bone, however, osteotomy may hinder bone healing. In those patientsas well as for those with osteoarthritis or pain unrelieved by other treatmentstotal hip replacement is most often the treatment of choice.

Nonsurgical Physical Therapy Rehabilitation While physical therapy cannot cure avascular necrosis, in some cases it can help slow the progression of the disease and decrease the associated pain. A physical therapist can teach the correct way to use the appropriateassistive device (such as a cane or walker) to decrease weight bearing on the joint . They can provide proper exercises to help increase the strength of the muscles around the affect area (which will also decrease the weight on the joint). They may also use modalities such as electrical stimulation, ultrasound, joint mobilization, and heat to attempt to increase bloody supply to the area and help decrease pain. You may work with a physical therapist who will show you ways to safely move and stretch your hip. The goal is to keep your hip mobile and to avoid losing range of motion. Your therapist will also instruct you to use a walker orcrutches. Keeping weight off your hip while you are standing or walking may help the bone to heal while protecting the femur from further damage.

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Rehabilitation role in Avascular Necrosis of femoral head

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Treatment for Avascular Necrosis of femoral head

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Prognosis of avascular necrosis of femoral head is poor. Eventually almost all patients develop subchondral collapse, following which progression toosteoarthritis is inevitable.

43 After Surgery Physical Therapy Rehabilitation After a simple drilling operation, you will probably use crutches for six weeks or so. The drill holes weaken the bone around the hip, making it possible to fracture the hip. Using crutches allows the bone to heal safely and reduce the risk that you may fracture your hip. Patients who have had bone and blood vessels grafted are required to limit how much weight they place on the hip for up to six months. When you are safe in putting full weight through the leg, your doctor may have you work with a physical therapist to help regain hip range of motion and strength. Patients who require artificial hip joint replacement follow a structured program of physical therapy beginning shortly after surgery.

Spondylolisthesis

It is more commonly seen in females than males. The most probable cause is due to congenital abnormality in the development of the neural arch. The pain usually starts after an injury and the symptoms are rare before adolescence. Clinical features of Spondylolisthesis

Classification of slip

Slip in Spondylolisthesis is measured by measuring the anterior slip of vertebral body.Meyerding classified the slip into 4 grades:

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Fillard discovered a formula for calculation of the percentage of slipPercent slip= The displacement of L5 over S1/Width of S1

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Patient complains of low backache, which is worst after some activity and is relieved by rest. The pain may radiate down to one or both legs. A depression is seen above the 5th lumbar vertebra. There may be some associated neurological symptoms in the lower limb. There is exaggeration of lumbar lordosis. The movements of spine are grossly not limited.

Grade 1- slip from 0-25% upto 1/4 length Grade 2- slip from 25-50% upto 1/2 length Grade 3- slip from 50-75% upto 3/4 length Grade 4- slip more than 75%

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Spondylolisthesis is a condition in which the affected vertebra slips on the adjacent vertebra below it. It is very commonly seen at L5 and S1 vertebra level.

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44 Spondylolisthesis Treatment Treatment is given according to the grades of the slip. Grade 1 and 2 can be managed conservatively, while grade 3 and 4 require surgical intervention. Spondylolisthesis Treatment is given with the aim to achieve maximum correction of the exaggerated lordosis and then maintain the correction. Conservative Management usually comprises of Physical Therapy

1. Some heat modality like SWD(Short wave diatheramy) is given for pain relief. 2.Spondylolisthesis Exercises to correct the deformity

3.The patient is given guidelines for correction of posture and its maintenance. 4.Stretching of hamstrings is done at regular intervals. 5.Patient is adviced to lie prone to control the advancement of lordosis. 6.A thoraco-lumbar-sacral orthoses is given to prevent the lordosis. The brace has to be worn continuously. In spondylolisthesis surgery is indicated when there are neurological symptoms, slip is progressing or if the pain is very intense. Spinal fusion is done with or without the reduction of slip, postero-lateral fusion is very common. Spinal fusion prevents further progression of the slip. The spine may be internally stabilized with the help of rods and plates. Physiotherapy Management after Surgery During Immobilization

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During Mobilization

Gradual mobilization of spine is initiated. The patient is encouraged to perform functional activities and to perform all the activities of daily living.

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Deep breathing exercises Early ankle, foot and arm movements are also encouraged Assisted movements to knee joints are given Isometric exercises of gluteal muscles Gradually hip flexion is encouraged, but it should not exceed 60 degrees.

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Exercises to induce relaxation are given Strong abdominal exercises are given for abdominal muscles Flexion exercises for the spine, for example: sitting on a chair with back resting, then gradually bending the trunk forward from the lumbar region Active posterior tilting is tought to the patient to compensate the exaggerated lumbar lordosis.

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Kyphosis Treatment
Physical therapy is important for kyphosis treatment. It's especially useful for cases of postural kyphosis because a physical therapist can help correct posture and strengthen spinal muscles. However, physical therapy may also be recommended for patients with structural kyphosis, including Scheuermann's kyphosis and kyphosis caused by spinal fractures. Kyphosis Kyphosis is an abnormal posterior curve, usually found in the thoracic region of the spine. As such, it is an exaggeration of the normal posterior curve. If used without any modifying word, it refers to a thoracic kyphosis. In the low back, there is, occasionally, a lumbar kyphosis which is a reversal of the normal anterior curve. Since kyphosis is natural in the spine, we have to identify what excessive kyphosis is, which is generally the problem. Generally speaking, a normal for a thoracic kyphotic curve measures between 30 to 35. In excessive kyphosis would be greater than 35. Rounded Back or Increased Kyphosis : This posture is characterized by an increased thoracic curve, protracted scapulae (round shoulders), and usually an accompanying forward head. Potential Sources Of Pain

Stress on posterior longitudinal ligament. Fatigue of the thoracic erector spinae and scapular retractor muscles. Thoracic outlet syndrome Cervical posture syndromes

Potential Muscle Impairments

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Faulty upper quadrant posture leads to an imbalance in the length and strength of the scapular and glenohumeral musculature and decreases the effectiveness of the dynamic and passive stabilizing structures of the Glenohumeral(GH) joint. Typically with increased thoracic kyphosis, the scapula is protracted and tipped forward, and the GH jointis in an internally rotated posture. With this posture, the pectoralis minor, levator scapulae, and the shoulder internal rotators are tight, and the lateral rotators of the shoulder and upwards rotators of the scapula test weak and have poor muscular endurance. There is no longer the stabilizing tension on the supirior joint capsule and the coracohumeral ligament or compressive forces from the rotator cuff muscles. Therefore, the effect of gracity tends to cause an inferior force on the humerus.

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Decreased flexibility in the muscles of the anterior thorax (intercostal muscles), muscles of the upper extremity originating on the thorax (pectoralis major and minor, latissmus dorsi, and serratus anterior), muscles of the cervical spine and head attached to the scapula (levator scapulae and upper trapezius), and muscles of the cervical region. Stretched and weak thoracic erector spinae and scapular retractor muscles (rhomboids and middle trapezius).

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46 Common Causes of Kyphosis are

Classifications of Kyphosis

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Kyphosis can be manifest as part of the clinical picture of a number of generalized conditions. Children with high-level myelodysplasia generally develop lumbar kyphosis due to the absence of posterior structures. Two of the more malevolent mucopolysaccaridoses, Hunter and Hurler syndromes, may present with kyphosis in infancy. Thoracolumbar kyphosis also commonly affects infants with achondroplasia. Fortunately, most resolve with walking. Other unusual causes include Gaucher's disease, juvenile osteoporosis, and pseudoachondroplasia. Kyphosis in conditions accompanied by ligamentous laxity such as Ehlers Danlos syndrome andMarfan syndrome commonly affect the thoracolumbar or lumbar spine. Lumbar or thoracolumbar kyphosis is difficult to treat as junctional kyphosis above or below the instrumented portion of the spine often occurs unless excellent sagittal plane alignment is achieved. Kyphosis accompanyingneurofibromatosis often is accompanied by severe rotatory deformity and can be very difficult to treat. Cervical kyphosis can be a part of diastrophic dysplasia or Larsen's syndrome . In parts of the world, where tuberculosis is prevalent, screening of children for kyphosis can aid earlier diagnosis.As children with cystic fibrosis live longer into adult life, kyphosis accompanying this condition is more often being reported. For conditions such as juvenile osteoporosis or Maroteaux-Lamy syndrome, in which the kyphosis is flexible and radiographically corrects when the patient is placed supine over a bolster, bracing can be effective. Scheuermann's Kyphosis A thoracic kyphosis of more than 40

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Postural Scheuermann's Congenital Neuromuscular Myelomeningocele Traumatic Post-surgical Post-irradiation Metabolic Skeletal dysplasias Collagen disease Tumor Inflammatory

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Postural-It is usually seen in tall individuals. Bad posture in school or mental and physical tension can also lead to faulty posture. If due to some reason, there is exaggeration of lumbar lordosis then there is compensatory kyphosis in the thoracic spine. Kyphosis may result due to Scheurmann's disease which is the osteochondritis of the vertebral bodies. Ankylosing spondylitis is another major cause of kyphosis. It produces a stiff kyphotic spine. In adolescent age group, it may be due to arthritis or rheumatism.

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Three or more adjacent vertebra that are wedged 5 Characterized by schmorls nodes, irregular endplates, and a narrowing of verterbral disc space. Increased veterbral anterior/posterior diameter at the apex

Clinical Findings

According to the severity and the extent of disease, there are three degrees:

1-First degree 2-Second degree 3-Third degree

Kyphosis Treatment

Early diagnosis help prevent the progression of the severity. Treatment is given according to the degree of deformity. Its important to realize, however, that correction of kyphotic posture takes time. It involves exercises, stretches, mobilizations, as well as continual postural correction. First Degree Kyphosis Treatment

It is usually due to poor posture. Postural Kyphosis Treatment include certain physical therapy exercises to strengthen the patient's paravertebral muscles. Further, the patient must make a conscious effort to work toward correcting and maintaining proper posture.

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Kyphosis Treatment-Stretches:-

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Whole relaxation of the body is done. Using mirror, the patient is made aware of his poor posture and proper instructions are given accordingly to correct the posture. Mobilizing exercises are given for whole spine. Strengthening exercises are given for abdominal muscles and back extensors. There may be associated tightening in hamstring muscles. Hencestretching of hamstring is done. Breathing exercises especially diaphragmatic and lateral costal breathing are taught to the patient. Gluteal and abdominal contractions are also very useful.

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An adult presenting with low back pain or a teenager with poor posture with or without pain Physical examination usually reveals a sharp, rigid kyphosis Kyphosis is increased with flexion and incompletely corrected with extension Lumber hyperlordosis, increased pelvic tilt and associated hamstring tightness Sagittal plumb line should cross C7-T1, T12-L1, and posterior sacrum normally Normal thoracic kyphosis : 30-40, mean = 34 Normal lumbar lordosis : 55-65(two-thirds of lordosis at L4-L5 and L5-S1) Lumbar lordosis should be about 30greater than thoracic kyphosis 30% have associated mild scoliosis.

48 While it is essential to strengthen the muscles that are causing the slouching of the thoracic spine to occur, it is also important to stretch the muscles that are holding the postural dysfunction in place. Two muscles that can significantly contribute to excess thoracic flexion include the abdominals, as well as the diaphragm. Abdominal stretching: Stretching your abs can help tremendously in reducing thoracic kyphosis, because at the same time you stretch them, you are mobilizing your spine. One of the best ways to stretch your abs is by laying over a swiss ball. Its important to make sure you relax as you do this stretch, and breath naturally, as this will serve to improve the release you get. Foam rolling the thoracic spine: This technique involves laying over a foam roll, for the purpose of mobilizing your spine. Basically this means stretching it backwards over the roll. This technique can be quite tender on your spine at first, particularly at those spinal segments that are not moving very well, but can improve quickly over about 2 weeks with consistent work on the roller. Second and third Degree Kyphosis Treatment

Physical Therapy in Scheuermann's Kyphosis Treatment

Physical therapy is often used at the same time as bracing. Because the brace supports so much of the spine, some believe that wearing the brace can weaken the muscles. Physical Therapy help avoid this. Otherwise, when the brace comes off, the muscles may not be able to support the spine very well, and the spine may still curve too much. The physical therapist also help with flexibility and range of motion. Many patients with Scheuermann's kyphosis also have very tight hamstring muscles. Physical therapy can help alleviate those tight muscles. Physical Therapy in Kyphosis Treatment Caused by Spinal Fractures Physical therapy won't correct the kyphotic curve caused by spinal fractures, but to prevent more fractures, it may be useful to learn good (or better) posture. A physical therapist can also help strengthen spinal muscles so that spine is better supportedtaking some of the weight and pressure off vertebrae. A physical therapist can also help with safe exercises. Exercise is important to bone health, so a PT can develop an exercise plan that may involveweight-bearing exercises (such as walking or tennis) and strengthening exercises (such as weight lifting). Surgical Procedure for Structural Kyphosis Treatment The surgical procedure for structural kyphosis treatment involves halo traction for several weeks. In some cases, bone graft may be required to maintain the correction. Sometimes spinal decompression and stabilization may also be required.Spinal Instrumentation and Fusion are surgical procedures that may be used to correct spinal deformity and to provide permanent

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The Deformity is in advanced stage. Hence to correct it brace is given to the patient. Along with bracing, exercises also play role in improving mobility of the spine.

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49 stability to the spinal column. These procedures join and solidify the level where a spinal element has been damaged or removed (e.g., intervertebral disc). Instrumentation uses medically designed hardware such as rods, bars, wires, and screws. These devices hold the spine straight during fusion. Post Surgical Physiotherapy

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, an acid and alcohol fast bacillus. It is one of the most serious, disabling disease which attacks nerve and skin. Leprosy which is also calledHansens Disease is the commonest cause of peripheral neuritis and about 20 million of the population is affected by it. Mode of spread

The leprosy disease is common in tropical countries like Asia, Far East, Tropical Africa, Central and South America and in some Pacific Islands. The disease is still endemic in Southern Europe, North Africa and the middle East. Infectivity

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It is not absolutely sure how leprosy spreads from one person to another. We know that it is much less infectious than small-pox and many other diseases. Some people have such high resistance that they do not get infected by leprosy disease, no matter how closely they are in contact with any infectious person. Great majority of leprosy patients cannot infect other people. Even the few infectious patients are no longer infected if they have been taking adequate treatment for 3-6 months, though they do need to continue drug treatment for a very long time. This fact shows that leprosy is not dangerous as most of the people think. It is a chronic infectious disease of only man and attacks mainly nerves and skin. It is diagnosed and treated with drugs and it can be controlled with little precautions, which reduce physical

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The most important mode of spread of Mycobacterium leprae is by dropletsfrom the sneeze of leprosy patients, whose nasal mucosa is heavily infected. It is not certain whether the organism enters by inhalation or through the skin. The incubation period is between 2-5 years.

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Leprosy Disease

Physical therapy is added post-operatively enabling the patient to build strength, flexibility, and increase range of motion. The patient continues physical therapy on an outpatient basis for a period of time. Additionally, the therapist provides the patient with a customized home exercise program for kyphosis treatment.

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Proper chest physiotherapy is given to avoid complications Movements to lower limb and neck should be given twice daily to the patients who are on the tractions. Gradual mobilizing and strengthening exercises for the spine are given.

50 damage or disability from occuring. Leprosy disease may cause great emotional distress to the patient and their families, and it may seiously affect the social life of the patient. Types of Leprosy Disease All types of leprosy are caused by mycobacterium leprae. The amount of patient's resistance determines whether he/she can get leprosy at all and if he can, then which type he will get. The three main types of leprosy are:

Tuberculoid Borderline Lepromatous

However, when treating neuritis it is necessary to divide borderline leprosy into 3 types making five types in all. These five types are:

According to the type and difference in resistance the skin sign changes. In tuberculoid, cases have good resistance. Borderline cases have only fair resistance and lepromatous cases have little or no resistance. Damage to hand and feet can occur in all three types, if the mycobacterium leprae damages nerve trunk. Symptoms of Leprosy Disease Because the bacteria that cause leprosy multiply very slowly, symptoms usually do not begin until at least 1 year after people have been infected. On average, symptoms appear 5 to 7 years after infection. Once symptoms begin, they progress slowly. Leprosy disease affects mainly the skin and peripheral nerves Characteristic rashes and bumps develop. Infection of the nerves makes the skin numb or the muscles weak in areas controlled by the infected nerves.

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Tuberculoid leprosy: A rash appears, consisting of one or a few flat, whitish areas. Areas affected by this rash are numb because the bacteria damage the underlying nerves. Lepromatous leprosy: Many small bumps or larger raised rashes of variable size and shape appear on the skin. There are more areas of numbness than in tuberculoid leprosy, and certain muscle groups may be weak. Much of the skin and many areas of the body, including the kidneys, nose, and testes, may be affected. Borderline leprosy: Features of both tuberculoid and lepromatous leprosy are present. Without treatment, borderline leprosy may become less severe and more like the tuberculoid form, or it may worsen and become more like the lepromatous form.

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Tuberculoid Leprosy(TL) Borderline Tuberculoid(BT) Borderline Borderline(BB) Borderline Lepromatous(BL) Lepromatous Leprosy(LL)

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51 The most severe symptoms result from infection of the peripheral nerves, which causes deterioration of the sense of touch and a corresponding inability to feel pain and temperature. People with peripheral nerve damage may unknowingly burn, cut, or otherwise harm themselves. Repeated damage may eventually lead to loss of fingers and toes. Also, damage to peripheral nerves may cause muscle weakness that can result in deformities. For example, the fingers may be weakened, causing them to curve inward (like a claw). Muscles may become too weak to flex the foota condition calledfootdrop. Infected nerves may enlarge so that during a physical examination, doctors can feel them. Skin infection can lead to areas of swelling and lumps, which can be particularly disfiguring on the face. Other areas of the body may be affected by Leprosy Disease:

During the course of untreated or even treated leprosy disease, the immune system may produce inflammatory reactions. These reactions can cause fever and inflammation of the skin, peripheral nerves, and, less commonly, the lymph nodes, joints, testes, kidneys, liver, and eyes. The skin around bumps may swell and become red and painful, and the bumps may form open sores. People may have a fever and swollen lymph glands.

Symptoms (such as distinctive rashes that do not disappear, enlarged nerves, loss of the sense of touch, and deformities that result from muscle weakness) provide strong clues to the diagnosis of leprosy. Examination of a sample of infected skin tissue under a microscope (biopsy) confirms the diagnosis. Because leprosy bacteria do not grow in the laboratory, culture of tissue samples is not useful. Blood tests to measure antibodies to the bacteria have limited usefulness because antibodies are not always present. Leprosy Treatment

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The good news is that leprosy is curable. In 1981, the WHO recommended the use of a combination of three antibiotics -- usually dapsone, rifampin, and clofazimine -- for treatment, which takes six months to a year or more. Certain cases may be treated with two antibiotics, but rifampin is a key component of either regimen. Since 1995, the WHO has provided these drugs free of charge to all leprosy patients worldwide.

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Diagnosis of Leprosy Disease

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Feet: Sores may also develop on the soles of the feet, making walking painful. Nose: Damage to the nasal passages can result in a chronically stuffy nose and nosebleeds and, if untreated, complete erosion of the nose. Eyes: Damage to the eyes may lead to glaucoma or blindness. Sexual function: Men with lepromatous leprosy disease may have erectile dysfunction (impotence) and become infertile. The infection can reduce the amount of testosterone and sperm produced by the testes. Kidneys: The kidneys may malfunction. In severe cases, kidney failure may occur.

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52 During the course of treatment, the body may react to the dead bacteria with pain and swelling in the skin and nerves. This is treated with pain medication, prednisone or thalidomide (under special conditions). Because some leprosy bacteria are resistant to certain antibiotics, doctors prescribe more than one drug. The drugs chosen depend on the type of leprosy:

Because the bacteria are difficult to eradicate, antibiotics must be continued for a long time. Depending on the severity of the infection and the doctor's judgment, treatment continues from 6 months to many years. Some doctors recommend lifelong treatment with dapsone for people with lepromatous leprosy. Goals of Physical Therapy for Non-Surgical patients Of Leprosy Disease the major aim is to prevent or reduce complication, deformity and disability in body through Physical Therapy. Means

The ways of reaching these Goals are

Teachings

Treating and Helping

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By teaching the patient. By treating and helping the patient.

What the disease of leprosy is? The possible complications and deformities resulting from leprosy. prevention of complication, deformities and disabilities.

To respect themselves enough to take medication regularly and to take care of complications. To protect their own anaesthetic hands, feets and eyes. To keep their skin soft and supple. To keep their joint flexible. To preserve all posible movements of hands and feet. To keep their muscles strong. To use their hands, feet and eyes safely, in daily work.

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Multibacillary: The standard combination of drugs is dapsone, rifampin and clofazimine. People take rifampin and clofazimine once a month under a health care practitioner's supervision. They take dapsone plus clofazimine once a day on their own. This regimen is continued for 12 to 24 months, depending on the severity of the disease. Paucibacillary: People take rifampin once a month with supervision and dapsone once a day without supervision for 6 months. People who have only a single affected skin area are given a single dose of rifampin, ofloxacin, and minocycline.

53 Goals of Physical Therapy for Surgical patients Of Leprosy Disease

To protect and prevent further damage and deformity. To improve and restore function. To improve appearance of hands, feet, face and eyes.

Surgical Techniques used in Leprosy Disease

Physical Therapy Goals:

Physical Therapy Technique:

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To increase and regain range of motion. Improve muscle strength perticularly in muscles to be transferred. Clean supple skin in areas of surgery. Teach home self care. Protect tissue during wearing. Prevent/reduce swelling. Muscle re-education after tendon transfer. Safe use of any new restored skill in work.

For increasing/regaining ROM: ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected. To improve strength specially in tendon transfer: Active exercise in all part in which surgery is performed. Clean supple skin: It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection. Home care: teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care. Protect tissue during healing: Rest, body position and POP cast. Prevent/Reduce swelling: Elevation, active and passive exercise. Muscle Re-education after tendon transfer: Teaching new restored skills in movements provided by tendon transfer. Self restored skills in daily work: Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection.

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Tendon Transfer: Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements. Tendon Lengthening: Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening. Capsulotomy: To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture. Arthrodesis: Elimination of unstable and deformed joints. Tenodesis: Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.

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Ankylosing Spondylitis (AS)

Ankylosing Spondylitis (AS) is a sero negative, progressive chronic inflammatory disease. Over 90% of patients are HLA-B27 positive. It starts with back pain and a general feeling of ill health which eventually leads to stiffening and inability to bend the spine. In worst cases, the spine becomes like a solid rod of bone between the skull, neck and pelvis hence named as POKER'S BACK. Over 90% of patients possess HLA-B27 (Human Leucocyte Antigen). AS results in bony ankylosis beginning with ossification of ligaments and tendons of the spine, particularly at junctions with bones. ossification usually starts at the dorso lumbar region or sacro iliac joint. Around the joint there is loss of cortex and erosions with consequent widening of joint space. Later in the disease process, there is sclerosis and finally ankylosis. Etiology

The exact cause of Ankylosing Spondylitis (AS) is unknown but there are two factors which are thought to be the cause of this condition.

Epidemiology

Prevalence varies in different races, in white population it is between 1-10 patients per 1000 persons. The age of onset is commonly in 18-30 but can start at any age. males are more commonly affected than females, usually the ratio is 3:1. The first degree relatives of the patient of AS have more chances to develop this condition. Pathology

The pathology of AS include the following processSynovitis Initially, the inflammation of the synovium occur, which may be identical histologically to that in rheumatoid arthritis(RA). Mostly commonly the synovitis starts, firstly from the sacroiliac joints followed by the other region of the spine. Enthesopathy This term refers to an inflammatory reaction at the enthesiswhich is the zone of ligamentous attachment to the bone, and this is the characteristic feature of AS that occurs commonly in the spine and near the pelvis. Capsular Inflammation Cartilage Destruction and Bony Erosion This occur due to synovitis and the inflammation of the ligament and the capsules. The cartilage of the joint gets destroyed, and becomes rough and the bony erosion occurs.

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Genetic Factors. Environmental factors.

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55 Ossification All the above factors lead to the formation of new bones at these areas, and bridging takes place between the vertebral bodies, usually from the edge of one body to that of the next, along the outer layer of the disc. This typical phenomenon is known as the marginal syndesmophyte formation. Ossification also occurs in the anterior and posterior longitudinal ligament and also in other ligaments of the spine. Ankylosis All the features of the above and most important the ossification part, results into fusion of all the vertebrae of the spine, and this condition is called bamboo spine. The formation of the syndesmophytes starts usually from the dorso-lumbar region. After bony fusion the pain may subside, leaving the spine permanently stiff. Ankylosing Spondylitis Symptoms The severity of symptoms can vary from mild to very severe. Common symptoms may include:

Less common symptoms may include:

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Associated Conditions Iritis. Aortic regurgitation- Heart disease conduction defects. Apical pulmonary fibrosis. Inflammatory bowel disease. Myelopathy secondary to atlanto-axial subluxation.

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Stiffening and pain (arthritis) of the: Lower back Sacroiliac joint, possibly radiating down the legs Pain that is often worse at night Stiffness that is worse in the morning Symptom improvement with exercise or activity Occasionally, pain and stiffness in other joints: Knee Upper back Rib cage Neck Shoulders Feet Chest pain, which may suggest heart, heart valve (aortic insufficiency), or lung involvement Eye pain, visual changes, increased tearing which may suggest eye involvement (uveitis)

Fatigue Loss of appetite or weight loss Fever Numbness (if arthritic spurs compress the spinal nerves)

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56 Complications of Ankylosing Spondylitis

Ankylosing Spondylitis Diagnosis and Investigation

HLA-B27 test This is positive in about 95% of patients.

Haemoglobin Normochromic or normocytic anaemia may occur but in contrast to RA, patients with active disease often have a normal haemoglobin and blood film. Synovial Fluid Contains a moderate number of mononuclear leucocytes in contrast to the increased polymorphonuclear leucocyte count of RA fluid.

Pulmonary Function Tests In patients with thoracic involvement usually show diminished vital and total lung capacity, increased residual volume and functional residual volume. Flow measurements are usually normal. Nuclear scans Technitium stannous pyrophosphate bone scans, can often detect areas of active inflammation in AS, before standard changes are present. Radiological Study

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a)Sacro-iliac joint:

The features of different sites are:

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Rheumatoid Factor Rheumatoid factors are absent.

Sclerosis of the ilium and sacrum on either side of the joint. Hazziness of the joint margins which later on show erosions. Narrowing of joint space which may progress to fusion. When ankylosis is complete, the periarticular sclerosis fades. Sometimes leaving the evidence of the previous joint line, known asGhost joint.

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Erythrocyte Sedimentation Rate The sedimentation rate is generally raised in proportion to the inflammatory activity in about 70% of patients.

Early diagnosis is important in order to start on the Ankylosing Spondylitis treatment program. Making an accurate diagnosis for ankylosing spondylitis can be difficult, however, due to the fact that the symptoms of ankylosing spondylitis are so similar to other, more common back problems and the symptoms and signs occur slowly over a period of years.

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Neurological involvement/cauda equina syndrome. Spinal fracture. Spinal cord compression. Amyloidosis. Painful heel or achilles tendinitis. Romanus lesions. Reduced chest expansion and vital capacity. Possibility of chest infection.

57 b)Spine: Spinal changes include

In Advance Disease

Most patients who maintain disciplined exercise, posture programme and take anti-inflammatory medications i.e proper Ankylosing Spondylitis treatment plan are able to lead relatively normal and active life with minor adjustments in life style. Less than 10% develop crippling disease. Ankylosing Spondylitis Treatment

There is no specific therapy or cure for AS. The aim of Ankylosing Spondylitis Treatment are:1. To control pain.2. Maintain maximum skeletal mobility.3. Prevent deformity. Ankylosing Spondylitis Treatment include:

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Drugs used in Ankylosing Spondylitis Treatment

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Drug Therapy . Surgical Management. Physiotherapy Management.

The course of AS varies. Symptoms may be persistant or intermittent over the years or we can say that the disease is present throughout the life but does not shorten the life of the patient. AS shows a wide range of severity. In some individuals, the disease is mild and although it may show periods of exacerbation with increased pain and stiffness, there is little permanent limitation of the spine. At the other end, the disease may progress or may be uncontrolled, causing marked and permanent spinal rigidity. Since patients with spinal pain tend to flex the back and neck, and ankylosis occurs in this position producing variable degrees of a fixed 'C' shaped deformity. Hip involvement is prognostically important, because it adds to the difficulty in mobility and further impairs functions.

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Ankylosing Spondylitis Prognosis

The characteristic bamboo spine results from syndesmophyte or paraspinal ligament calcification around the normal disc space. Spondylodiscitis may develop in the lower thoracic and upper lumbar segments. Erosive changes in the anterior vertebral bodies adjacent to the disc, which become progressively destroyed and causes angulation of the spine. The appearance may resemble infection or trauma but is probably part of the spondylitic process.

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Squarring of the vertebral bodies i.e loss of normal anterior concavity on the lateral view. Syndesmophyte formation usually first seen at the thoraco-lumbar level. Arthritic changes and later apophysial joint fusion occurs which is best seen in cervical spine. Atlanto-axial subluxation. Calcification of the paraspinal ligaments. The romanus sign, is the erosion surrounded by sclerosis at the vertebral body margin.

58 Nonsteroidal anti-inflammatory drugs (NSAIDs), like naproxen (Naprosyn) or indomethacin (Indocin) are used to relieve pain and stiffness. In severe cases, sulfasalazine (Azulfidine), another drug to reduce inflammation, or methotrexate (Rheumatrex), an immune-suppressing drug, is recommended. In cases where chronic therapy is needed, potential drug side effects must be taken into consideration. Corticosteroid drugs are effective in relieving symptoms, but are usually reserved for severe cases that do not improve when NSAIDs are used. To avoid potential side effects, treatment with corticosteroids is usually limited to a short amount of time with a gradual weaning from the drug. Corticosteroid therapy or medications to suppress the immune system may be prescribed to control various symptoms. Some health care professionals use cytotoxic drugs (drugs that block cell growth) in people who do not respond well to corticosteroids or who are dependent on high doses of corticosteroids. Drugs called TNF-inhibitors have been shown to improve the symptoms of ankylosing spondylitis.

Surgery may be performed if pain or joint damage is severe.

Surgery plays a very small part in the management of this condition. About 6% of people with AS need to have a hip replaced. This will successfully restore mobility and eliminate pain of the damaged joint. In rare cases surgery is used to restore a straighter posture of the spine and neck to people who have become severely stooped. Physiotherapy Management in Ankylosing Spondylitis Treatment The physiotherapy management consists of the physical examination or assessment of the patient and the physiotherapy methods used for Ankylosing Spondylitis Treatment. A) PHYSICAL EXAMINATION:

i) Sacroiliac Joint: There are certain simple tests, which may be positive if the SI joint is affected.

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SI joint tenderness and paraspinal muscle spasm. Lateral compression of the pelvis with the examiner's hand will elicit pain. Gaenslen sign- Instruct the patient to lie supine on the edge of the examining table with knee flexed and with one buttock over the edge. Ask the patient to drop the unsupported leg off the table, this procedure will elicit pain in the contralateral SI joint by stretching it. SLR test (straight leg raising test)- The patient is in supine lying position and then asked to lift the leg upwards with his knee extended. By this, pain is felt on the affected side at the SI joint. Pump Handle Test- The patient is in supine lying and then, do the flexion of the hip and knee and then give some extra pressure as to touch the knee to the opposite side of the shoulder. By this procedure, the pain is felt on affected side.

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Surgery as a Ankylosing Spondylitis Treatment

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59 ii) Spine: Loss of spinal motion can be detected quite early in most cases. As mentioned before early diagnosis is important in order to start on the Ankylosing Spondylitis treatment program. cervical spine

iv) Lung Function Test: Early involvement of the costo-vertebral joints in the disease process makes careful spirometry and measurement of chest cage movement essential. Less than 5cm of chest expansion during inspiration in an adult is considered to be reduced. v) Measurement of Postural Deformity: In this, loss of secondary spinal curve occurs, first the lumbar lordosis is lost and then the cervical lordosis and increase of thoracic curve develops. So the patients spine become rounded. It is advisable to make objective measurement of these. In physiotherapy department using spondylometer helps in measurement of postural deformity. B) PHYSIOTHERAPY TREATMENT:

Regular physiotherapy is very essential in the management of a patient of AS and only physiotherapist is the person who can help the patient to fight with the disease. AIMS OF PHYSIOTHERAPY MANAGEMENT IN ANKYLOSING SPONDYLITIS TREATMENT:

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General instruction to patients:Make the exercise part of your daily routine. Try to do a complete set of exercises at least twice daily at a time convenient to you.

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Relieve pain. Maintain the mobility of joints affected like spine, hip, thorax, shoulder etc. Prevent and correct deformity. Increase chest expansion and vital capacity. Attention to posture. To maintain and improve physical endurance. Advice to patient.

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iii) Examination of peripheral joint movements: All the joints are measured for active and passive range of motion, done with the help of goniometer. Commonly involved joints are temporomandibular , hip, knee and shoulder.

The cervical spine also become stiff and flexion deformity develops. The measurement is done by goniometry. Tragus to wall test- For the flexion deformity, measurement can be made from the wall behind and the tragus of the ear. Fleche Test- This test detects an early involvement of the cervical spine. Ask the patient to stand on the heel and back touched on the wall and then ask the patient to touch his back of the head to the wall and at the same time the chin is not moved upward. If the patient can't do this, shows the involvement of the cervical spine. Thoraco-lumbar flexion extension. Lumbar or spinal forward flexion (Schobere test). Lateral spinal flexion. Combined hip and spinal flexion.

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Heat and cold application amy precede exercises to enhance relaxation and decrease pain. Perform only those exercises given to you by your physiotherapist. Perform exercises on a firm surface. Exercise slowly with a smooth motion, do not rush. Avoid holding your breath while exercising. Modify the exercise regime during an acute attack and contact your physical therapist if you have any complaints or problems with the exercises.

Pain Relief:-

Pain and muscle spasm are treated by the following modalities and the relaxation is advised-

Maintaining the mobility of joints, by giving mobility exercises to particular joints, which are affected like, spine, hip, shoulder, thoracic cage are essential in Ankylosing Spondylitis Treatment. Maintenance of the mobility is very important and the basic aim is that all the joints are moved to their maximum limit and by this, we can delay the process of ankylosis. Hydrotherapy:-

Prevent and correct deformity by giving attention to posture:

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Hydrotherapy, in real sense refers to the therapeutic use of water. The therapeutic effects of water in relation to Ankylosing Spondylitis TreatmentThe relief of pain and muscle spasm. The maintenance or increase in range of motion of joints. The strengthening of weak muscles and an increase in their tolerances to exercise. The importance of circulation. The encouragement of functional activities. The maintenance and improvement of balance, co-ordination and posture.

The spondylitic patient should always be conscious of his posture while sitting, standing and walking patient should maintain the erect posture during these activities. This helps to prevent and correct deformity and thus help in Ankylosing Spondylitis Treatment. Sleeping should occur in prone position or supine on a firm mattress with a thin or no pillow by this, the spine remain in extended position and not in flexion. The design of chairs is important particularly for those who spend most of their working hours sitting at desk. Low arm chair should be avoided, an upright chair with some cushioning to support the lower lumber spine is better. Adjust the height of the working table and ensure that the patient does not stoop on that.

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Exercises for mobilization of joints:-

Infra red. Hot packs. Cryotherapy. Steam bath. Hydrotherapy.

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Avoidance of prolonged immobilisation or bed rest, because of this, the spinal extensors become weak and by this the extended position of the spine is not retained.

Increase chest expansion and vital capacity:To increase the chest expansion and vital capacity, the breathing exercises are required. Breathing exercises that are used in Ankylosing Spondylitis Treatment:

Apical breathing exercises. Diaphragmatic breathing exercises. Lateral costal breathing exercises.

Improvement of physical endurance in Ankylosing Spondylitis Treatment:-

Endurance is a quality which develops in response to repetitive contraction. Endurance is improved by working muscles against light resistance and high repetition i.e for longer time. Group Therapy Classes:-

The group therapy classes means that number of patients of the same disease are collected under one roof and physiotherapist can give treatment simultaneously to all the patients. The advantages of group therapy classes in Ankylosing Spondylitis Treatment:

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The patient can give support to the other member of the class that is another patient. Shared problems providing a good medium for patient's education and latest information about the disease process. Development of competitiveness and motivational aspects. Improvement in physical fitness.

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Deep breathing exercises are encouraged. Ballooning exercise is also very useful in Ankylosing Spondylitis Treatment. They increase the vital capacity of the lung. Thoracic mobility exercises.

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osteoarthritis
what is osteoarthritis ?

Patients with osteoarthritis often ask, how can exercise help me? Wont exercise make my arthritis knee pain worse? Studies for instance, have shown that strengthening the quadriceps muscles can reduce arthritis knee pain and disability. One study shows that a relatively small increase in strength (20-25 percent) can lead to a 20-30 percent decrease in the chance of developing knee osteoarthritis. Diagnosis

Usually other imaging techniques are not necessary to clinically diagnose osteoarthritis. Osteoarthritis Treatment Lifestyle modification (such as weight loss and exercise), physical therapyand analgesics are the mainstay of treatment. Acetaminophen / paracetamol is used first line and NSAIDS are only recommended as add on therapy if pain relief is not sufficient.

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Diagnosis is made with reasonable certainty based on history and clinical examination. X-rays may confirm the diagnosis. The typical changes seen on X-ray include: joint space narrowing subchondral cyst formation subchondral sclerosis (increased bony formation around the joint) osteophytes Plain films may not correlate with the findings on physical examination or with the degree of pain

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Osteoarthritis is a common cause of pain and disability in the aging population. Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causeshereditary, developmental, metabolic, and mechanical may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax. Treatment generally involves a combination of exercise, lifestyle modification and analgesics. If pain becomes debilitating joint replacement surgery may be used to improve the quality of life. OA is the most common form of arthritis.

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63 Goal of Osteoarthritis Exercises Main aim of Osteoarthritis Exercises are to reduce pain, improve function, and prevent disability, all with the ultimate goal of improving quality of life. There are many ways that these goals can be achieved through exercise programs, as discussed below.

Osteoarthritis Exercises There are mainly three kinds:

Osteoarthritis Exercises Plan

How Often Should You Exercise?

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Range-of-motion Osteoarthritis Exercises There are several types of knee therapy exercises to help increase the range of motion of the knee joint and begin to re-strengthen the muscles that support the knee. The facilitated heel slides range of motion exercises are the movements described here.In people with osteoarthritis, improving flexibility has an even greater benefit than simply providing a warm up before exercise. There are a few different types of stretching exercises; static, ballistic and something calledproprioceptive neuromuscular facilitation (PNF). Strengthening exercises Strengthening exercises can be classified into three categories: isometric, isokinetic, and isotonic exercises.

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Discuss the osteoarthritis exercises plan with your health care provider. Start under supervision of a physical therapist or a qualified athletic trainer. Apply heat to sore joints before you begin exercising. Begin exercising with stretching, flexibility and range of motion exercises. start strengthening exercises slowly with small light weights or resistance band. Increase the difficulty of your exercise routine slowly. apply cold packs to sore joints and muscles after osteoarthritis exercises. ease off exercise programme and talk to your health care provider if your joints get painful, inflammed or red.

Range-of-motion: Either daily or every alternate day. Strengthening exercises: Every alternate day. Endurance exercises: For 20 to 30 minutes three times a week.

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Range-of-motion: To maintain normal joint movement and relieve stiffness. These make the joints flexible. Strengthening exercises: To increase the strength of muscles that support the joints affected by arthritis. Aerobic or endurance exercises: They improve cardiovascular fitness, control weight and improve overall body function.

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Muscle Strengthening Improving Flexibility and Joint Motion Improve Aerobic Functioning Weight Loss

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Some examples of exercises specifically for the legs good for those with osteoarthritis of the knee and or hips.

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Quad sets: while in a seated position, with legs fully extended in front of you, make a muscle with your thighs trying to push the back of your knee down towards the floor. Hold for 10 seconds, relax and then repeat. Wall slide: place your back up against the wall with your hips and knees bent to a 90 degree angle as if you were sitting in a chair. Hold this position for 10 seconds, then come up and relax. Repeat. Isotonic Quad exercise: sitting in a chair with your feet planted flat on the floor, raise your right leg straight out in front of you. Relax and bring back to the floor. Repeat on the left. As you are able to you can add ankle weights to increase resistance. Isometric Hamstrings while lying on the floor place heels on surface such as a couch or an exercise ball. Press down using the backs of your thighs and hold contraction for 10 seconds. Relax and then repeat. Isotonic Hamstrings lying on your belly with a pillow under your abdomen to support your back, bend your knee and bring your foot back towards your buttock. Bring back down to the floor repeat on the other side. Isometric Glutes Lying down on a flat surface back flat on the floor, bend your knees so that your feet are flat on the floor. Raise your buttocks up off the ground contracting your butt muscles together. Hold for 10 seconds then relax. Calf muscles Strenthening Using a wall or chair for balance, go up on your toes using your calf muscles hold yourself. Contract for 10 seconds, relax and repeat.

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Isometric exercises are those in which you are strengthening your muscles by contracting them and not moving them through their normal range which might be painful if you have arthritis. An example of this is simply contracting your leg muscles, without moving your joints. Isometric exercises are often the best type of exercise to begin with in a strengthening program, particularly in patients who can not tolerate repetitive joint motion. A problem with isometric exercises is that they tend to raise the blood pressure more than others. Isotonic exercises are those in which you contract your muscle throughout the full range of motion, again using constant weight or resistance, such as performing a biceps curl while holding a dumbbell. Lastly, isokinetic exercises involve constant speed of motion throughout the joint range during muscle contraction, while the amount of resistance may vary throughout the range. Isokinetic exercises are infrequently used, due to equipment requirements and uncertain correlation to functional activities. When beginning resistance training, it is good to start with just a single set of up to 15 repetitions, done 2 days a week. It should incorporate exercises that target major muscle groups such as quadriceps, hamstrings, and gluteal muscles. One possible goal is to complete 2 sets of 10 repetitions before resistance is increased. For people who have restrictions in their ability to execute full range of motion, it is better to use lighter and easier weights with additional repetitions. For patients in which putting the joint through repetitive range of motion aggravates their pain, it is best to start with isometric exercises. A word of caution in patients with a history of heart problems; isometric exercises may not be the best type of strengthening for you and, therefore, it is best to discuss this with your doctor before implementing such an osteoarthritis exercises plan.

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Spondylosis often affects the lumbar spine in people over the age of 40. Pain and morning stiffness are common complaints. Usually multiple levels are involved (eg, more than one vertebrae). The lumbar spine carries most of the body's weight. Therefore, when degenerative forces compromise its structural integrity, symptoms including pain may accompany activity. Movement stimulates pain fibers in the annulus fibrosus and facet joints. Sitting for prolonged periods of time may cause pain and other symptoms due to pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending (eg, manual labor) may increase pain. Spondylosis Definition

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SPONDYLO is a Greek word meaning vertebra. Spondylosis generally mean changes in the vertebral joint characterized by increasing degeneration of the intervertebral disc with subsequent changes in the bones and soft tissues. Disc degeneration, spinal canal stenosis, spondylolisthesis are the resultant pathological changes. Lumbar spondylosis encompasses lumbar disk bulges, herniations, facet joint degeneration, and vertebral bony overgrowths (osteophytes). Degenerative changes, including osteophyte formation, increase with age but are often asymptomatic. Disk herniation is symptomatic when it

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Lumbar Spondylosis is a condition associated with degenerative changes in the intervertebral discs and facet joints. Spondylosis, also known as spinal osteoarthritis, can affect the lumbar, thoracic, and/or the cervical regions of the spine. Although aging is the primary cause, the location and rate of degeneration is individual. As the lumbar discs and associated ligaments undergo aging, the disc spaces frequently narrow. Thickening of the ligaments that surround the disc and those that surround the facet joints develops. These ligamentous thickening may eventually become calcified. Compromise of the spinal canal or of the openings through which the spinal nerves leave the spinal canal can occur.

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Lumbar Spondylosis

Endurance and flexibility exercises: Aerobic exercise strives to improvecardiovascular function through activities that will increase your heart rate. Traditionally, this can be achieved via activities such as walking, jogging, biking, swimming and rowing, when these are done for an appropriate amount of time. With any aerobic activity, one must remember to consider proper breathing techniques, adequate hydration and nutrition, and prior cardiovascular status. Factors such as frequency of activity, duration of exercise, intensity can all be tailored to your personal needs and abilities. On the whole, it is recommended that for benefits of aerobic exercise to be achieved, that you should aim to have 30 minutes of moderate activity most days of the week. Within that 30 minute time interval, there should be a warm up, a workout and a cool down. In people who are sedentary, the first goal should be to minimize time spent sitting throughout the day. Exercise in water, like swimming or water aerobics, relieves weight on stiff or sore joints. The ability to move freely in water can also be a liberating experience, improving your psychological outlook. Walking or using a stationary bike or elliptical trainer helps promote weight loss. The less weight you carry, the less stress there is to your joints.

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66 causes nerve root compression and spinal stenosis. Common symptoms include low back pain, sciatica, and restriction in back movement. Treatment is usually conservative, although surgery is indicated for spinal cord compression or intractable pain. Relapse is common, with patients experiencing episodic back pain. What Causes Lumbar Spondylosis?

Pathology

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The degenerative effects of aging can cause the fibers of the discs to weaken, causing wear and tear. Constant wear and tear and injury to the joints of the vertebrae causes inflammation in the joints. Degeneration of the discs leads to the formation of mineral deposits within the discs. The water content of the center of the disc decreases with age and as a result the discs become hard, stiff, and decreased in size. This, in turn, results in strain on all the surrounding joints and tissues, causing the sensation of stiffness. With less water in the center of the discs, they have decreased shock absorbing qualities. An increased risk of disc herniation also results, which is when the disc abnormally protrudes from its normal position. Each vertebral body contains four joints that act as hinges. These hinges are known as facet joints or zygapophyseal joints. The job of the facet joins is to allow the spinal column to flex, extend, and rotate. The bones of the facet joints are covered with cartilage (a type of flexible tissue) known as end plates. The job of the end plates is to attach the disks to the vertebrae and to supply nutrients to the disc. When the facet joints degenerate, the size of the end plates can decrease and stiffen. Movement can stimulate pain fibers in the facet joints and annulus fibrosus. Furthermore, the vertebral bone underneath the end plates can become thick and hard.

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Age: As a person ages the healing ability of the body decreases and developing arthritis at that time can make the disease progress much faster. Persons over 40 years of age are more prone to developing lumbar spondylosis. Obesity: Overweight puts excess load on the joints as the lumbar region carries most of the bodys weight, making a person prone to lumbar spondylosis. Sitting for prolonged periods: Sitting in one position for prolonged time which puts pressure on the lumbar vertebrae. Prior injury: Trauma makes a person more susceptible to developing lumbar spondylosis. Heredity or Family history

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Risk factors for developing lumbar spondylosis

One of the structures that form the disks is known as the annulus fibrosus. The annulus fibrosus is made up of the 60 or more tough circular bands of collagen fiber (called lamellae). Collagen is a type of inelastic fiber. Collagen fibers, along with water and proteoglycans (types of large molecules made of a protein and at least one carbohydrate chain) help to form the soft, gel-like center part of each disk. This soft, center part is known as the nucleus pulposus and is surrounded by the annulus fibrosus.

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Spondylosis is mainly caused by aging. As people age, certain biological and chemical changes cause tissues throughout the body to degenerate. In the spine, the vertebrae (spinal bones) and intervertebral disks degenerate with aging. the intervertebral disks are cushion like structures that act as shock absorbers between the vertebral bones.

67 Degenerative disease can cause ligaments to lose their strength. A ligament is a tough band of tissue that attaches to joint bones. In the spine, ligaments connect spinal structures such as vertebrae and prevent them from moving too much. In degenerative spondylosis, one of the main ligaments (known as the ligamentum flavum) can thicken or buckle, making it weaken. Knobby, abnormal bone growths (known as bone spurs or osteophytes) can form in the vertebrae. These changes can also cause osteoarthritis. Osteoarthritis is a disease of the joints that is made worse by stress. In more severe cases, these bones spurs can compress nerves coming out of the spinal cord and/or decreased blood supply to the vertebrae. Areas of the body supplied by these nerves may become painful or develop loss of sensation and function. Symptoms of lumbar spondylosis

Physical Examination

A thorough physical examination reveals much about the patient's health and general fitness. The physical part of the exam includes a review of the patient's medical and family history. Often laboratory tests such as complete blood count and urinalysis are ordered. The physical exam may include:

X-rays and Other Tests

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Radiographs (X-rays) may indicate loss of vertebral disc height and the presence of osteophytes, but is not as useful as a CT Scan or MRI. A CT Scan may help reveal bony changes sometimes associated with spondylosis. An MRI is a sensitive imaging tool capable of revealing disc, ligament, and nerve abnormalities. Discography seeks to reproduce the patient's symptoms to identify the anatomical source of pain. Facet blocks work in a similar manner. Both are considered controversial.

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Palpation (exam by touch) determines spinal abnormalities, areas of tenderness, and muscle spasm. Range of Motion measures the degree to which a patient can perform movement of flexion, extension, lateral bending, and spinal rotation. A neurologic evaluation assesses the patient's symptoms including pain, numbness, paresthesias (e.g. tingling), extremity sensation and motor function, muscle spasm, weakness, and bowel/bladder changes. Particular attention may be given to the extremities. Either a CT Scan or MRI study may be required if there is evidence of neurologic dysfunction.

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Symptoms of lumbar spondylosis follow those associated with each of the various aspects of the disorder: disc herniation, sciatica, spinal stenosis, degenerative spondylolisthesis, and degenerative scoliosis. Pain associated with disc degeneration may be felt locally in the back or at a distance away. This is called referred pain, as the pain is not felt at its site of origin. Lower back arthritis may be felt as pain in the buttock, hips, groin, and thighs. As with spinal stenosis or disc herniation in the lumbar region, it is important to be aware of any bowel or bladder incontinence, or numbness in the perianal area. These signs and symptoms could represent an important massive nerve compression needing surgical intervention (cauda equina syndrome).

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68 The physician compares the patient's symptoms to the findings to formulate a diagnosis and treatment plan. The results from the examination provide a baseline from which the physician can monitor and measure the patient's progress. Treatment of lumbar spondylosis Each patient is treated differently for arthritis depending on their individual condition. In the early stages lifestyle modifications or medicines are used for treatment and surgery is needed only if these measures are ineffective.

Uploaded by malton1. Some of the ways of Treating Lumbar Spondylosis are:

In more severe cases surgical methods are advised to improve pain and increase motion. Physical Therapy Management in Lumbar Spondylosis Goals

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Management of acute symptoms

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Relief of pain . Restoration of movements. Strengthening of muscles. Education of posture. Analysis of precipitating factors to reduce recurrence of the patient's problems.

Rest and Support- With acute joint symptoms, a lumbar corset may be helpful to provide rest to inflamed facet joints. When acute symptoms decrease, discontinue corset by gradually increasing the time without the corset. Often the most comfortable position is flexion, esp. if there are neurologic signs due to decrease in the foraminal space from joint swelling or osteophytes. Education of posture- Head, neck and shoulders should be supported by the back rest of chair with a small pillow in the lumbar spine, the feet supported and the arm resting on arm rests or on a pillow in the lap.

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Modifying lifestyle including occupational changes if doing manual labor, losing weight and quitting smoking. Physical therapy which teaches the patient to strengthen the paravertebral and abdominal muscles which lend support to the spine. General exercises which help build flexibility, increase range of motion and strength. A corset or a brace could be used to provide support; cervical collars may be used to alleviate pain by restricting movement. Rest combined with anti-inflammatory medications, muscle relaxants andanalgesics. More powerful anti-inflammatory drugs like corticosteroids can also be injected into the joints to help control pain. Hot or cold packs on the affected area, ultrasound and electric stimulation are some of the other treatments which are used.

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Management of subacute and chronic phase

Scoliosis Exercises Program

It is not surprising, therefore , that the usefulness of exercises in case of scoliosis has been questioned. For many years, the attitude has been that scoliosis exercises are of little or no value. The idea is not new. The following is a statement made years ago by Risser:"It was customary at the scoliosis clinic at ...Orthopedic Hospital, as late as 1920-1930, to send new patients with scoliosis to the gymnasium for exercises. Invaribly the patients who were 12 to 13 years of age showed an increase of the scoliosis...it was therefore assumed that exercises and spinal motion made the curve increase". Except in some isolated cases, program of scoliosis exercises for patients continued to be looked upon with scepticism. In the American Academy of Orthopedic Surgeons 1985 Lecture series, this statement appears:"Physical Therapy cannot prevent a progressive deformity, and there are those who believe specific spinal exercises programs work in a counterproductive fashion by making the spine more flexible than it ordinarily would be and by so doing making it more susceptible to progression". Overemphasis on flexibility was wrong. Adequate musculoskeletal evaluation has been lacking, and as a result there has been little scientific basis upon which to justify the selection of

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Throughout the years, elaborate programs of exercise have been instituted in response to the treatment needs of the scoliosis patients. The creeping scoliosis exercises advocated by Klapp were discarded when problems with children's knees forced the discontinuance of such a program. Exercises that overemphasized flexibility created problems by making the spine more vulnerable to collapse. When treating patients with S-curves, one must avoid exercises that adversely affect one of the curves, while attempting to correct the other.

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Scoliosis Exercises

Increase ROM- Free active exercises of lumbar spine. Pelvic tilting forward, backward in crook lying, quadriped, sitting and standing. Mobilization- Restoration of intersegmental mobility by accessory pressure enables the patient to regain full functional painfree movement. stretching exercises. Strengthening exercises. Posture correction.

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Modalities- Hot or cold packs on the affected area, ultrasound and electric stimulation are some of the other treatments which are used to decrease pain and reduce muscle spasm. Relaxation- by soft tissue techniques. Teach self relaxation techniques,e.g like deep breathing exercises and physiological relaxation (Laura Mitchell method) and hydrotherapy. Traction- Gentle intermittent joint distraction and gliding techniques may inhibit painful muscle responses and provide synovial fluid movement within the joint for healing. Gentle ROM within the limits of pain-.

70 therapeutic scoliosis exercises. Scoliosis is a problem of asymmetry. To restore symmetry requires the use of asymmetrical scoliosis exercises along with appropriate support. Stretching of tight muscles is desirable, but overall flexibility of the spine is not. It is better to have stiffness in the best attainable position than to have too much flexibility of the back. Dysfunctions associated to scoliosis

Scoliosis Exercise General Guideline

Scoliosis exercises should be carefully selected on the basis of examination findings. There must be adequate instruction to ensure that scoliosis exercises will be performed with precision. The object is to use asymmetrical exercises to bring about optical symmetry. Regarding the thoracic curve correction, the subject reaches in a diagonally upward direction, slightly forward from the coronal plane, sitting tall with spine in as good anteroposterior alignment as possible. The aim is to practise holding the corrected position in order to develop a new kinesthetic sense of what is straight. The faulty position has become so customary that the straight position feels abnormal. The person who monitors this exercise should stand behind the subject as the exercise is being performed to be sure that both curves are being corrected at the same time . In a right thoracic, left lumbar scoliosis, there is often weakness of the posterolateral part of the right External oblique muscle, and shortness of the upper anterior part of the left External oblique. In the supine position, the subject places the right hand on the right lateral chest wall, and the left hand on the left side of the pelvis. Keeping the hands in position, the object of the exercise is to bring the two hands closer by contracting the abdominal muscles, without flexing the trunk. It is as if the upper part of the body shifts towards the left, and the pelvis shifts towards the right. By not allowing trunk flexion, and contracting the posterior lateral fibers of the External oblique, there will be tendency toward some counter-clockwise rotation of the thorax in the direction of correcting the thoracic rotation that accompanies a right thoracic curve. Perform vice-versa for left thoracic, right lumbar scoliosis. All too often, early cases of lateral curvature are "treated" merely by observation and x-rays at specified specified intervals. Early tendencies toward a lateral curvature are potentially more serious than the anteroposterior deviations seen in the usual faulty postures. Instruction in good body mechanics and appropriate scoliosis exercises, plus the necessary shoe alteration to

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Insufficient awareness of his/her own posture which makes children less involved in the treatment process. Myofascial limitations which make three-plane corrective movements of scoliosis corrections difficult. Incorrect feet loading. Disturbed stabilization of lower trunk. Increased myofascial tension between the thoracolumbar scoliosis apex and the iliac crest which limits the spine shift of the scoliosis correction. Limited mobility of 3-4 ribs on the side of the scoliosis concavity, disturbed mechanism of thorax movements during breathing (breathing with convexities). Incorrect posture patterns caused by the long-lasting scoliogenic stimulation.

71 mechanically assist in correction of allignment constitutes more rational treatment than mere observation. Correction of lateral pelvic tilt associated with a lateral curvature can be helped by proper heel lifts. Cooperation by the subject is of utmost importance. The lifts can be used in all shoes and bedroom slippers. But no amount of lift can help if the subject continue to stand with weight predominantly on the leg with the higher hip and with knee flexed on the side of the lift. If tightness develops in the Tensor fasciae latae and Iliotibial band on one side, the pelvis will be tilted down on that side. If there is Gluteus medius weakness on one side, the pelvis will ride higher on the side of the weakness. The habit of standing with weight mainly on one leg and the pelvis swayed sideways weakens the abductors, especially the Gluteus medius on that side. If tightness of the Tensor fasciae latae on one side and weakness of the Gluteus medius on the other is mild, treatment may be as simple as breaking the habit and standing evenly on both legs. If the imbalance is more marked, treatment may involve stretching of the tight Tensor fasciae latae and Iliotibial band and use of a lift on the low side. The lift will help stretch the tight Tensor and relive strain on the opposite Gluteus medius. Along with the use of appropriate Scoliosis exercises, it is important to avoid those exercises that would have an adverse effect. There is an inherent danger in increasing overall flexibility of the spine. Gains in flexibility in the direction of correcting the curves are indicated, provided that strength is also increased in order to maintain the corrections. If the subject has the potential for gaining in strength, and is dedicated to a strict program of strengthening exercises and the wearing of a support, scoliosis exercises that increase flexibility can have a desirable end result. A subject who is developing a kyphoscoliosis along with a lordosis should not do back extension exercises from a prone position. In an effort to obtain better extension in the upper back, the low back problem increases. Extension of the upper back may be done sitting on a stool with the back against a wall, but the low back must not arch in an effort to make it appear that the upper back is straight. In the same instance, "upper" abdominal exercises by the trunk curl or sit-up should be avoided even if upper abdominals are weak. The exercises will be counter productive because curling the trunk is rounding the upper back. If there is a developing kyphoscoliosis, such an exercise would increase the kyphotic curve. Scoliosis Exercises of the lower abdominals, in the form of pelvic tilt, or pelvic tilt and leg sliding, emphasizing the action by the External oblique, would however, be strongly indicated. The significance of muscle imbalance and overall faulty posture as etiological factors in idiopathic scoliosis should not be overlooked. Scoliosis is a complex postural problem. As such, it calls for thorough evaluation procedures to determine the existence of weakness or tightness of muscles that results in distortion of alignment. Support

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In addition to scoliosis exercises and proper shoe corrections, many early scoliosis patients need some support. It may be that only a corset type of support is needed or, as in more advanced cases, a more rigid support. There are two main types of braces. Braces can be custom-made or can be made from a prefabricated mold. All must be selected for the specific curve problem and fitted to each

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72 patient. To have their intended effect (to keep a curve from getting worse), braces must be worn every day for the full number of hours prescribed by the doctor until the child stops growing.

Milwaukee brace Patients can wear this brace to correct any curve in the spine. This brace has a neck ring. Thoracolumbosacral orthosis (TLSO) Patients can wear this brace to correct curves whose apex is at or below the eighth thoracic vertebra. The TLSO is an underarm brace, which means that it fits under the arm and around the rib cage, lower back, and hips. Today, there are newer materials that provide greater versatility and ease of handling, but the basic principles for use of supports remain with little change: Obtain the best possible allignment; allow for expansion in the area of concavity; apply pressure in the area of convexity to the extent tolerated without adverse effects or discomfort. Importance of Early Intervention

Instead of waiting to see if a curve gets worse before deciding to do something about it, why not treat the problem to help prevent the curve getting worse?

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It may mean taking a picture of the child's back in the usual sitting or standing position and taking another in a corrected position so the child can see the effect that the scoliosis exercise has on the posture. It also means providing incentives that help keep the person intrested and cooperative because achieving correction is an ongoing project. For those in whom the curve has become more advanced, it is necessary and advisable, in many instances, to provide some kind of a support in order to help maintain the improvement in alignment that has been gained through an scoliosis exercise program. Scoliosis exercises patterns of adults and children vary widely. A series of safe and effective abdominal exercises that strengthen the back and improve posture are leg and arm extensions, back extension, triceps raise, bent-over raise, standing raise, upright row and one-arm row. When a scoliosis curve is progressive and severe, therapeutic scoliosis exercises are not a substitute for surgery. SCOLIOSIS EXERCISES FOR PATIENTS WEARING THE MILWAUKEE BRACE Scoliosis Exercises 1 through 5 are held to the count of five and done ten times once daily. Exercises 6 and 8 are to be done many times a day. 1. Pelvic tilt backlying with the knees bent.Lie down on your back with knees bent. Keep the shoulders flat on the floor and breathe regularly. Tighten the buttocks. Force the lumbar spine towards the bars by tightening and pushing backward with the abdominal muscles.

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Doing something in the very early stages of treating a lateral curve does not mean getting involved in a vigerous, active program of exercises, but, rather, prescribing a few carefully selected scoliosis exercises that help to establish a kinesthetic sense of good alignment. It means providing goodinstruction to the patient and the parents in how to avoid habitual positions or activities that clearly are conducive to increasing the curvature.

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73 2. Pelvic tilt supine with the knees straight. Lie down on your back with knees straight. Repeat the same procedure mentioned above. 3. Spine extension in the facelying position.Lie flat on the stomach, with arms on the side. Tilt the pelvis, pull away from the front of the girdle. Raise the head, arms and shoulders about 6 inches against resistance between the shoulder blades.

5. Filling out the Thoracic Valley. Lie on your side with a small pillow under the thoracic pad. The top arm and leg should be straight, lower arm and leg bent. Tilt the pelvis. Breathe in while pushing chest back toward the posterior uprights.

7. Active correction of the Thoracic Lordosis and Rib Hump. Tilt the pelvis in the standing position. Inhale deeply, spread the ribs and press the chest wall backward toward theposterior uprights. 8. Active correction of the curves.Tilt the pelvis. Keep the pelvis tilted and shift away from the Thoracic Pad. Same with the Lumbar Pad. Now, tilt pelvis shift away from both pads and stretch up tall out of the brace. SCOLIOSIS EXERCISES TO BE DONE OUT OF THE MILWAUKEE BRACE Exercises are to be held for the count of 5 and done 10 times once or twice daily. 1. Pelvic tilt backlying with the knees bent.Keep the shoulders flat on floor, but breathe regularly. Tighten the buttocks. Force the small fo the back into the floor by tightening and pushing backward the abdominal muscles. Try to Crush the Therapists hand under the back. 2. Pelvic tilt with the knees straight.Lie down flat on the back with knees straight repeat the same procedure. 3. Sit up with pelvic tilt.With the knees bent, tilt the pelvis and hold the tilt. With the elbows straight, roll up to touch the knees with fingers. Roll back down slowly, then release the tilt. 4. Deep breathing exercises.Divide the chest into three parts; abdomen, lower ribcage and upper ribcage. Inhale deeply and then exhale completely in each part. Later, when you can do this well, combine all three into one deep breath. 5. Hamstring stretch.Sitting with legs out in front of you, touch your toes. As you progress, try to touch your head to your knees. 6. Back stretch. Sitting Indian style, touch head to floor in front of you.

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6. Pelvic tilt standing.In standing position relax the knees, tilt the pelvis by pulling in the abdomen and tucking the hips under. Walk, holding the tilt. Make this posture a habit.

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4. Pushup with the pelvis tilted.

74 8. Back strengthening.Sit Indian style with back as flat as possible to the wall. Hold a ball overhead and raise straight up. Be sure to keep your elbows to the wall. 7. Rotational stretch.Sitting Indian style with hands behind head, rotate as far as possible from side to side trying to touch your elbow to the opposite knee. 9. Spine extension in the prone (facelying) position. Tilt the pelvis, make a Tunnel under your abdomen. Arms at your sides, palm down. Pinch shoulder blades together and raise head and shoulders and arms about 6 inches from the floor against resistance. 10. Pushup with pelvis tilted.Be sure you are a straight line from knees to shoulders.

12. Side stretch standing.Standing with one arm overhead and one arm at side, bend to the side opposite the raised arm. 13. Side stretch sitting on heels.Sit on heels, forehead near floor, arms outstretched. Stretch out your arms and slowly bend your trunk to one side. Repeat to other side. ADDITIONAL TRUNK STRENGTHENING SCOLIOSIS EXERCISES 1. Bicycle.Lie down flat on the floor, with the legs off the floor. Now try mimic pedaling a bicycle. 2. Abdominal strengthening.With knees bent, back flat to table, rotate knees side to side.

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3. Back strengthening.Sitting on your heels, hands behind your back, keep tummy on your thighs. Lift head and shoulders. 4. Back strengthening.Sitting in a chair, lean forward with tummy on your knees, hands behind your head. Raise head and shoulders only. 5. Back strengthening.With waist at edge of table, raise trunk and arms in straight line to table. 6.Hitch ExerciseFor lumbar curve or thoracolumbar curve, another option is hitch exercise. Patients are instructed to lift their heel on the convex side of their curve while keeping their hip and knee straight, and to hold the hitched position for 10 seconds. In the hitch position, pelvis on the convex side is lifted, lateral tilt at the inferior end vertebra is reduced or reversed, and the curve is corrected. Yoga exercises are very useful in providing relief from scoliosis. They restore the normal shape, function and mobility of the spine. The most effective yoga exercises include passive back arch, crocodile twist, supine knee chest twist, and other trunk and pelvic

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11. Pelvic tilt in the standing position.With the head, shoulders and back against the wall and the heels 3 inches from the wall, stand tall. Relax the knees, tiltthe pelvis. Walk away holding the tilt. Make this posture a habit. Learn to do this correction without the wall; pull in tummy and tuck hips under.

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75 exercises. These exercises are quite helpful in raising one's lowered shoulder and decreasing back pain.

For first two days

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For third and fourth day

After fifth day

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Cervical Rib refers to an abnormal protrussion in the cervical region which can either be due to abnormal enlargement of the transverse process of C7vertebra or a small rib or fibrous band running from the 7th cervical vertebra to the first true rib or to the sternum but usually it is present posteriorly upto a short distance. It is usually diagnosed in middle age group persons though is present since birth. The cause is that by middle age, the shoulders start drooping which causes the cervical rib to get depressed

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Appropriate techniques for rolling, sitting and standing are taught to the patient. The patient is encouraged to do all the above activities without giving much pressure over the spine. The patient is to be made ambulatory as soon as possible. Hence first balancing is taught to the patient. As soon as the patient is able to balance himself, he is given gait training with the help of parallel bars, crutch or cane.

CERVICAL RIB SYNDROMES

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Full range passive movements are given to hip and knee joint in addition to activities of first two days. Active movement must also be initiated within the limit of pain.

Deep breathing exercises are given to the patient to increase the vital capacity. VIbration with assisted coughing. Early toe, ankle and upper arm movements within the limit of pain must be initiated as early as possible. Change the position of the patient every 2 hours.

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Scoliosis Physical therapy (Post Operative)

76 and hence compressing the nerve root of the concerned region. This rib is usually asymptomatic but it may give rise to neurological symptoms if it exerts pressure on the subclavian artery or the brachial plexus like

paraesthesia of hand hypothenar wasting atonia in the muscles of the shoulder girdle.

Clinical Features Local Symptoms

There is often a tender supraclavicular lump which is bony hard and is fixed when palpated. Sensory Symptoms (a) Tingling in hands or fingers; confined either to radial side or ulnar side or sometimes involve even whole hand. (b) Pain may sometimes radiate downwards from the arm. Motor Symptoms

(a) Loss of gripping power of the hand.

(b) Tendency of dropping things from the hand. (c) Wasting of palmar muscles; either thenar or hypothenar or interossei muscles.<br.< p=""></br.<> Vascular Symptoms (a) Cold and clumpsy extremities, particularly the fingers. (b) Skin colour changes to blue associated with trophic changes.

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A cervical rib is a supernumerary (extra) rib which arises from the seventh cervical vertebra. It is a congenital abnormality located above the normal first rib. A cervical rib is present in only about 1 in 200 (0.5%) of people; in even rarer cases, an individual may have not one but two cervical ribs. The presence of a cervical rib can cause a form of thoracic outlet syndromedue to compression of the brachial plexus or subclavian artery. Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand, near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson's sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.

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77 (c) There is rare risk of gengrene. (d) Radial pulse becomes feeble or may even be absent. Diagnosis 1- Mainly by X-ray to detect presence of Cervical ribs , which could be easily palpated. 2-Adson's Test

Foraminal Compression Test/Spurling's Test

Spurling's test is an orthopedic test used to diagnose nerve root compression primarily at the cervical level. It should not be used in instances in which vertebral instability is suspected. Shoulder Abduction Test

Differential Diagnosis

The differential diagnosis for Cervical Ribs is quite broad and includes neurologic, vascular, pulmonary, cardiac, and esophageal disorders. 1)Some of the more common conditions include herniated cervical disk, cervical spondylosis, and peripheral neuropathies. 2) Peripheral vascular disease like Raynaud's disease. 3) Neurological conditions-like syringomyelia, polio, muscular dystrophy, motor neuron disease. Medical treatment

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Surgical treatment

Anti-inflammatory drugs and analgesics are provided as a conservative means of treatment.

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Shoulder Abduction Test is an orthopedic test used to help diagnose a cervical nerve root injury or cervical disc herniation. It is performed by having the patient abduct their shoulder and place their hand on top of their head. A positive test will involve a decrease in radiculopathy or pain.

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Indications- Evaluation of Cervical Ribs/Thoracic Outlet Syndrome. Technique- Patient breathes deeply,Neck extended,Chin turned toward affected side.The examiner lifts the arm away to the side to 90 degrees and performs external rotation of the shoulder, and notes whether the radial pulse disappears. However there are many false positives, as the radial pulse may disappear in normal people as the head of the humerus (upper arm bone) compresses the brachial vessels when the arm is taken beyond 90 degrees. Repeat test with chin to opposite side. Interpretation- Positive test finding ( Decreased Radial Pulse and/or Distal extremity pain reproduced ) suggests interscalene compression.

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78 surgery is essential in conditions of severe, progressive vascular and neurological signs and symptoms which are unbearable for the patients. It includes: (a) Removal of extra segment. (b) Dividing the scalene group of muscles. Physiotherapy treatment

Genu Valgum is also known as knock knee. In the valgum deformity, the knees are tilted toward the midline i.e Legs curve inwardly so that the knees are closer together than normal. It can result from injury or septic destruction of the lateral half of the lower femoral epiphyseal plate, results in arrested growth of the lateral condyle of the femur. The continued growth of the medial condyle results in unilateral knock knees.The typical gait pattern is circumduction, requiring that the individual swing each leg outward while walking in order to take a step without striking the planted limb with the moving limb. Not only are the mechanics of gait compromised but also, with significant angular deformity, anterior and medial knee pain are common. These symptoms reflect the pathologic strain on the knee and its patellofemoral extensor mechanism. Bilateral Valgum deformity can result from condition which softens bone tissue. It may be due to

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Rickets Osteomalacia Rheumatoid Arthritis Muscular paralysis of semimembranosus or semitendinosus Fracture

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Genu Valgum

For pain relief- Heat modalities are used like short wave diathermy but it should not be applied in case of sensory impairments. To improve distal circulation- Exercises of hand and finger should be started. TO improve tone, power and endurance- Strengthening exercises of whole arm perticularly small muscles of the arm. Correction of posture by postural guidance- In this, patient is taught to use postural mirror to see that his shoulders are in level, head is straight, looking forward. Planning specific exercises- To develop particular muscles groups for specific movements of shoulder girdle like elevation, retraction, and raising the arm overhead as these movements brings spontaneous relief. The important exercises areSelf resisted scapular elevation. Self resisted scapular adduction. Endurance training exercise for the shoulder girdle muscles. Progressive resistance exercises for shoulder girdle muscles with weight. Deep Tissue Massage for TOS ( thoracic Outlet Syndrome).

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On the basis of symptoms of the patient, the regime of physiotherapy is planned.

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May be secondary to flat foot, osteoarthritis

The degree of knock knee is measured by the distance between the medial malleoli at the ankle when the child lies down with the knees touching each other. Diagnostic Test

Treatment of Genu Valgum

Degree of deformity, muscle chart and ROM are measured. In mild cases of Genu Valgum in young children, wearing of boots with the inner side of heel raised by 3/8" inch and elongated forward heel (Robert Jones heels) corrects the deformity. In more complicated cases, the child requires a supracondyles closed wedge osteotomy. Post operative Physiotherapy

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Polio is non curable and there is no polio treatment available , bed rest during the acute stage and avoidance of injections, corrective surgery and physiotherapy along with rehabilitation helps the patient. Physiotherapy is a cornerstone of management of polio and post polio syndrome. There is an increasing evidence base for the effectiveness of physiotherapy in alleviating PPS (post polio syndrome) associated physical problems. Patients with prior polio or post polio syndrome should have access to regular physiotherapy assessment, and treatment should be made available when needs are identified. Types of polio: Spinal Paralytic poliomyelitis: In this the motor neurons in the anterior horns of spinal cord are affected. Paralysis is usually asymmetrical, predominantly involves proximal

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Gradual knee mobilization is the main part of the treatment. Some heat modalities may be given for relief of pain. Strengthening exercises for quadriceps, hamstrings and gluteus muscles are given. When the patient is able to walk, he is given correct training for standing, balancing, weight transferring and walking.

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Polio Treatment

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The Q angle which is formed by a line drawn from the anterosuperior iliac spine through the center of the patella and a line drawn from the center of the patella to the center of the tibial tubercle, should be measured next. In women, the Q angle should be less than 22 degrees with the knee in extension and less than 9 degrees with the knee in 90 degrees of flexion. In men, the Q angle should be less than 18 degrees with the knee in extension and less than 8 degrees with the knee in 90 degrees of flexion.

80 muscle with pain and tenderness. Most commonly it affects the leg. Extent of weakness can vary from a single muscle group to complete tetraparesis. Bulbar Paralytic poliomyelitis: It occurs due to damage to the medulla, pons and midbrain with dysfunction of the cranial nerve nuclei and respiratory and vasomotor regulating centres in the medulla. It can lead to respiratory muscle failure, distress of respiratory control, dysphagia, dysphonia and dysarthria. Cardiovascular, sweating and gut mobility disturbances may occur. Bulbospinal paralytic poliomyelitis: It is also known as respiratory poliomyelitis. It has symptoms both of spinal cord and bulbar poliomyelitis. It affects the part of spinal cord C3 to C5 segments and causes paralysis of the diaphragm. Dysphagia and respiratory failure follow. Polio encephalitis: There is inflammation of motor neurons within the brain stem, motor cortex and the spinal cord. It leads to the stiffness of back and neck, muscle cramps, headaches and paraesthesias. Paralysis occurs within 10 days after symptoms develop progress in 2 to 3 days and complete by the time fever subsides. Polio Symptoms

Polio treatment The disease may be staged as:-

Stage 1: Acute stage of paralysis: : it begins with fever and headache, followed by neck stiffness and meningitis. Muscles are painful and tender. Paralysis soon follows and reaches its maximum in 2-3 days. Limbs are weak and there may be difficulty with breathing and swallowing. If the patient does not succumb to respiratory failure, pain and pyrexia subsides after 7-10 days and the patient enters the convalescent stage. Stage 2: Recovery/convalescent stage: : This stage is prolonged. The return of muscle power is most noticeable during the first 6 months, but there may be continuing improvement for up to 2 years. Stage 3: Residual paralysis: : Some cases do not progress beyond the early stage of meningeal irritation. In others, however recovery is incomplete and the patient is left with some degree of asymmetric flaccid paralysis or muscle weakness.

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Polio treatment in the acute stage of muscle paralysis: It involves meticulous attention to intensive care during the acute paralytic phase.

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There are many symptoms of polio and not everyone will experience all of the symptoms. They symptoms vary according to the type of polio the individual has. In mild polio, some of the symptoms are: headache, nausea, vomiting, general discomfort or a slight fever for up to three days. In nonparalytic polio (aseptic meningitis): the symptoms are similar to mild cases, with the addition of moderate fever, stiff neck and back, fatigue and muscle pain. The symptoms for polio and paralytic polio different. Individuals with paralytic polio experience tremor, muscle weakness, fever, stiffness, constipation, muscle pain and spasms, and difficulty swallowing.

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Polio treatment in the recovery or convalescent stage:

Sitting up can be encouraged if the paralysis is not severe. As soon as the fever drops, exercises should be started to prevent contractures and return strength. Passive, active assisted to active resisted/ strengthening exercises, sitting balance training, standing balance training in parallel bars, gait training should be started. Crutches, leg braces(calipers) and other aids may help the child to move better and may prevent contractures or deformities. Whenever possible make exercises fun. Active games, swimming and other activities to keep limb moving as much as they can are important throughout the childs rehabilitation.

Polio

Examination of the patient

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A comprehensive and detailed assessment is necessary at the first consultation to establish a baseline from which future changes can be evaluated and a polio treatment plan developed. An assessment will usually have three components; neurological musculoskeletal cardiorespiratory neurological musculoskeletal cardiorespiratory

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Rehabilitation (stage 3) in poliomyelitis once all the recovery has taken place. Goals of polio treatment in the stage of residual paralysis: Strengthening of all the innervated muscles. Preventing contractures and deformities. Making the patient as independent as possible. Emotional and psychological support.

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Feeding by nasogastric tube in those with bulbar dysfunction. Endotracheal intubation and ventilation should be instituted in case of respiratory muscle failure or bulbar and laryngeal muscle paralysis. Pulmonary atelactasis and infection are treated with antibiotics and regular physiotherapy intervention. Rest on a firm mattress with back supported on a lumbar board. Avoid forceful exercise as this may increase paralysis. Avoid massage. Moist hot packs to the affected muscles produce considerable relief from the pain. Analgesics can also be used to relief pain. Feet to be supported by rigid boards at 90 angle. Early spinal bracing for the back if it is weak. Hip and knees should be positioned as straight as possible and arms in abduction with mild support. Passive range of motion for the joints to avoid contracture formation. Positon the patient with face down and hip extended every 2 hourly to prevent pressure sores and deformities.

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82 Neurological Examination in polio treatment include

New weakness in previously affected or unaffected muscles Decreased muscular endurance Gait changes History of falls Decreased function Other lower motor neuron signs decreased tone, reflexes and muscle atrophy

Musculoskeletal Examination in polio treatment include

Cardiorespiratory Examination in polio treatment include

During the stage of residual paralysis following problems may require polio treatment.

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Common biomechanical deficits in post polio Genu Recurvatum

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Each child will have a different combination and severity of paralyzed muscles and will have his own special needs. For some children, normal exercises and play may be all that are needed. Others may require braces or other aids to help them move about better. Those who are severely paralyzed may require wheelchair.

Isolated muscle weakness without deformity: Quadriceps paralysis may make walking impossible, it is best managed with a splint which holds the knee straight. Elsewhere, isolated weakness may be treated by tendon transfer. Deformity: Unbalanced paralysis may lead to deformity. At first it is passively correctable and can be counteracted by a splint. Fixed deformity require tendon transfer and joint stabilization, if necessary by arthrodesis. Flail joint: If the joint is unstable or flail it must be stabilized either by permanent splintage or by arthrodesis. Shortening: Lack of muscle activity undermines normal bone growth. Leg length inequality of upto 3 cm can be compensated for by shoe modification. Anything more may require operative lengthening of the limb.

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Reduced pulmonary function results from the virus affecting the medullary respiratory centres, the muscles of respiration and the cranial nerves. Thoracic cage deformity, e.g. kyphoscoliosis Breathing problems Measurement of peak flow, oxygen saturation, and interpretation of theresults of pulmonary function tests Forced expiratory techniques such as coughing and huffing to assess apatients ability to expectorate secretions effectively should be assessed

Range of motion testing especially for the joints affected Muscle testing, especially of muscles that are weak. Also test muscles that need to be strong to make up for the weak ones (shoulder strength for crutch use) Check for deformities, contractures, dislocations, difference in leg length, spinal curve etc

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Knee flexion contracture Inadequate dorsiflexion in swing Dorsiflexion collapse in stance Genu valgum Mediolateral ankle instability

Orthotic prescription Before prescribing orthosis it is necessary to assess:

ADLs training and occupational therapy role in polio treatment

Prevention

Individual children should be protected by immunization with polio vaccine. Two types of polio vaccines are available, an inactivated (killed) injectable polio vaccine (IPV) and a live attenuated (weakened) oral polio vaccine (OPV). Both vaccines are highly effective. Prognosis

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During early phase of the illness, it is difficult to evaluate the extent of paralysis because of pain and spasm of the muscles. Paralyzed muscles generally recover power to a variable degree. About 5-10% of the patients may develop bulbar or respiratory paralysis. Though bulbar paralysis is not invariably fatal, many patients succumb to it. Prognosis is generally worse for the older children and in those who had a sudden onset of illness with high fever.

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Washing and toilet: supporting rails, bath or shower seats and adjustments to the height of washing bowl, basin or bath may be provided Dressing: clothes with zip fasteners and Velcro may be provided Housing, domestic aids and furnitures may be modified for the severely disabled Transport: wheelchairs must be strong enough for rough roads and be patient propelled whenever possible. Motorized wheelchairs and cars with special control are also available

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A child with foot drop can be given an ankle foot orthosis of plastic or metal. A child with weak knee may need a long-leg brace of plastic or metal. It may be with or without a knee joint that locks straight for walking and bends for sitting. Child with weak trunk may require long leg braces attached to a body brace or body jacket.

Strength of hip abductors and hip extensors Knee extensor Hip, knee and ankle stability Strength of upper limb Limb length measurement and gait pattern Contractures and derformities

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Lateral Epicondylitis
What is Lateral Epicondylitis (tennis elbow) ateral Epicondylitis is a common clinical entity characterized by pain and tenderness at the common origin of the extensor group muscles of the forearm,usually as a result of a specific strain, overuse, or a direct bang.It is considered a cumulative trauma injury that occurs over time from repeated use of the muscles of the arm and forearm, leading to small tears of the tendons (Tendonitis).

The condition that is commonly associated with playing tennis and other racket sports, though the injury can happen to almost anybody.

A tear occurs at the teno-muscular junction, in the tendon, or at the teno-periosteal junction. The resulting inflammation produces exudate in which fibrin forms to heal the torn tissue.Repeated activity causes microtrauma, with subsequent granulation tissue formation on the underside of the tendon unit and at the teno-periosteal junction. The granulation tissue formed appears to contain large number of free nerve endings, hence the pain of the condition. The major problem is that the granulation tissue does not progress quickly to a mature form, and so healing fails to take place, almost a type oftendinous 'nonunion'. Frequency of Lateral Epicondylitis

Most patients with Lateral Epicondylitis are between the age of 30 to 55 years, and many have poorly conditioned muscles. 95% of tennis elbow occurs in non-tennis players.10-50% of regular tennis players experience tennis elbow symptoms of varying degree sometimes in their tennis lives. Etiology of Lateral Epicondylitis

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The most common cause of Lateral Epicondylitis in tennis players is a 'late' mechanically poor backhand, that places excess force across the extensor wad, that is, the elbow leads the arm. Other contributing factors include incorrect grip size,string tension, poor racket dampening, and underlying weak muscles of the shoulder,elbow and arm.Tennis grips that are too small often exacerbate or cause tennis elbow. Often a history of repetitive flexion-extension or pronation-supination activity and overuse is obtained (eg.,twisting a screw driver, lifting heavy luggage with the palm down). Tightly gripping a heavy briefcase is a very common cause.Raking leaves, baseball, golfing, gardening, and

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The tendinous origin of extensor carpi radialis brevis (ECRB) is the area of most pathologic changes. Changes can also be found at musculotendinous structures of the extensor carpi radialis longus, extensor carpi ulnaris and extensor digitorum communis. Overuse and repetitive trauma in this area causes fibrosis and micro tears in the involved tissues. Nirschl referred to the micro tears and the vascular in growth of the involved tissues as angiofibroblastic hyperplasia.

Pathophysiology of Lateral Epicondylitis

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85 bowling can also cause Lateral Epicondylitis. Less commonly,tendonitis is simply a result of single acute injury. Clinical Presentation At first, the athlete may be aware of only fatigue and spasm of dorsal forearm muscles related to unaccustomed activity. Then they may note the onset of aching lateral elbow pain after playing. Eventually the pain may become so constant and severe so as to stop the athlete from further playing and to interfere with activities of daily living, such as carrying a briefcase, wringing wet clothes or even holding a cup of tea. Grip becomes weak.Morning stiffness may be felt.

Physical Examination

-Point tenderness over or just distal to the lateral humeral epicondyle (the bony attachment of the common extensor tendon) which gives rise to burning sensation when pressure is applied. -Tenderness over muscles of dorsal forearm.

-Pain with resisted wrist extension, finger extension and resisted radial deviation. -Pain with passive stretching of wrist extensors.

-With long standing symptoms, there is likely to be considerable atrophy and weakness of extensor muscles and limitation of passive wrist flexion. Accessory movements of the elbow and superior radio-ulnar joint may be reduced in along term problem. Special tests for Lateral Epicondylitis

1)Cozen's test- The patient's elbow is stabilized by the examiner's thumb, which rests on the patient's lateral epicondyle. The patient is then asked to make a fist, pronate the forearm and radially deviate and extend the wrist while the examiner resists the motion. A positive sign is indicated by sudden severe pain in the area of lateral epicondyle of the humerus. 2)Mill's test-While palpating the lateral epicondyle, the examiner pronates the patient's forearm, and flexes the wrist fully and extends the elbow. A positive test is indicated by pain over the lateral epicondyle of humerus. 3)Maudsley's test- The examiner resists extension of the 3rd digit of the hand, stressing the extensor digitorum muscle and tendon. A positive test is indicated by pain over the lateral epicondyle of the humerus. Differential Diagnosis

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86 -Evaluation should note possible sensory paresthesias in the superficial radial nerve distribution to rule out Radial tunnel syndrome.It is the most common cause of refractory lateral pain and coexists with Lateral Epicondylitis in 10% of the patients. -The cervical nerve roots should be examined to rule out cervical radiculopathy. -Other conditions that should be considered include bursitis of the bursa below the conjoined tendon, chronic irritation of the radiohumeral joint or capsule, radiocapitellar chondromalacia or arthritis, radial neck fracture, panner's disease, little league elbow and osteochondritis dissecans of the elbow. Investigations

Activity Modification

-In non-athletes, elimination of activities that are painful is key to improvement (eg., repetitive valve opening). -Treatment such as ice and NSAIDs may lessen the inflammation, but continued repetition of the aggravating motion will prolong any recovery.

-Lifting should be done with the palm up whenever possible, and both upper extremities should be used in a manner that reduces forcible elbow extension, supination and wrist extension. Correction of mechanics

-If a late poor backhand causes pain, correction of mechanics of the game is warranted.Avoidance of ball impact that lacks a forward body weight transference is stressed. -If typing with unsupported arms exacerbates the pain, placing the elbows on stalked towels for support will help. -Calculation of grip-The distance from the proximal palmar crease to the tip of the middle finger determine the proper grip size.The figure obtained represents the circumference of the racket handle. Nonsteroidal Anti-inflammatory Drugs

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-Often repetitive pronation-supination motions and lifting heavy weights at work can be modified or eliminated. Activity modifications such as avoidance of grasping in pronation and substituting controlled supination lifting instead may relieve symptoms.

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Conservative treatment of Lateral Epicondylitis

X-rays are not necessary. Rarely, magnetic resonance imaging (MRI) scans may be used to show changes in the tendon at the site of attachment onto the bone. MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word "tear" to refer to this defect can be misleading. The word "tear" implies injury and the need for repair--both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.

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87 -If not contraindicated, we use Cox-2 inhibitors (rofecoxib, celecoxib) for their improved safety profile. Icing 10-15 minutes of icing, four to six times a day.

Your doctor may suggest an injection of a small dose of steroid to the affected area. This is not the sort of steroid banned for athletes. If used it can last for up to three months, and although it may need to be repeated you seldom need more than two or possibly three injections.

ROM of exercises emphasizing end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation). Forearm extensor stretch may be performed with the athlete facing the wall.The dorsum of the hand is placed on the wall, and the elbow remains locked. By leaning forward the wrist is forced into 90 degree of flexion,stretching the posterior forearm tissues. Wrist flexion may be combined with a pronation stretch.Keeping the elbow locked, the forearm is maximally pronated and wrist flexed.Overpressure is applied by other hand and static stretch is performed. The scar tissue is more pliable when warm. So stretching exercises can be given after some superficial heating modality.

Brace is used only during actual play or aggravating activity. The tension is adjusted to comfort while the muscles are relaxed so that maximal contraction of the finger and wrist extensors is inhibited by the band. The band is placed 2 finger breadths distal to the painful area of the lateral epicondyle. Some authors recommend 6-8 weeks use of a wrist splint positioned at 45 degree of dorsiflexion. Range of Motion Exercises

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Electrotherapy

Exercises emphasize end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation). -Soft tissue mobilization- Cross fibre friction massage is done with and perpendicular to the tissue involved.

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Counterforce Bracing

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Stretching

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88 -TENS for pain relief -LASER -Phonophoresis or iontophoresis may be helpful. Strengthening exercises for Lateral Epicondylitis A gentle strengthening program should be used for grip strength, wrist extensors, wrist flexors, biceps, triceps, and rotator cuff strengthening.

The exercise program includes-Active motion and submaximal isometrics.

-Theraband extension is performed with athlete sitting.One end of the band is placed under the foot and the other end is gripped. -Wrist curls-Sit with the hand over the knee.With palm up, bend the wrist 10 times holding a 1-2 pound weight.Increase to two sets of 10 daily; then increase the weight by 1 pound upto 5-6 pounds. Repeat this with palm down, but progress to only 4 pounds. -Forearm strengthening-Hold the arm out in front of the body, palm down. The patient clenches the fingers, bends the wrist up, and holds it tight for 10 seconds. Next with the other hand, the patient attempts to push the hand down. Hold for 10 seconds, 5 repetitions, slowly increasing to 20 repetitions 2-3 times a day. -Elbow flexion and extension exercises.

-Squeeze a sponge ball repetitively for forearm and hand strength. -Mobilization with movement (MWM)- In this a sustained mobilization is applied to a joint. The mobilization is applied at the same time the patient performs a painful action with the affected joint (extension of wrist). -Progress strength, flexibility, and endurance in a graduated fashion with slow-velocity exercises involving application of gradually increasing resistance. Later on upper limb plyometrics, closed chain activities and sport specific activities are done. Surgical treatment of Lateral Epicondylitis Operative treatment is required in less than 2% cases. Extensor tenotomy-Release of ECRB with debridement of chronic inflammatory tissues is the treatment of the choice.

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-Isotonic eccentric hand exercises with graduated weights not to exceed 5 pounds.

However,the acute inflammatory phase must have resolved first, with two weeks of no pain before initiation of graduated strengthening exercises.Development of symptoms (pain) modifies the exercise progression, with a lower level of intensity and more icing if pain recurs.

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89 Guidelines of Surgery-Persistent pain (more than 1 year), pain at rest, high activity level, failure of quality rehab program.

The condition require detailed examination because of the proximity of other medial structures that may mimic Medial Epicondylitis. Exclusion of other etiologies of medial elbow pain is important for appropriate treatment.

Flexor/Pronator tendinitis Curler's elbow Reverse tennis elbow Medial Epicondylitis Incidence

Medial Epicondylitis is less common than tennis elbow, occurring at a ratio of 1:15. Causes

Repetitive trauma resulting in microtears is a causative factor. Throwing athletes who have repetitive valgus stress on the elbow and repetitive flexor forearm musculature pull develop an overuse syndrome that affects the medial common flexor origin.Flexor-pronator tendinitis is a weight training ailment. In doing curls, the elbow flexors are the prime movers, but the wrist flexors must also resist the force of gravity throughout the lift. Occupation that require repetitive and strenuous forearm and wrist movement like carpentry. Tennis, racquetball, squash, and throwing often produce this condition. The serve and forearm strokes are the most likely to bring on pain. Clinical Features

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Golfer's elbow is characterized byPain on the inner side of your elbow. Pain may extends along the inner side of your forearm. Stiffness Elbow may feel stiff, and it may hurt to make a fist. Weakness in hands and wrists. Numbness or tingling Many people with Golfer's elbow experience numbness or a tingling sensation that radiates into one or more fingers usually the ring and little fingers.

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Other names for Golfers elbow

Golfer's elbow,often also called Medial Epicondylitis is defined as a pathologic condition that involves the pronator teres and flexor carpi radialisorigins at the medial epicondyle. However, abnormal changes in the flexor carpi ulnaris and palmaris longus origins at the elbow may also be present. Golfer's elbow, is an inflammatory condition and is far less frequent than tennis elbow

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90 The pain of Golfer's elbow may appear suddenly or gradually. The pain may get worse when: Swing a golf club or racket Squeeze or pitch a ball Shake hands Turn a doorknob Pick up something with your palm down Flex your wrist toward your forearm Physical Examination

Diagnosis

Golfer's elbow is usually diagnosed based on your medical history and a physical exam.An Xray can help the doctor rule out other possible causes of elbow pain, such as a fracture or arthritis. Rarely, more comprehensive imaging studies such as magnetic resonance imagining (MRI) are done. Differential Diagnosis

Special Tests

1)Medial Epicondylitis test- While the examiner palpates the patient's medial epicondyle, resisted wrist flexion and pronation is done. A positive sign is indicated by pain over the medial epicondyle of humerus. 2)Tinel's sign at elbow- The area of the ulnar nerve in the groove between the olecranon process and medial epicondyle is tapped. A positive sign is indicated by a tingling sensation in the ulnar distribution of the forearm and hand distal to the point of compression of the nerve.

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Physiotherapy treatment of Medial Epicondylitis

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-Point tenderness over or just distal to the medial humeral epicondyle. More localized tenderness compared to lateral epicondylitis. -Pain with resisted wrist flexion. -Medial soft tissue swelling. -Tenderness over the muscles of volar forearm. -Pain with passive stretching of wrist flexors.

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91 Non-operative treatment of Golfer's elbow is similar to that of tennis elbow and begins with modifying and stopping activities that produce tension overload, the underlying etiology of Golfer's elbow, and correction of training errors (overuse) and throwing mechanics causing the tension overload. Acute stage management

Decrease inflammation/pain.Promote tissue healing.Retard muscle atrophy.

Cryotherapy- Icing and NSAIDs are used for control of edema and inflammation.

Stretching to increase flexibility. wrist extension-flexion elbow extension-flexion forearm supination-pronation. Phonophoresis Friction massage

Iontophoresis-With an anti-inflammatory. Avoid painful activity-Such as gripping. Sub-acute stage management Goals-

Improve flexibility.Increase muscle strength and endurance. Increase functional activities and return to function. Emphasize concentric-eccetric strengthening. Concentrate on involved muscle group-Wrist flexor-extensors, Forearm pronator-supinators, elbow flexor-extensors. Initiate shoulder strengthening (Rotator cuff). Continue flexibility exercises. Use counterforce brace Continue use of cryotherapy after exercise or function. Initiate gradual return to stressful activities and previously painful movements. Chronic stage management

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Goals

92 GoalsImprove muscular strength and endurance. Maintain/enhance flexibility. Gradual return to sport (high level activities). Continue strengthening exercises (concentric-eccentric).

Continue flexibility exercises. Gradually diminish use of counterforce brace. Equipment modifications (grip size, string tension, playing surface). For persistent symptoms

Surgical intervention for golfers elbow may be indicated for symptoms that persist longer than 1 year.

Chronic Achilles tendonitis, also sometimes called Achilles tendinitis , is a painful and often debilitating inflammation of the large tendon in the back of the ankle (achilles tendon). It is a common overuse injury that tends to occur in middle-age recreational athletes. The overuse causes inflammation that can lead to pain and swelling. Furthermore, it can lead to small tears within the tendon, and make it susceptible to rupture. Achilles Tendon Dysfunction

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The Achilles tendon is the largest and strongest tendon in the body. The tendon has no true synovial sheath but is encased in a paratenon of varying thickness. The vascular supply to the tendon comes distally from intraosseous vessels from the calcaneus and proximally from intramuscular branches. There is relative area of avascularity 2-6 cm from the calcaneal insertion that is more vulnerable to degeneration and injury. Achilles tendon injuries are commonly associated with repetitive impact loading due to running and jumping. The primary factors resulting in damage of the Achilles tendon are training errors such as sudden increase in

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Achilles Tendonitis

Cortisone injection ( 0.5 ml of betamethasone) into the area of maximal tenderness may be useful, but should be given no more than 3 injections per year and no more frequently than every 3 months.

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Continue to emphasize deficiencies in shoulder and elbow strength.

93 activity, a sudden increase in training intensity (distance, frequency), resuming training after a long period of inactivity, and running on uneven or loose terrain . Achilles dysfunction can also be related to postural problem (e.g., pronation), poor footwear (generally poor hindfoot support), and a tight gastrosoleus complex. Causes of Chronic Achilles Tendonitis

There are three stages of tendon inflammation:

Peritenonitis Tendinosis Peritenonitis with tendinosis

Peritenonitis is characterized by localized pain during or following activity. As this condition progresses, pain often develops earlier on during activity, with decreased activity, or while at rest. Tendinosis is a degenerative condition that usually does not produce symptoms (i.e., is asymptomatic). It may cause swelling or a hard knot of tissue (nodule) on the back of the leg. Peritenonitis with tendinosis results in pain and swelling with activity. As this condition progresses, partial or complete tendon rupture may occur. Symptoms of Chronic Achilles Tendonitis

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Diagnosis

The main complaint is pain over the back of the heel. This is 2-6 cm above the point where the tendon inserts on the heel bone. Patients with Chronic Achilles tendonitis usually experience the most significant pain after periods of inactivity. Therefore patients tend to experience pain after first walking in the morning and when getting up after sitting for long periods of time. Patients will also experience pain while participating in activities, such as when running or jumping. Chronic Achilles tendinitis pain associated with exercise is most significant when pushing off or jumping. It may cause swelling over the Achilles tendon. Patient complains of pain when rising up on toes and pain when stretching the tendon. The range of motion of ankle may be limited.

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Overuse of the Achilles tendon Tight calf muscles Lots of uphill running Increasing the amount or intensity of sports training, sometimes along with switching to racing flats, which are racing shoes with less heel lift Over-pronation, a problem where your feet roll inward and flatten out more than normal when you walk or run Wearing high heels at work and then switching to lower-heeled shoes for exercise An Achilles tendon may tear when you move swiftly and forcefully. For example, the tendon might tear when you jump or start sprinting.

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There may be several factors leading to Chronic Achilles Tendonitis. These are:

94 In diagnosing Chronic Achilles Tendonitis, examine the patients f oot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays, ultrasound or MRI. Differential Diagnosis of Chronic Achilles Tendonitis

Achilles Tendonitis Treatment

Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:

General guidelines for chronic Achilles tendonitis -Correct underlying training and biomechanical problems

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-Soften a hard heel counter or use shoe counter heel cushions to minimize posterior "rubbing" symptoms. -Begin a runner's stretching program before and after exercises. -Oral anti-inflammatories (COX-2 inhibitors).

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Immobilization Ice Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen Physical therapy.

Stop rapid increase in mileage Stop hill running Correct functional overpronation and resultant vascular wringing of the tendon with a custom orthotic that usually incorporates a medial rear foot post. Stop interval training Correct improper intensity of training, duration, schedule, hard surface, poor shoewear

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Partial rupture of Achilles tendon Retrocalcaneal bursitis (of retrocalcaneal bursa) Haglund's deformity (pump bump) Calcaneal apophysitis Calcaneal exostosis Calcaneal stress fracture (positive squeeze test) Calcaneal fracture PTT tendinitis (medial pain) Plantar fasciitis (inferior heel pain)

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95 -Avoid cortisone injections ; this will cause weakening or rupture of the tendon. -Cryotherapy (ice massage)after exercise for anti-inflammatory effect. -Correct leg length discrepancy if present. First try 1/4 inch heel insert for a half inch leg length discrepancy; if not improved, go to 1/2 inch insert. Overcorrection (too rapid an orthotic correction) may worsen symptoms. -Shock wave Therapy

-If symptoms persist after 4-6 weeks of conservative measures, immobilization in a removable cam boot or cast may be required for 3-6 weeks.

-Eccentric strengthening of Achilles tendon should condition the tendon and make it less susceptible to overuse injuries; however these exercises are not used until the patient is assymptomatic and painless for 2-3 weeks.

toe raises in pool plantar flexion against progressively harder therabands multiple sets of very light (20 pound) total gym or slider board exercises.

If these treatments fail to improve symptoms, surgery may be needed to remove inflamed tissue and abnormal areas of the tendon. Prevention

The best treatment of Chronic Achilles tendonitis is prevention. Stretching the Achilles tendon before exercise, even at the start of the day, will help to maintain flexibility in the ankle joint. Problems with foot mechanics can also be treated with devices inserted into the shoes.

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swimming deep water running bicycling walking eccentric exercises for Achilles strengthening light jogging

-Slow, painless progression to preinjury activities

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96

Quadricep Strain
Quadricep Strain usually occur during sprinting, jumping or kicking. Strains are seen in all the quadriceps muscles but are most common in rectus femoris, which is more vulnerable to strain as it passes over two joints: the hip and the knee. The most common site of strain is the distal musculotendinous junction of the rectus femoris.

What are the causes of Quadricep Strain?

A Quadricep Strain, including ruptures, partial ruptures or strains are usually caused by a sudden twist, over-stretch or an over contraction of the muscle, such as while playing football or sprinting. Grades of quadricep strain

Treatment of Quadricep Strain (or Tears) Acute Stage

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Grade 1- strain is a minor injury with pain on resisted active contraction and on passive stretching. Patient feels tightness in the thigh.Unable to walk properly.Probably not much swelling. An area of local spasm is palpable at the site of pain. An athlete with such a strain may not cease activity at the time of the pain but will usually notice injury after cool down or the following day.Trying to straighten the knee against resistance probably won't produce much pain (unlike a grade 2 or 3). Healing time-2 to 10 days. Grade 2- strain cause significant pain on passive stretching as well as on unopposed active contraction. Probably cannot walk properly. The athlete may notice swelling. There is usually a moderate area of inflammation surrounding a tender palpable lesion. Straightening the knee against resistance causes pain. The athlete with a grade 2 strain is generally unable to continue the activity. Healing time-10 days to 6 weeks. Grade 3- strain of the rectus femoris occurs with sudden onset of pain and disability during intense activity. A muscle fibre defect is usually palpable when the muscle is contracted. Unable to walk properly without the aid of crutches. Bad swelling appearing immediately. A static contraction will be painful and might produce a bulge in the muscle. In the long term, they resolve with conservative management, often with surprisingly little disability. Healing time-6 to 10 weeks.

RICE NSAIDs if not contraindicated. Crutchs in a touch-down or partial weight bearing (painless) fashion. Hold all lower extremity athletic participation. Avoid SLR in early rehabilitation because of increased stress on torn rectus femoris. Electrical stimulation, Laser if superficial and pulsed ultrasound.

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Like all muscles strains, quadricep strain may be graded into mild (grade 1), moderate (grade 2) or severe, complete tears ( grade 3). The athlete feels the injury as a sudden pain in the anterior thigh during an activity requiring explosive muscle contraction. There is local muscle pain and tenderness and, if the strain is severe, swelling and bruising.

97 Intermediate Stage (usually 3-10 days postinjury) Goals

Regain normal gait. Regain normal knee and hip motion. Usually intermediate stage begins 3-10 days postinjury, depending on severity of injury.

Exercises and Modalities

Return to Function Stage

Note: Even quadriceps tears with palpable defects typically respond to this conservative regimen. Persistant defects are common, but rarely, if ever, require surgery or cause loss of function. Employ preactivity quad stretching program and appropriate warm-up regimen with return to sports. Criteria for Return to Play

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Quadricep Strain Prevention

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Terminal knee extension exercises. Increase aquatic program (deep water running). Begin knee extension with light weights. Myofascial tension in knee flexion. SLR, quads sets progressing to PRE (progressive resistance exercises) with 1-5 pound weight on the ankle. Increase low impact exercises to progress endurance and strength. Progress bicycle resistance and intensity of workout. Elliptical trainer. Thera-bands for hip flexion, extension, abduction, adduction. Walking progression on jogging (painless). 30-degrees mini squats (painless). Initiate sports specific drills and agility training. Isokinetic equipment (at higher speeds) with patient supine.

Quadriceps flexibility equal bilaterally. Asymptomatic with functional drills at full effort. Quadricep strength 85-90% (via isokinetic testing) of contralateral quadricep.

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Initiate a gentle quadriceps and hamstring stretching program. PNF pattrens. Aquatic rehabilitation program in deep water with floatation belt. Cycling with no resistance Moist heat before stretching exercises Begin higher dosage ultrasound (for thermal effects) and or electrical stimulation, when swelling has been controlled.

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Always warm up and cool down and stretch thoroughly before and after taking part in any physical or sporting activity in order to reduce the risk of injury. Make sure you spend time strengthening the groin and thigh muscles to improve your performance and reduce the risk of injury. Try to keep your body weight within normal limits for your height, as excessive body weight can aggravate hip pain caused by conditions like arthritis.

Piriformis Muscle Syndrome

Piriformis Muscle Syndrome is a nerve condition in the hip causing pain and loss of feeling in the back of the thigh often to the bottom of the foot.It involves compression of the sciatic nerve at the hip by the piriformis muscle.

The piriformis muscle attaches from the front of 2nd and 4th sacral segments,the gluteal surface of ileum and the sacro-tuberous ligament.It then travels through the greater sciatic notch to attach to the upper medial side of the greater trochanter. Its position is such that sciatic nerve rests directly on the muscle and in 15% of the population the muscle is divided into two with sciatic nerve passing between two bellies. CAUSES 1-Pressure on the sciatic nerve at the hip by anything that may cause the piriformis muscle to spasm and constrict the nerve and can cause Piriformis Muscle Syndrome. 2-This include strain from a sudden increase in the amount of intensity of activity or overuse of lower extremity. RISK INCREASES WITH

1-Sports involving running,jumping or prolonged walking. 2-Being born with nerve traveling through the piriformis muscle. 3-Poor physical conditioning(strength and flexibility). SIGNS AND SYMPTOMS 1-Tingling,numbness or burning in the back of the thigh to the knee and occasionally the bottom of the foot. 2-Occasionally tenderness in the back. 3-Pain and discomfort(burning,dull ache) in the hip or groin, mid buttock area, or back of thigh and sometimes to the knee. 4-Heaviness or fatigue of the leg.

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ANATOMY

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99 5-Pain that is worse with sports activities such as running, jumping,long walk, walking uphill and is increased by prolonged sitting. 6-Pain that is lessened by lying flat on the back. 7-Examination of lumber spine and SI joint is unrevealing. 8-Resisted lateral rotation of the affected hip joint gives pain. 9-Passive stretch into internal rotation is painful and limited.

SPECIAL TEST piriformis stretch test in side lying position with the test leg uppermost. DIAGNOSIS

PHYSIOTHERAPY TREATMENT 1-REST-The patient should temporarily stop running, bicycling, or doing any activity that elicits pain. A patient whose pain is aggravated by sitting should stand up immediately or, if unable to do so, change positions to raise the painful area from the seat.

3-PIRIFORMIS STRETCHING-Specific stretching exercises for the posterior hip and piriformis can be beneficial. Treatment usually begins with stretching exercises and massage, and avoidance of contributory activities. 4-STRENGTHENING EXERCISES-strengthening of the core muscles (abs, back, etc.) to reduce strain on the piriformis. Stretching exercises will target the piriformis, but may also include the hamstrings and hip muscles, in order to adequately reduce pain and increase range of motion. 5-PAIN RELIEVING MODALITIESultrasound therapy LASER interferential therapy TENS shortwave diathermy 6-ORTHOTICS-Custom foot orthotics also help with both treatment and prevention.

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2-ICE-Patients with Piriformis Muscle Syndrome may also find relief from ice and heat. Ice can be helpful when the pain starts, or immediately after an activity that causes pain. This may be simply an ice pack, or ice massage. Alternating heat and ice is often helpful.

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Diagnosis of Piriformis Muscle Syndrome is by physical examination. Pain with forceful internal rotation of the flexed thigh (Freiberg's maneuver), abduction of the affected leg while sitting (Pace's maneuver), raising of the knee several centimeters off the table while lying on a table on the side of the unaffected leg (Beatty's maneuver), or pressure into the buttocks where the sciatic nerve crosses the piriformis muscle while the patient slowly bends to the floor (Mirkin test) is diagnostic. Imaging is not useful except to rule out other causes of sciatic compression. Differentiation from a lumbar disk disorder is sometimes difficult, and referral to a specialist may be needed.

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100 7-GAIT TRAINING-Gait correction can reduce the use of the piriformis, allowing the muscle to relax and heal itself. 8-Anti-inflammatory drugs 9-Corticosteroid injections

Torticollis is a condition of the neck in which the childs head tilts toward one

shoulder and the chin rotates towards the opposite shoulder. It occurs when one of the

may be caused by any number of factors, including the babys position in the uterus, or trauma to the SCM muscle during birth. A pediatrician, or a pediatric orthopedist usually

Babies with torticollis may exhibit other signs and symptoms including

plagiocephaly (flattening of the back of the head on one side), hip dysplasia (when the top of the thighbone or femur does not securely fit into the socket or the acetabulum), and abnormality of the bones in the neck ( the vertebrae ). You may notice plagiocephaly from continually keeping the head turned and weight bearing on the same area all of the time. In advanced cases of torticollis there may be flattening of the forehead on one side with increased forehead prominence on the opposite side. Plagiocephaly will usually resolve itself when new positions are introduced and as the child increases his/her range of motion. However, some cases may require use of a special helmet to assist in reshaping the head. About 8% of babies born with torticollis have congenital hip dysplasia. When this occurs as a parent you may notice, one thigh looking longer then the other, asymmetrical skin folds, or one hip moving differently then the other. It is important to have the babies hips tested and/or x-rayed to rule out this out. Neck x-rays are also sometimes advised to rule out any abnormality of the vertebrae. Physical Therapy for Torticollis

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diagnoses torticollis in the first 2-3 months of life.

muscles in the childs neck, called the sternocleidomastoid (SCM) is tight. This condition

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Torticollis

101 Torticollis limits the ability for a child to move their head freely to see, hear and interact with his/her environment. Because of this torticollis may lead to delayed body awareness, weakness and difficulties with balance, and asymmetrical use of their arms and legs through developmental stages. This asymmetry can lead to uneven weight

respond very well to physical therapy intervention. It is important that parents get their

child into physical therapy as soon as possible. The older the child is the tighter the SCM

level.

At the physical therapy initial evaluation the parents will be given a home

ideas to discourage the childs favored position, and strengthening exercises to help decrease any asymmetry that may be occurring. Your therapist will help work with you and establish the best program and ideas for your child. The combination of physical therapy and a consistent home exercise program is the key to success! Most parents are surprised at how quickly you see changes and improvements with your childs posture, and interaction with their environment.

1) To encourage the child to turn his/her head lay the child on his/her back. Position yourself and the childs toys on the opposite side of which the child prefers. 2) If the child likes holding his/her ear closer to the right shoulder, lay the child on his/her right side with a pillow underneath their head. This will stretch the childs neck to the opposite side. (If the child holds their head tilted to the left lie the child on their left side.) 3) During tummy time turn the childs head to the opposite of the preferred side. If your child likes to look to the right, you would lay him/her on the stomach with their head turned to the left and their right ear on the floor.

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exercise program including range of motion exercises, massage instructions, positioning

General Activities for a child with Torticollis

becomes and the harder it becomes to stretch the child due to their increased activity

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bearing through the legs and favoring one side of the body. Most cases of torticollis

102 4) Be observant and aware of: What side the baby is held on and which way they tend to look. How the baby is fed and the position of their head. If the parent consistently holds the bottle to one side, it will be beneficial to switch

direction.

How the child is positioned in his/her crib. When the parent walks into the room to pick the child up, does the child consistently look towards one

side to see them? If so, place the childs head on the opposite end of the crib.

look in one direction?

How is the baby positioned in his/her car seat? If the childs head is

consistently tilting to one direction, put a towel roll on the side the head is tilting toward to help support the neck in a more neutral position

Physical Therapy Assessment

Basic Orthopedic Physical Therapy Assessment

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Patient history Observation Examination of movement Special tests Reflexes and cutaneous distribution Joint play movements Palpation Diagnostic imaging

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Are all of the childs toys on one side of the crib encouraging him/her to

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sides. This will encourage the child to look to their non-preferred

103 In Orthopedic Physical Therapy examining of the musculoskeletal system it is important to keep the concept of function in mind. Note any gross abnormalities of mechanical function beginning with the initial introduction to the patient. Continue to observe for such problems throughout the interview and the examination. On Orthopedic Physical Therapy examination of a patient who has no musculoskeletal complaints and in whom no gross abnormalities have been noted in the interview and general physical examination, it is adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient to perform a complete active range of motion with each joint or set of joints. If the patient presents complaints in the musculoskeletal system or if any abnormality has been observed, it is important to do a thorough Orthopedic Physical Therapy examination, not only to delineate the extent of gross abnormalities but also to look closely for subtle anomalies.

Use the opposite side for comparisons: it is easier to spot subtle differences as well as identify symmetrical problems. If there is any question, use your own anatomy as a control. Glean the maximum information from observation. Concentrating on one area at a time, inspect the area for discoloration (e.g., ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). While noting these changes, attempt to determine whether they are limited to the joint or whether they involve the surrounding structures (e.g., tendons, muscles, bursae). Observe the patient's eyes while palpating the joints and the surrounding structures in Orthopedic Physical Therapy examination. A patient's expression of pain depends on many factors. For this reason the verbalization of pain often does not correlate directly with the magnitude of the pain. The most objective indicator of the magnitude of tenderness produced by presence on palpation is involuntary muscle movements about the eyes. Therefore, the examiner should observe the patient's eyes while palpating the joints and surrounding structures. With practice the examiner will become skilled in evaluating the magnitude of pain produced by the examination and will be able to do a skillful evaluation without producing excessive discomfort to the patient. Note areas of tenderness to pressure, and if possible identify the anatomic structures over which the tenderness is localized. On Orthopedic Physical Therapy examination One should also note areas of enlargement while palpating the joints and surrounding structures. By noting carefully the consistency of the enlargement and its boundaries, one can decide whether this is due to bony widening, thickening of the synovial lining of the joint, soft tissue swelling of the structure surrounding the joint, an effusion into the joint capsule, or nodule formation, which might be located in a tendon sheath, subcutaneous tissue, or other structures about the joint.

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To perform an Orthopedic Physical Therapy examination of the muscles, bones, and joints, use the classic techniques of inspection, palpation, andmanipulation. Start by dividing the musculoskeletal system into functional parts. With practice the examiner will establish an order of approach, but for the beginner it is perhaps better to begin distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the lower extremity, again begin distally with the foot and proceed proximally through the hip.

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104 While palpating the joints, note areas of increased warmth (heat). A method for doing this that will help even the most inexperienced to perceive subtle increases in heat is to choose the most heat-sensitive portion of the hand (usually the dorsum of the fingers) and, beginning proximally, lightly pass this part of your hand over all portions of the patient's extremity several times. As you proceed from proximal to distal, the skin temperature gradually cools. If you find an area becoming slightly warmer, this represents increased heat. Have the patient perform active movements through an entire range of motion for each joint in Orthopedic Physical Therapy examination. Defects in function can be most rapidly perceived by having the patient perform active functions with each region of the musculoskeletal system. This reduces Orthopedic Physical Therapy examination time and helps the examiner to identify areas in which there is poor function for more careful evaluation. Manipulate the joint through a passive range of motion only if the patient is unable actively to perform a full range of motion, or if there is obvious pain on active motion. In passively manipulating a joint, note whether there is a reduction in the range of motion, whether there is a pain on motion, and whether crepitus is produced when the joint is moved. Note also whether the joint is stable or whether abnormal movements may be produced in Orthopedic Physical Therapy examination. Orthopedic Physical Therapy Examination of the Neck 1. Observe the patient as a whole.

2. Observe the neck and shoulders from in front and behind.

3. Palpate the front and back of the neck with the patient seated and the examiner behind. 4. Assess neck flexion by asking the patient to touch their chest with their chin. 5. Assess extension by asking the patient to look up and as far back as possible. 6. Assess lateral flexion to both sides by asking the patient to touch their shoulder with their ear. 7. Assess rotation by asking the patient to look over their shoulder, to the left and right. 8. Begin the neurological assessment of the upper limb by examining themotor system. This involves asking the patient to assume a certain position and not let you overcome it. Begin with shoulder abduction. 9. Shoulder adduction. 10. Elbow extension. 11. Elbow flexion.

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12. Wrist extension. 13. Wrist flexion.

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105 14. Finger extension. 15. Finger flexion. 16. Thumb abduction. 17. Finger abduction 18. Elicit the reflexes of the upper limb beginning with the biceps jerk. 19. Triceps jerk. 20. Brachioradialis jerk. 21. Assess co-ordination of the upper limb.

22. Test sensation of the upper limb and determine the distribution of any loss. Orthopedic Physical Therapy Examination of the Shoulder 1. Observe the whole patient, front and back. 2. Observe the shoulder. 3. Observe the axilla.

4. Palpate for tenderness over the sterno-clavicular joint, clavicle, acromioclavicular joint, acromion process, supraspinatus tendon and the tendon of the long head of biceps. 5. Observe shoulder abduction from in front and behind, through the entire range of movement. Note the presence of difficulty in initiation or a painful arc. 6. Secure the scapula to assess gleno-humeral movement. 7. Assess flexion and extension.

8. Assess external rotation with elbows in to the sides and flexed to 90 . 9. Assess internal rotation by asking the patient to place both hands behind the head. 10. Assess internal rotation by asking the patient to reach over their opposite shoulder, behind the neck and behind the back. (3 photos) 11. Test biceps function by asking the patient to flex the elbow against resistance. 12. Test serratus anterior function by asking the patient to push against a wall, looking for winging of the scapula.

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106 13. Test for pain with palpation of subacromial Bursa - indicates impingement of the rotator cuff. 14. The apprehension test standing. Abduct, externally rotate and extend the patient's shoulder while pushing on the head of the humerus with the opposite hand to test for anterior subluxation or dislocation. 15. Apprehension test lying down. 16. Assess any marked instability in the shoulder.Anterior - instability (moves too far forward);Posterior - instability (moves too far back). Orthopedic Physical Therapy Examination of the Elbow

2. Feel for tenderness. Accentuate the pain of tennis elbow. 4. Tennis elbow: point tenderness.

5. Tennis elbow: pain on resisted extension. 6. Tennis elbow: pain on passive stretch. 7. Examine extension. 8. Examine flexion. 9. Examine supination.

10. Examine pronation.

11. Pivot shift of elbow (instability).

12. Provocative test for Cubital Tunnel Syndrome (puts tension on ulnar nerve at elbow). 13. Palpate the ulnar nerve.

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Orthopedic Physical Therapy Examination of the Wrist and Hand 1. Observe the hand positioned on a pillow or a table. Ensure you have adequate exposure. 2. Observe the palm of the hand. 3. Observe the dorsum of the hand.

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1. Observe the whole patient, front and back, looking especially for deformity.

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107 4. Review the anatomy of the hand noting the tip of the styloid process, theanatomical snuffbox bordered by extensor pollicis brevis and extensor pollicis longus tendons and the abductor pollicis longus. 5. Feel for tenderness. 6. Test active movements of the wrist. 7. A useful method for screening of flexion and extension of the wrists. 8. Test passive movements of the wrist beginning with extension. 9. Flexion. 10. Radial deviation. 11. Ulnar deviation. 12. Pronation. 13. Supination. 14. Test thumb extension. 15. Test thumb abduction. 16. Test thumb adduction. 17. Test opposition. 18. Observe movement of fingers from extension to flexion. 19. Test flexor digitorum profundus function by holding the proximal interphalangeal joint extended and asking the patient to flex the finger. Successful finger flexion indicates the tendon is intact. 20. Test flexor digitorum superficialis function by holding the other fingers extended while asking the patient to flex the finger being tested. Successful flexion indicates the tendon is intact. 21. Assess joint hyperextension. 22. Axial compression test. 23. Asses ulnar nerve function with Froment's test. 24. Asses ulnar nerve/interosseus muscle function by asking the patient to abduct their fingers while slowly pushing the hands together until the weaker one collapses.

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108 24. Asses ulnar nerve/interosseus muscle function by asking the patient to abduct their fingers while slowly pushing the hands together until the weaker one collapses. 25. Assess median nerve function. 26. Assess the function of the hand with the fine pinch grip (paperclip).

28. Tripod grip (pen). 29. Wide grip (mug). 30. Power grip. Orthopedic Physical Therapy Examination of the Back 1. Observe the patient as a whole, front and back. 2. Ask the patient to walk on their toes.

3. Ask the patient to walk on their heels. 4. Back extension. 5. Back flexion.

6. Bony Excursion: measure the distance between two bony points when standing. 7 Ask the patient to flex forward, the bony points should move at least 5 cm. 8. Lateralflexion

9. Rotation (make sure to anchor pelvis)

10. FABER test in Orthopedic Physical Therapy Examination: Flexion Abduction External Rotation. Press firmly on the knee. Pain in the groin suggests a hip problem and pain in the back refers to the sacroiliac joint. 11 Straight leg ranging, dorsiflexion increases the sciatic stretch. Watch for pain and limitation. 12. Femoral stretch test: Hip extension and passive flexion of the knee. Watch for pain and limitation. A Neurological examination including: 13. Knee extension.

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27. Flat pinch grip (key).

109 14. Kneeflexion 15. Knee jerk reflex 16. Ankle jerk reflex. 17. Sensation 18. Pain on compression of the head can often be attributed to non-organic pathology. Orthopedic Physical Therapy Examination of the Hip 1. Observe the whole patient. 2. Trendelenburg test (normal). 3. Positive Trendelenburg Test. 4. Ask the patient to walk and observe their gait.

5. Test iliopsoas function by asking the patient to lift their thigh off the seat against resistance 6. Ensure the Anterior Superior Iliac Spines are horizontal. 7. Check the position of the medial malleoli.

8. Measure from the ASIS to the medial malleoli.

9. Measure the distance from the xiphisternum to the medial malleoli. 10. Feel for the femoral head. It is deep to the femoral pulse. 11. Thomas Test in Orthopedic Physical Therapy Examination: Flex both hips to eliminate the lumbar lordosis. Extend the hip you are examining and if it is normal it should return to the bed. A fixed flexion deformity of the hip will not allow it to extend to the neutral position. 12. Check the patient is not compensating with a lumbar lordosis. 13. Check the ASIS are horizontal again. Anchor leg over the edge of the bed and abduct the other hip. 14. Assess adduction. 14. Assess adduction. 15. Internal rotation.

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110 Orthopedic Physical Therapy Examination of the Knee 1. Observe the patient as a whole. 2. Observe the knee joint front and back. Note any genu valgum (a slight degree of which is normal) or genu varum.

4. Ask the patient to squat.

5. Assess patellae tracking from extension to flexion. Note quadriceps action.

7. Observe the knee with the patient lying on the bed.

9. Measure the circumference of the of the knee and leg. 10. Feel the temperature of the knee and leg.

11. Soloman's test. Lift the patella away from the femur. In synovial thickening it will be hard to grasp. 12. Effusion: Tap Test. Push sharply on the patella and with an effusion it will strike the femur and bounce back. 13. Effusion: Feel for fluid fluctuance.

14. Effusion: Bulge Test.Empty the suprapatellar pouch with pressure above the patella. Wipe hand along the medial side to displace fluid laterally. Compress the lateral side and watch for a bulge medially. 15. Feel the superficial and posterior surface of the patella by pushing it medially. 16. To test for patello-femoral tenderness press patella against the femur and ask the patient to tighten their thigh muscles. 17. Palpate for tenderness with the knee flexed to 90. Feel along the joint line, the ligaments and the tibial tubercle. 18. Assess extension of the knee. 19. Flexion.

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8. Pick a bony landmark on the knee and measure a fixed distance from it to the approximate centre of the quadriceps.

6. Patellar apprehension test. Apply lateral pressure to patellar as the patient flexes the knee. Observe facial expressions for fear of impending dislocation.

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3. Observe knee from side. Note any genu recurvatum.

111 20. Internal and external rotation of the knee is limited. 21. Test collateral ligaments by applying medial and lateral pressure to the lower leg which is tucked away under the examiners arm. 22. Look for posterior sag of the femur signifying posterior cruciate dysfunction.

24. Posterior drawer test. (Posterior cruciate) 25. Lachmans test.

26. MC test - lift leg off the bed and if tibia drops there is cruciate dysfunction.

27. MacMurrays test:Place the thumb and finger on the joint line. Watching the patients face for pain, flex the leg, externally rotate the foot, abduct and extend leg to test for medial meniscal "clicks".Flex the leg, internally rotate and adduct for lateral meniscal "clicks". 28. Ask the patient to lie prone and examine the back of the knee. Orthopedic Physical Therapy Examination of the Ankle and Foot Observe patient as a whole from front and back.

1. From behind check hind-foot alignment and "too many toes" sign (tib. post dysfunction). 2. & 3. Check for inversion (tibialis function) and eversion (peroneal function). 4. Single stance heel raise test. 5. Windlass test. 6. Coin test.

7. Dorsi flexion.

8. Plantar flexion.

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9. Mid foot abduction/adduction. 10. Extension fore foot. 11. Flexion fore foot. 12. Tib. anterior test.

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23. Anterior drawer test. Femur should not move forward significantly unless the anterior cruciate ligament is torn.

112 13. Tib. posterior test. 14. Peroneal tendons test. 15. Ankle instability - inversion test. 16. Ankle instability - Anterior draw test. 17. Ankle instability - Posterior draw test. 18. Simmond's test for TA. 19. Examine the sole. 20. Check pulses, sensation, reflexes.

Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon (the cord that joins muscle to bone). NEWS & FEATURES

Epidemic at the Computer: Hand and Arm Injuries Hazards At the Keyboard: A special report: Automation: Pain Replaces the Old Drudgery Alternative Names

Inflammation of the tendon sheath Causes

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The synovium is a lining of the protective sheath that covers tendons. Tenosynovitis is inflammation of this sheath. The cause of the inflammation may be unknown, or it may result from: Infection Injury Overuse

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Strain The wrists, hands, and feet are commonly affected. However, the condition may occur with any tendon sheath. Note: An infected cut to the hands or wrists that causes tenosynovitis may be an emergency requiring surgery.

Difficulty moving a joint Joint swelling in the affected area Pain when moving a joint

Pain and tenderness around a joint, especially the hand, wrist, foot, or ankle

Fever, swelling, and redness may indicate an infection, especially if a puncture or cut caused these symptoms. Exams and Tests

Treatment

The goal of treatment is to relieve pain and reduce inflammation. Rest or keeping the affected tendons still is essential for recovery. You may want to use a splint or a removable brace to help immobilize the tendons. Applying heat or cold to the affected area should help reduce the pain and inflammation.

For tenosynovitis caused by infection, your health care provider will prescribe antibiotics. In some severe cases, surgery may be needed to release the pus around the tendon. After recovery, do strengthening exercises using the muscles around the affected tendon to help prevent the injury from coming back. Outlook (Prognosis)

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Most people fully recover with treatment. However, if the condition is caused by overuse and the activity is not stopped, tenosynovitis is likely to come back. In chronic conditions, the tendon may be damaged and recovery may be slow or incomplete. Possible Complications If tenosynovitis is not treated, the tendon may become permanently restricted or it may tear (rupture). Infection in the tendon may spread to other places in the body, which could be serious.

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Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen can relieve pain and reduce inflammation. Local injections of corticosteroids may be useful as well. Some patients need surgery to remove the inflammation surrounding the tendon, but this is not common.

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A physical examination shows swelling over the involved tendon. The health care provider may touch or stretch the tendon, or have you move the muscle where it is attached to see whether you experience pain.

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When to Contact a Medical Professional Call for an appointment with your health care provider if you have pain or difficulty straightening a joint or extremity. If you suspect infection, contact your health care provider immediately. Prevention Avoiding repetitive movements and overuse of tendons may help prevent tenosynovitis.

Synovitis is the inflammation of a synovial (joint-lining) membrane, usually painful, particularly on motion, and characterized by swelling, due to effusion (fluid collection) in a synovial sac. Synovitis is a major problem in rheumatoid arthritis, in juvenile arthritis, in lupus, and in psoriatic arthritis. It may also be associated with rheumatic fever, tuberculosis, trauma, or gout. Rheumatoid arthritis involves synovitis. In rheumatoid arthritis, the synovial membrane lining the joint becomes inflamed. The cells in the membrane divide and grow and inflammatory cells come into the joint from other parts of the body. Symptoms of Synovitis

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Because of the mass of inflammatory cells in rheumatoid arthritis, the joint appears swollen and feels puffy or boggy to the touch. The increased blood flow that is a feature of the inflammation makes the joint warm. The cells release enzymes into the joint space which causes further pain and irritation. If the process continues for years, the enzymes may gradually digest the cartilage and bone of the joint leading to chronic pain and degenerative change

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SYNOVITIS

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115 Rehabilitation The goal of rehabilitation for synovitis is to decrease inflammation and pain to the synovium and affected joint(s) and then to restore range of motion and strength to the joint(s). Early in the course of synovitis, the physical therapist may instruct the individual to elevate the affected joint to help reduce swelling. The therapist also will educate the individual on how to avoid pressure on the inflamed synovial tissues by applying an elastic bandage, sling, or soft foam pad to protect the involved area until the swelling decreases.

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Once pain and swelling have been greatly reduced, the physical therapist will perform passive stretching exercises to help restore full range motion to an affected joint. Exercise will be progressed to active stretching and strengthening as appropriate to restore function without recurrence of pain. Modifications may be made by the physical therapist depending on the location of the affected joint, the stage of the inflammation (i.e., acute flare-up or chronic pain), and whether surgery was required. However, this condition rarely requires surgical intervention.

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When pain and inflammation of the acute stage of synovitis have lessened, heat modalities such as moist heat packs may be used to help relieve joint pain and stiffness and to increase blood flow to the synovium to promote healing. Ultrasound is another heat treatment used in physical therapy. It uses high frequency sound waves to produce heat that penetrates deep into the involved synovial membrane and surrounding joint. Iontophoresis, which uses a small electric current to drive anti-inflammatory medication into the inflamed tissues, may also be used.

There are several possible treatments to control inflammation resulting from synovitis. At the initial flare-up, the physical therapist may use cold modalities (e.g., ice packs) to control swelling and pain for as long as the joint area is warm to the touch. Electrostimulation combined with a cold treatment may be used to relax muscles around the inflamed joint and help to decrease pain and inflammation.

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DISC PROLAPSE
Causes A true herniated nucleus pulposus is most common in young and middle-aged adults. It rarely occurs in children. Degenerative changes in the spine that occur with aging actually make it less likely to develop a true herniated disc. This is because the nucleus in the middle of the disc dries out, making it less likely to squeeze out of the disc.

Symptoms

The symptoms of a true herniated disc may not include back pain at all. The symptoms come from pressure on, and irritation of, the nerves. But many people do have back pain because they have other problems in their back when the disc ruptures. The symptoms of a herniated disc usually include

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Where these symptoms occur depends on which nerve(s) has been affected in the lumbar spine. Therefore, the location of the symptoms helps determine your diagnosis. Knowing where the pain is perceived gives your doctor a better idea of which disc has probably ruptured.

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A herniated disc causes problems in two ways. First, the material that has ruptured into the spinal canal from the nucleus pulposus can cause pressure on the nerves in the spinal canal. There is also some evidence that the nucleus pulposus material causes a chemical irritation of the nerve roots. Both the pressure on the nerve root and the chemical irritation can lead to problems with how the nerve root functions. The combination of the two can cause pain, weakness, and numbness in the area of the body to which the nerve supplies sensation.

pain that travels into one or both legs numbness or tingling in areas of one or both legs muscle weakness in certain muscles of one or both legs loss of the reflexes in one or both legs

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Discs can also rupture from a small amount of force, usually due to weakening of the annulus from repeated injuries that add up over time. As the annulus becomes weaker, at some point lifting or bending causes too much pressure across the disc. The weakened disc ruptures while doing something that five years earlier would not have caused a problem. This is due to the effects of aging on the spine-the most common reason for a disc herniation in the lumbar spine.

Discs can rupture suddenly because of too much pressure all at once. For example, falling from a ladder and landing in a sitting position can cause a great amount of force through the spine. If the force is strong enough, either a vertebra can break or a disc can rupture. Bending places high forces on the discs between each vertebra. If you bend and try to lift something that is too heavy, the force can cause a disc to rupture.

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117 Diagnosis Diagnosing a herniated nucleus pulposus begins with a complete history of the problem and a physical exam. Your doctor will want to make sure that you are aware when you have to urinate or have a bowel movement. If there is a problem, it could indicate that a herniated disc in the lumbar spine is pushing against the spinal cord. Diagnostic Tests X-rays The doctor may suggest taking X-rays of your low back. Regular X-rays can't show a herniated disc, but they can give your doctor an idea of how much wear and tear is present in the spine.

Discogram When surgery for lumbar disc herniation is being considered, doctors may order a discogram to locate which discs are causing pain. EMG and SSEP Electrical tests can confirm that the pain in your leg is actually coming from a damaged nerve. These tests may be required before a decision is made to proceed with surgery.

Conservative Treatment The treatment of a herniated disc depends on the symptoms. If the symptoms are getting better, your doctor may suggest watching and waiting to see if they go away. If they are getting steadily worse, your doctor may be more likely to suggest surgery. Many people, who initially have problems due to a herniated disc, find their symptoms completely resolve over several weeks or months. Observation You may not need any treatment other than watching to make sure that the problem does not progress. If the pain is bearable and symptoms from nerve or spinal cord pressure are not getting worse, your doctor may just want to watch and wait. Pain medications Depending on the severity of your pain, medications can be used to help control it. Over-thecounter pain relievers, such as ibuprofen, Tylenol(tm), and some of the newer anti-inflammatory medications, may be helpful. Make sure to follow the directions and not take too many. If these types of medications do not control the pain, your doctor may prescribe stronger pain pills-narcotic or non-narcotic pain medications. Narcotic pain medications are very strong but also very addictive. Non-narcotic pain medications are less addictive, but are somewhat less

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Treatment Options

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CT Scan Sometimes the X-ray and MRI do not tell the whole story. Other tests may be suggested. A myelogram, usually combined with a CT scan, may be necessary to give as much information as possible.

MRI The MRI scan is the most common test used to diagnose a herniated disc. This test is painless and accurate. There do not appear to be any side effects with the test. MRI has almost completely replaced other tests when a herniated disc is suspected.

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118 effective than narcotics. Most physicians do not like to prescribe narcotics for more than a few days or weeks. Learn more about medications used to treat back pain. Rest If the pain is more severe, it may be necessary to take a few days off from work and decrease your activities. Your doctor may also prescribe a back brace to help limit movement around the injured disc. After two days, you should begin to get moving. Start with a gentle walking program and increase the distance you walk each day. Physical Therapy Patients with a herniated disc are commonly prescribed physical therapy. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

Therapy visits are designed to help control symptoms, enabling you to resume normal activities. Exercises focus on improving strength and coordination of the low back and abdominal muscles. The emphasis of therapy is to help you learn to take care of your back through safe exercise and self-care when symptoms flare up. Therapy sessions may be scheduled two to three times each week for up to six weeks. The goals of physical therapy are to help you

learn ways to manage your condition and control symptoms resume appropriate activity levels learn correct posture and body movements to reduce back strain maximize your flexibility and strength

Surgical Treatment Surgical treatment for a herniated disc depends on several factors such as your specific problem and your surgeon's experience.

How should things be lifted? Dos:

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Hold heavy objects close to your body rather than away from it. The feet must be about shoulder-width apart. A wide, solid base of support is important. Holding the feet too close together will be unstable; too far apart will make movement difficult. Legs must be bent at the knees while lifting weights from floor level and the back must be kept straight. The stomach muscles must be pulled in. This will support the back in a good lifting position and will help prevent excessive force on the spine.

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Laminotomy and Discectomy Microdiscectomy Endoscopic Discectomya

Epidural Steroid Injection (ESI) The ESI is usually reserved for more severe pain from nerve root irritation due to a herniated disc. It is not usually suggested unless surgery is fast becoming an option. An ESI is only successful in reducing the pain from a herniated disc in about half the cases.

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Push up with the legs. The legs are much stronger than the back muscles. If an object is too heavy, or awkward in shape get someone to help you lift.

Don'ts:

THE REHABILITATIVE MANAGEMENT OF BURN PATIENTS IN THE POST-ACUTE PHASE

Introduction The most important rehabilitative commitment after a serious burn trauma is to guarantee to the patient maximum autonomy and functionality in order to ensure the best possible quality of life in the social, family, and working environments. To achieve this aim, physiotherapists use a wide range of techniques, such as kinesitherapy, and a number of devices. It is possible to distinguish three phases:

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In this paper we will consider the post-acute phase, i.e. the period when the burn patient is still in hospital but in the plastic surgery ward, and no longer in the intensive care unit. Once the

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1. Acute phase. Prevention of: A. articular limitations B. muscle or tendon contractures C. breathing complications D. oedema 2. Post-acute phase. Aims: A. recovery of muscular tone trophism B. return of patient to normal overall condition C. restoration of patients autonomy in shortest time possible (depending on pathology) 3. Chronic phase (sequelae). Aims: A. scar prevention B. treatment of orthopaedic sequelae C. treatment of neurological sequelae D. return of patient to social environment, family, and working life

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Avoid sudden and awkward movements while holding something heavy. Never bend your back to pick something up Don't twist or bend. Face in the direction you are walking.

120 acute phase is over, treatment will be oriented towards early neuromotor recovery in order to reduce the negative effects of overlong immobilization in bed.1,2 Contraindications to kinesitherapy 1. Poor general condition of the patient 2. Skin graft (at least 5-10 days of immobility are necessary; initiation of rehabilitation to be arranged with the plastic surgeon) 3. Presence of muscle or tendon injuries Procedures Various procedures are used: 1. 2. 3. 4. 5. 6. 7. 8. 9. Assisted active mobilization Active mobilization Mobilization against resistance Dynamic proprioceptive re-education Stretching Postural sequences Recommencement of standing (orthostatism) Re-education for the recommencement of walking Splinting

Exercises Numerous exercises are available:

1. Exercises performed with the help of the physiotherapist in order to overcome loss of articular and muscular movement. 2. Exercises performed autonomously by the patient during the day in order to improve circulation and metabolic exchange. 3. Exercises performed against resistance by the therapist in order to counteract muscular hypotrophy and restore the memory of movements. 4. Exercises in cases of neurological injury in order to make movements that are as precise as possible, using the whole kinetic chain and not just single isolated movements (as recommended by Freeman, Perfetti, and Kabat. 5. Exercises for the passive connective and active muscular parts of the body. 6. Kinesitherapy allowing the patient analytic recovery of movement. Postural sequences are the next step (variation of decubitus: lateral, sitting with legs straight, sitting with legs out of bed); helpful aids are elastic bandages on the lower limbs in order to prevent circulatory disorders. The patient will need to learn to do all this by himself in the shortest amount of time possible to reach autonomy in moving between bed and wheelchair and consequently in personal cleanliness. 7. There are two possibilities, depending on the patients clinical conditions: a. transfer from bed to wheelchair; b. sitting up in bed. A long stay in bed requires exercises aimed at transferring weight distribution and controlling the trunk. 8. Various devices are used to assist walking in the early stages, an activity that gradually becomes once again autonomous. The physiotherapist plays an important role here: he or she teaches the patient how to walk, initially with devices and later weaning the patient from their use in order to achieve autonomous walking, if possible. Care must be

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121 taken when there are skin grafts and orthopaedic or neurological injuries. Walking helps to orient the positioning of grafted skin (Benninghoff). 9. Static-dynamic exercises counteract hypertrophy and scar contractures by using forces that release scar tension in a constant, continuous, and adjustable manner. Such exercises, in cases of neurological injuries, compensate for the loss of movement. Silicon may be interposed to increase compression at the level of the hand, palm, and back. This is very important from the acute phase on.3-6 Bandaging - compression therapy In 1968 Fujimori demonstrated that a moderate and constant compression of burned skin prevents scar hypertrophy. When compression is applied early, it prevents the formation of nodules and collagen spirals within the scar and creates hypoxaemia in its vascular network: this causes precocious, artificial ageing that will determine an orientation parallel to the cutaneous surface of the collagen fibres. Bandaging is applied:

Compression is applied as follows:

pre-packaged elastic girdle elastic bandaging elastic garments silicon

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Girdles are made of elastic tissue that counteracts scar hypertrophy. Girdles are made to measure in order to adjust tension and compression (care must be taken to ensure they are be correctly worn, in order to avoid any haemostatic effect). Adhesive bandaging can be applied by the physiotherapist (this is useful also during postural sequences in the acute phase for the reduction of circulation disorders) before the use of girdles, since the adhesive bandaging can be applied directly on the dressing; the only disadvantage is a further reduction in range of motion. Made-to-measure elastic-compressive garments are useful only in the post-acute phase when oedema has stabilized and the skin has healed. These garments require continuous checking of their continued effectiveness. Compression needs to be continuous over time to be effective; the use of pads in the lower back and subscapular area can be considered - this requires careful hygiene and good patient compliance. Silicon has flattening, hydrating, decongesting, and softening effects on the scar. It can be placed in between elastic girdles (costs, however, are high). Massotherapy is another useful technique. Massotherapy: 1. Reorganizes the capillary network and local circulatory flow 2. Reduces oedema and itching 3. Makes the skin more elastic, frees adhesions, and makes the new skin stronger

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in the acute phase, to prevent oedema after skin grafting in burns in the course of healing during the chronic phase

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122 4. Helps the patient to regain sensitivity 5. Relaxes neighbouring tissues Massaging must be gentle and superficial. Connective tissue massage is important as it stimulates body areas by modifying their connective trophism through the reflected action of the skins sympathetic terminal reticulum. The daily use of rapidly absorbed hydrating lotions is recommended, as this prevents avoid maceration under the girdles.7 Manual lymphatic drainage Manual lymphatic drainage has analgesic and immunological effects on the vegetative nervous system, as also on the musculature of blood and lymph vessels. This technique is required when there is impairment of venous and lymphatic circulation, with consequent oedema; it enables the lymph to flow - even by alternative routes - and thus prevents the creation of fibrous tissue and consequent sclerosis. The association of various bandaging techniques cannot always be used since the scars may still be open. 1. Vegetative effect - the vegetative nervous system is composed of two antagonistic systems: the sympathetic and the parasympathetic nervous systems. The sympathetic nervous system prevails over the parasympathetic; manual lymphatic drainage acts on the latter, increasing its effect. 2. Analgesic effect. Manual lymphatic drainage can excite the cells that inhibit pain, thus reducing it (see the gate control theory). 3. Immunological effect. Manual lymphatic drainage permits an increase of the bodys defence mechanisms by activating lymph routes. This defence depends on resistance, i.e. the set of possibilities for reaction activated by the organism before an immune response. 4. Effect on smooth musculature of blood and lymph vessels. Manual lymphatic drainage acts by toning the smooth musculature of blood vessels at capillary level, through contraction of the pre-capillary sphincters. Blood pressure diminishes, thus determining emptying of tissues.8

Physical therapy

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At the end of each treatment it is useful to make an overall evaluation. This includes: cutaneous assessment (baths, surgery) articular, neuromotor, and breathing assessment assessment of functional recovery (functional independence rating), with particular reference to walking and management of personal care.8

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1. Ultrasounds: these improve the detachment of adherences and reduce oedema (they reduce fibrosis): 3 Hz, intensity 1.5 W/m2. 2. Transcutaneous electrical nerve stimulation (TENS): this is to decrease pain during the process of scar healing. 3. Vacuum therapy: this therapy uses different-size nozzles that go over all the scars lengthwise. The action is exerted on the circulation in the scar, by increasing and reducing pressure.

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123 RESUME. Le but le plus important dans la rducation du grand brl est le rtablissement de son autonomie et de sa fonctionnalit maximale possible dans la vie sociale, familiale et professionnelle. On peut distinguer trois phases: aigu, post-aigu et chronique. Les Auteurs considrent la phase post-aigu et en particulier les contre-indications la kinsithrapie, les pansements et la thrapie de compression, le drainage lymphatique manuel et la thrapie physique

Common to all individuals with cerebral palsy is difficulty controlling and coordinating muscles. This makes even very simple movements difficult.

Cerebral palsy may involve muscle stiffness (spasticity), poor muscle tone, uncontrolled movements, and problems with posture, balance, coordination, walking, speech, swallowing, and many other functions.

Types of cerebral palsy are as follows:

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Mental retardation, seizures, breathing problems, learning disabilities, bladderand bowel control problems, skeletal deformities, eating difficulties, dental problems, digestive problems, and hearing and vision problems are often linked to cerebral palsy. The severity of these problems varies widely, from very mild and subtle to very profound. Although the magnitude of the problems may wax and wane over time, the condition does not get worse over time.

Spastic (pyramidal): Increased muscle tone is the defining characteristic of this type. The muscles are stiff (spastic), and movements are jerky or awkward. This type is classified by which part of the body is affected: diplegia (both legs), hemiplegia (one side of the body), or quadriplegia (the entire body). This is the most common type of CP, accounting for about 70-80% of cases. Dyskinetic (extrapyramidal): This includes types that affect coordination of movements. There are 2 subtypes.

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Cerebral palsy (CP) is an umbrella term for a group of disorders affecting body movement, balance, and posture. Loosely translated, cerebral palsy means brainparalysis. Cerebral palsy is caused by abnormal development or damage in one or more parts of the brain that control muscle tone and motor activity (movement). The resulting impairments first appear early in life, usually in infancy or early childhood. Infants with cerebral palsy are usually slow to reach developmental milestones such as rolling over, sitting, crawling, and walking.

Cerebral Palsy

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Athetoid: The person has uncontrolled movements that are slow and writhing. The movements can affect any part of the body, including the face, mouth, and tongue. About 10-20% of cerebral palsy cases are of this type. Ataxic: This type affects balance and coordination. Depth perception is usually affected. If the person can walk, the gait is probably unsteady. He or she has difficulty with movements that are quick or require a great deal of control, such as writing. About 5-10% of cases of cerebral palsy are of this type. Mixed: This is a mixture of different types of cerebral palsy. A common combination is spastic and athetoid.

cerebral Palsy Causes Cerebral palsy results from damage to certain parts of the developing brain.

At one time, problems during birth, usually inadequate oxygen, were blamed for cerebral palsy.

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Risk factors linked with cerebral palsy include the following: Infection, seizure disorder, thyroid disorder, and/or other medical problems in the mother

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Some cases begin after birth (postnatal).

This damage can occur early in pregnancywhen the brain is just starting to form, during the birth process as the child passes through the birth canal, or after birth in the first few years of life. In many cases, the exact cause of the brain damage is never known.

We now know that fewer than 10% of cases of cerebral palsy begin during birth (perinatal). In fact, current thinking is that at least 70-80% of cases of cerebral palsy begin before birth (prenatal).

In all likelihood, many cases of cerebral palsy are a result of a combination of prenatal, perinatal, and postnatal factors.

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Many individuals with cerebral palsy have normal or above average intelligence. Their ability to express their intelligence may be limited by difficulties in communicating. All children with cerebral palsy, regardless of intelligence level, are able to improve their abilities substantially with appropriate interventions. Most children with cerebral palsy require significant medical and physical care, including physical, occupational, and speech/swallowing therapy. Despite advances in medical care, cerebral palsy remains a significant health problem. The number of people affected by cerebral palsy has increased over time. This may be because more and more premature infants are surviving. In the United States, about 2-3 children per 1000 have cerebral palsy. As many as 1,000,000 people of all ages are affected. Cerebral palsy affects both sexes and all ethnic and socioeconomic groups.

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Birth defects, especially those affecting the brain, spinal cord, head, face,lungs, or metabolism Rh factor incompatibility, a difference in the blood between mother and fetusthat can cause brain damage in the fetus (Fortunately, this is almost always detected and treated in women who receive proper prenatal medical care.) Certain hereditary and genetic conditions Complications during labor and delivery Premature birth Low birth weight (especially if less than 2 pounds at birth) Severe jaundice after birth Multiple births (twins, triplets)

Lack of oxygen (hypoxia) reaching the brain before, during, or after birth

Brain damage early in life, due to infection (such as meningitis), head injury, lack of oxygen, or bleeding

Cerebral Palsy Symptoms The signs of cerebral palsy are usually not noticeable in early infancy but become more obvious as the childs nervous system matures. Early signs include the following:

Problems and disabilities related to CP range from very mild to very severe. Their severity is related to the severity of the brain damage. They may be very subtle, noticeable only to medical professionals, or may be obvious to the parents and other caregivers.

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Delayed milestones such as controlling head, rolling over, reaching with one hand, sitting without support, crawling, or walking Persistence of infantile or primitive reflexes, which normally disappear 3-6 months after birth Developing handedness before age 18 months: This indicates weakness or abnormal muscle tone on one side, which may be an early sign of CP.

Abnormal muscle tone: Muscles may be very stiff (spastic) or unusually relaxed and floppy. Limbs may be held in unusual or awkward positions. For example, spasticleg muscles may cause legs to cross in a scissor-like position. Abnormal movements: Movements may be unusually jerky or abrupt, or slow and writhing. They may appear uncontrolled or without purpose.

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Skeletal deformities: People who have cerebral palsy on only one side may have shortened limbs on the affected side. If not corrected by surgery or a device, this can lead to tilting of the pelvic bones and scoliosis (curvature of the spine). Joint contractures: People with spastic cerebral palsy may develop severe stiffening of the joints because of unequal pressures on the joints exerted by muscles of differing tone or strength.

Seizures: About one third of people with cerebral palsy have seizures. Seizures may appear early in life or years after the brain damage that causes cerebral palsy. The physical signs of a seizure may be partly masked by the abnormal movements of a person with cerebral palsy. Speech problems: Speech is partly controlled by movements of muscles of the tongue, mouth, and throat. Some individuals with cerebral palsy are unable to control these muscles and thus cannot speak normally. Swallowing problems: Swallowing is a very complex function that requires precise interaction of many groups of muscles. People with cerebral palsy who are unable to control these muscles will have problems sucking, eating, drinking, and controlling their saliva. They may drool. An even greater risk isaspiration, the inhalation into the lungs of food or fluids from the mouth ornose. This can cause infection or even suffocation. Hearing loss: Partial hearing loss is not unusual in people with cerebral palsy. The child may not respond to sounds or may have delayed speech.

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xams and Tests If your child has problems that suggest cerebral palsy, he or she will undergo a very thorough evaluation. There is no medical test that confirms the diagnosis of cerebral palsy. The diagnosis is made on the basis of various types of information gathered by the childs health care provider and, in some cases, other consultants. This information includes a detailed medical interview concerning medical histories of both the mothers and fathers families, the mothers medical problems before and during pregnancy, and a detailed account of the pregnancy, labor, delivery, and neonatal(newborn) period.

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Vision problems: Three quarters of people with cerebral palsy havestrabismus, which is the turning in or out of one eye. This is due to weakness of the muscles that control eye movement. These people are often nearsighted. If not corrected, strabismus can lead to more severe vision problems over time. Dental problems: People with cerebral palsy tend to have more cavities than usual. This results from both defects in tooth enamel and difficulties brushing the teeth. Bowel and/or bladder control problems: These are caused by lack of muscle control.

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Mental retardation: Some, although not all, children with cerebral palsy are affected by mental retardation. Generally, the more severe the retardation, the more severe the disability overall.

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You will be asked to relate in detail the childs medical problems and mental and physical development. You may be asked other questions as well. It is very important to answer all questions as completely and honestly as possible, as the answers may help your child. Lab studies: Various blood and urine tests may be ordered if your childs health care provider suspects that the childs difficulties are due to chemical, hormonal, or metabolic problems.Analysis of the childs chromosomes, including karyotype analysis and specificDNA testing, may be needed to rule out a genetic syndrome. Imaging studies: These studies provide a picture of structures inside the body. Such testing, when used on the brain or spinal cord, is often called neuroimaging. These tests are not always necessary, but in many cases, they may help identify the cause or extent of the cerebral palsy. They should be done as early as possible so that appropriate treatment, if indicated, can be begun immediately. Many individuals with mild cerebral palsy have no visible brain abnormalities.

CT scan of the brain: This scan is similar to an x-ray but shows greater detail and gives a more 3-dimensional image. It identifies malformations, hemorrhage, and certain other abnormalities in infants more clearly than ultrasound. MRI of the brain: This is the preferred test, since it defines brain structures and abnormalities more clearly than any other method. Children who are unable to remain still for at least 45 minutes may require a sedative to undergo this test.

Other tests: Under certain circumstances, your childs health care provider may want to do other tests.

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MRI of the spinal cord: This may be necessary in children with spasticity of the legs and worsening of bowel and bladder function, which suggest an abnormality of the spinal cord. Such abnormalities may or may not be related to cerebral palsy.

Electroencephalography (EEG) is important in the diagnosis of seizure disorders. A high index of suspicion is needed in order to detect non-convulsive or minimally convulsive seizures. This is a potentially treatable cause of a CP-look-alike, which is easier to treat when treated early. Electromyography (EMG) and nerve conduction studies (NCS) may be helpful in distinguishing CP from other muscle or nerve disorders.

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Ultrasound of the brain: Ultrasound uses harmless sound waves to detect certain types of structural and anatomic abnormalities. For instance, it can show hemorrhage (bleeding) in the brain or damage caused by lack of oxygen to the brain. Ultrasound is often used on newborns who cannot tolerate more rigorous tests such as CT scans or MRI.

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128 Physiotherapy There are many different treatments for cerebral palsy available today, however each case of cerebral palsy is as unique as the individual it affects. Different treatments will work for different patients, and to varying degrees of success. A treatment calledphysiotherapy is classified as a non-medicinal treatment of cerebral palsy with the use of exercise, massage, heat, and other external means of treatment. Physiotherapy is used to help cerebral palsy patients improve movement and motor skills. Since cerebral palsy is a physical and movement disorder that impairs the brain's ability to properly control muscle movement, physiotherapy can do wonders in helping cerebral palsy patients gain mobility. Cerebral palsy physiotherapy techniques are determined by the degree of physical limitations of the individual, and what will be most beneficial to the cerebral palsy patient. Physiotherapy generally consists of a few types of therapy and helps a cerebral palsy patient to improve their gross motor skills. Motor skills that utilize the large muscles in the body, such as those in the arms and legs, are known as gross motor skills. This kind of physiotherapy can help improve a cerebral palsy patient's balance and movement.

Physiotherapy also involves choosing the right type of adaptive equipment that can enhance a cerebral palsy patient's motor abilities. Wheelchairs, walkers, special eating utensils and other adaptive equipment provide a patient with the freedom to accomplish some tasks on their own. Other types of physiotherapy like speech and language therapy may also be incorporated into a cerebral palsy patient's program. Physiotherapy in the form of speech and language therapy that enables a cerebral palsy patient to communicate more easily with others by developing the facial and jaw muscles, improving speech or sign language messages, and introducing communication tools such as computers and other visual aids. Physiotherapy is an integral part in the majority of many cerebral palsy patients' daily lives. Physiotherapy has the ability to develop self-sufficiency in cerebral palsy patients where it was previously absent. A child with cerebral palsy can start physiotherapy at just about any age. Talk to your child's physician about setting up physiotherapy plan today.

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Occupational therapy is another element of physiotherapy used for cerebral palsy patients, and it is used for aiding in the development of fine motor skills. Fine motor skills focus on the use of smaller muscles, such as those in the face, fingers, toes, hands, and feet. Fine motor skills are used during daily living skills like eating, dressing, writing, etc., and are fine tuned by occupational physiotherapy.

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Physiotherapy can be great for increasing the success of learning to walk, standing without aid, using a wheelchair or other adaptive equipment, and other movement skills. The physical therapists involved in physiotherapy reduce further development of musculoskeletal problems by preventing muscle weakening, deterioration, and contracture through the correct physiotherapy techniques.

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129 Prevention Often the cause of cerebral palsy is not known, and nothing can be done to prevent it. However, some important causes of cerebral palsy can be prevented in many cases, including premature birth, low birth weight, infections, and head injuries.

Avoid using cigarettes, alcohol, and illicit drugs during pregnancy: these increase your risk of premature delivery. Rubella (measles) during pregnancy or early in life is a cause of cerebral palsy. Testing for rubella immunity before you become pregnant allows you to be immunized, which protects both you and your baby from contracting this potentially devastating illness. Appropriate prenatal care includes testing for Rh factor. Rh incompatibility is easily treated but can cause brain damage and other problems if untreated.

Make sure your child is restrained in a properly installed car seat and wears a helmet when riding on a bicycle.

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Routine vaccinations of babies can prevent serious infections such as meningitis that can lead to cerebral palsy.

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Seek appropriate prenatal care as early as possible in the pregnancy. Many women schedule a prepregnancy visit so they can be properly prepared for a healthy pregnancy. Appropriate care is available from physicians, physician assistants, nurse practitioners, and certified nurse-midwives.