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Total Knee Replacement Rehabilitation

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

A total knee replacement (TKR) is usually done as the surgical treatment option for advancedosteoarthritis of the knee joint.During the surgery, the knee joint is replaced with artificialmaterial. 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 andreplaced with a metal surface and the top of the tibia is removed and replaced with a plasticpiece that has a metal stem. If the knee cap has also degenerated, a plastic piece may beadded to the back surface to create a smoother joint surface.

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

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

Relative

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

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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Independent ambulation with an assistive device.

Perioperative considerations for Total Knee Replacement Rehabilitation

Component design, fixation method, operative technique (osteotomy, extensor mechanismtechnique), bone quality will all affect perioperative rehabilitation. Implant can be posteriorcruciate ligament (PCL) retaining, PCL sacrificing, or PCL sacrificing with substitution.

Rehabilitation of Patients with Hybrid Ingrowth Implant versus those with Cemented kneeImplant

Cemented Total Knee Arthroplasty

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

Hybrid or Ingrowth Total Knee Arthroplasty

Touch down weight bearing (TDWB) only with walker for first 6 weeks. Next 6 weeks, begincrutch 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

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.

Day 1

FOLLOW THE VIDEOS FOR BETTER UNDERSTANDING OF THE EXERCISES IN Total KneeReplacement Rehabilitation

Ankle pump

Initiate isometric exercises.

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


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

SLRThis exercise helps strengthen the quadriceps muscle also. Bend the uninvolved legby raising the knee and keeping the foot flat on the bed. Keeping your involved legstraight, 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. sandbags) at the ankle to further strengthen the muscles. The amount of weight is increasedin one pound increments.

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.

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

Day 2-2 weeks

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 30-40 degrees. Tighten your quadriceps and straighten your knee by lifting your heel off thebed. 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.

2-3 weeks

Continue previous exercises.


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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

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.

6 weeks onwards in Total Knee Replacement Rehabilitation

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.

Hip Replacement Rehabilitation

The Hip Replacement Rehabilitation protocols mentioned here for are general and should betailored to specific patients. For example, weight bearing should be limited to toe touch inosteotomy 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 theseosteotomies, weight-bearing should be delayed until some union is present. These patientsshould avoid SLR (straight leg raise) and side-leg-lifting until, surgeon agrees that it is safe to doso.Treatment may also have to be adjusted according to difficulty of initial fixation. In revisionsurgery, a stable press-fit acetabular component may be difficult to achieve and multiple-screwfixation may be required. Caution should be exercised in rehabilitation in these circumstanses.

Hip Replacement Rehabilitation might also have to be adjusted because ofstability. Abductionbrace may be used to prevent adduction and flexion of more than 80 degrees for upto 6 monthsin case of recurrent dislocations. Similarly, leg shortening through a hip at the time of revisionwith or without a constrained socket should be protected with an abduction brace until the softtissues 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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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 aftersurgery.

Preoperative Instructions

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.

Postoperative Hip Replacement Rehabilitation Regimen

Patient should be made to come out of bed in stroke chair twice a day with assistance within 1or 2 days postoperatively. Chair should not be of low height. Begin ambulation with assistivedevice (walker) twice a day. > Weight bearing recomendations in Hip ReplacementRehabilitation

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 acane in contralateral hand for 6 months. Wheelchair must be used for long distances withcareful avoidance of excessive hip flexion greater than 80 degrees while in wheelchair, this canbe achieved by placing a cushion in the wheelchair seat with highest cushion point posterior.

Isometric and bed Exercises (Hip Replacement Rehabilitation)

Straight Leg Raise (SLR)- Tighten knee and lift leg off the bed, keeping the kneestraight. 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 acount 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 bymoving the leg out to the side and back. Perform this exercise while lying on one side (5-6 weeks postoperatively). The patient should be turned 30 degree towards prone to


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utilize gluteus maximus and medius muscles. Most patients would otherwise tend torotate towards the supine position, thus abducting with the tensor fascia femoris.

ROM and Stretching Exercises (Hip Replacement Rehabilitation)

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 hipflexors 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 ahigh 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 toincrease hip flexion within safe parameters.

Perform extension stretching of the anterior capsule in standing by extending theinvolved leg while the uninvolved leg is mildly flexed at the hip and knee, supported bythe walker. Slowly thrust the pelvis forward and the shoulders backward for a sustainedstretch of the anterior capsule.

Abduction Pillow

Keep an abduction pillow between the legs while in bed. Use the abductor pillow while asleep orresting in bed for 5-6 weeks, it may then be safely discontinued.

Bathroom Rehabilitation : Permit bathroom privileges with assistance and an elevated commodeseat. 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

>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.

Transfer Guidances

Bed to Chair- Avoid leaning forward to get out of chair or off bed. Slide hips forward tothe edge of the chair first, then come to standing. Do not cross legs when pivoting fromsupine to bedside position. Therapist or nurse assists until able to perform safe, securetransfers.

Bathroom- Use elevated toilet seat with assistance. Continue assistance until able toperform safe, secure transfers.

Stair training in Hip Replacement Rehabilitation

Going up stairs- Step up first with the uninvolved leg, keeping crutches on the stepbelow until both feets are on the step above, then bring both crutches up on the step. Ifavailable hold the handrail.


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

Exercise Progression in Hip Replacement Rehabilitation:

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 lateralstep ups with a low step, if clinically safe. Progress hip abduction exercises until thepatient 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 gluteusmaximus) and with the knee extended to strengthen the hamstrings and gluteusmaximus.

Initiate general strengthening exercises, develop endurance and perform cardiovascularexercises.

Instructions for Home in Hip Replacement Rehabilitation

Continue with the previous exercises and ambulation activities. Continue to observeprecautions.

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.

Managing Problems After Total Hip Replacement :

1-Trendelenburg Gait(weak hip abductors)

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.

2-Flexion Contracture of the Hip

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

days.

The above mention Hip Replacement Rehabilitation Protocol should be tailored to individualpatients 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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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, andimprove strength of the rotator cuff muscles.

Restorative Programme : The basic aim of frozen shoulder exercises are:

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 ofhumerus.

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.

Mobilization is attained by 3 basic approaches:

i) Relaxationii) Passive mobilization techniqueiii) Specific frozen shoulder exercises to offer graduated stretching.

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

Relaxation

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

Relaxed Passive Mobilization

The patient is placed in supine position with the affected shoulder in maximum possibleabduction and neutral rotation and elbow in 90 degree of flexion. The physiotherapist graspingthe arm above the shoulder joint carries out relaxed passive gliding movement of head ofhumerus on glenoid. Axial traction and approximation is carried out along with antero-posteriorglide 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 effectivelyinduces relaxation and promotes mobility. Gentle relaxed passive movements reduces pain andpathologic limits of motion. The reduction in pain occurs because of the neuro-modulation effecton the mechanoreceptors with in the joint.
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Mobilization by accessory movements of acromio-clavicular, sterno-clavicular and/or scapulo-thoracic 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. Whileplanning the frozen shoulder exercises one must give due importance to the fact that contractedsoft tissue when objected to repeated prolong mild tension show extensibility and plasticelongation.

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

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

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:

By weight and pully- Tolerable weight must be used. This may be done in supine orsitting position.

By self assisted stretching- Method of performing is, the patient uses his normal orcontralateral arm for gradually stretching the affected shoulder.

Passive Mobilization Technique

For this, manipulation and mobilising techniques are given by "MAITLAND". By this patientrespond very well for acquiring full range by properly guided simple and specific Frozenshoulder exercises which ensures relaxed graduated stretching of the contracted capsule.

Frozen Shoulder Exercises for Home and Cautions:

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 orstiffness.

Patient having diabetes responds very slow to the treatment and also feel much morepain as compared to those who are non-diabetic.

Patient who are complaining of pain in the night (nocturnal pain) should be treated byheat therapy or thermo therapy.
http://www.metacafe.com/watch/3034735/shoulder_pain_pendulum_exercise/http://www.metacafe.com/http://www.metacafe.com/http://www.metacafe.com/watch/3034735/shoulder_pain_pendulum_exercise/


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The contralateral or normal shoulder should always be examined and given regularstretching exercise programme as a precautionary measure to maintain its functionalcapacity.

Frozen Shoulder Introduction:

Codman introduced the term "frozen shoulder" in 1934 to describe patients who had a painfulloss 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 withadhesive capsulitis have a painful restriction of both active and passive GH joint motion in allplanes, or a global loss of GH joint motion.

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

Adhesive Capsulitis is characterized by 3 stages:

Length of each stage is variable, but typically the first stage lasts for 3-6 months, the secondstage 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 senseof discomfort that radiates down the arm. Often, a specific traumatic event is difficult for thepatient 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 representsthe "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 diminishesduring this stage, leaving the patient with a shoulder that has restricted motion in allplanes Activities of daily become severely restricted. When performing activities, a sharp acutediscomfort can occur as the patient reaches the restraint of the tight capsule. Pain at night is acommon complaint and is not easily treated with medications or physical modalities. The stagecan 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 thefrozen stage into the thawing phase.

Diagnosis:

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


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

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

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

In general, a global loss of active and passive motion is present; the loss of external rotationwith the arm at the patient's side is a hallmark of this condition. The loss of passive externalrotation is the single most important finding on physical examination that helps to differentiatethe diagnosis from a rotator cuff problem because problems of the rotator cuff generally do notresult in a loss of passive external rotation.

Frozen Shoulder Treatment:

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

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

Frozen Shoulder Exercises (Rehabilitation Protocol):

Phase 1: Weeks 0-8

Goals

Relieve pain Restore Motion

No restriction or immobilization.

Pain Control

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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Motion: Frozen Shoulder Exercises

Initially focus on forward flexion and internal and external rotation with the arm at theside, 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.

Phase 1: Weeks 8-16

Criteria for progression to Phase 2

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

Goals

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

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 totwelfth thoracic spinous process.

Muscle strengthening

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

Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm atthe side. Perform internal rotation, external rotation, abduction and forward flexion.

Progress to open chain strengthening exercises with theraband for same greoup ofmuscles.

Progress to light weight dumbbell exercises for internal rotators, external rotators,

abductors and forward flexors. Perform strengthening of scapular stabilizers. Deltoid strengthening.

Phase 3: 4 months and beyond

Criteria for progression to Phase 3


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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

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.

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

Warning Signs:

Loss of motion

Continued Pain

Treatment of Complications:

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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cervical spondylosis,

Treatment of cervical spondylosis, also known as Cervical Osteoarthritis by physical therapymodalities. Cervical Osteoarthritis can be treated in physiotherapy department by variousmeans like:

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

Aims of Cervical Spondylosis Treatment

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.

Cervical Osteoarthritis Introduction

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

Degenerative disc disease Degenerative spondylosis Osteopytosis Spondylitis deformans

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 othertable works.

It starts with degeneration of disc resulting in, reduced space in between two vertebrae, laterosteophytes are formed in the periphery. This is followed by involvement of the posteriorintervertebral joints resulting in pain in the posterior part of the upper limb. Generally, this pain isalong with tingling, numbness and radiating in nature.


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The osteophytes formed may also compress the cord which will produce weakness of whole ofthe limb.

Predisposing Factors For Cervical Osteoarthritis

Faulty postureadapted is associated with wrong habits, anxiety and mental tension.

Occupational stressescauses continous pressure on the cervical segments. Thesections of society prone to stress and strain are-a) Officers, typists and others working on poorly and wrongly positioned desks andtables.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 bodyPersons having thick neck with a Dowager's Humpand long backs aremuch prone to spondylosis.

Sites

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 ordepression. It occurs gradually due to faulty posture.

2)Pain: The region of pain depends on the site where the cervical spine is affected by thepathology.a) Upper cervical spine- Headacheb) Mid cervical spine- Neck painc) Region from C4 to T2- Radiating pain; pain in shoulder girdle, shoulder and arm, eitherunilateral or bilateral.

3)Muscle weakness: Depending on which nerve root gets compressed, the concerned musclesthat are supplied by that nerve root gets affected and weakened. Usually, the postural musclesof the neck are weak. They are: upper cervical spine flexors, lower cervical spine extensors andside flexors.

4)Sensation: There occurs paraesthesia that means, pins and needles or altered sensation ofthe 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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6)Limitation of movement: All the neck movements get limited, often bilateral but is unilateral incase of acute onset of pain. The movement which gets very much limited is flexion of the uppercervical 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 ofmovements of the accessory intervertebral structures.

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

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

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.

10) Cervical spondylosis is usually associated with headache, vertigo and loss of balance whichis due to postural changes.

Investigations

The only investigation which can easily confirm the diagnosis apart from the symptoms of thepatient is radiograph. Early and proper diagnosis is necessary for Treatment Of CervicalSpondylosis/Cervical Osteoarthritis. The X-ray finding reveals that there is:

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

Treatment for Cervical Spondylosis

Heat Modalities

Heat is an effective mean of reducing and relieving pain in cervical osteoarthritis. The modalitiesthat 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 progressedgradually according to the conditions and requirements of the patient.


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Static Contractions and Strengthening Exercises

Isometric contractions of the cervical muscles improve the muscle endurance and tone as thecontractions improve the blood supply thereby the nutrition to the muscle is increased andhence muscle strengthening is done.

The basic technique of this exercise is that both Physiotherapist and patient exert equalpressure so that static; non dynamic action takes place in the cervical muscles. During all themovements, shoulder girdle should be stabilised so as to avoid trick movements. The pressurecan be applied by the physiotherapist or by the patient himself after teaching him the techniqueproperly.

Soft tissue technique

Kneading helps to release tightness of upper fibre of trapezius. Picking up, wringing and skinrolling 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 isused to relieve nerve root pressure.

Traction is always given in comfortable position with minimum weight which should begraduated slowly as for the patient's recovery. This depends on the frequency of remissions andexacerbations of the condition. It can be given in sitting or lying position. The traction can begiven 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 musclespasm. To relax the upper fibres of trapezius, patient is taught to push one hand then the othertowards the feet in the float support lying position.

For the lower fibres of trapezius and serratus anterior, sitting on the float with both handsholding down the float is the preferred position. This also stimulates the muscles and thereceptors of the neck and shoulder joint to hold the head in a good position.

Postural Awareness

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 andinitiated by the physiotherapist.

The ideal posture is straight neck with chin tucked in and back straight with no compensatoryactions or any trick movements. While sitting a high backed chair is provided to the patient withhead, neck and shoulder supported; a small pillow in the lumbar spine, feet properly supportedand arms resting on a pillow over the lap or on the arms of the chair.


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While sleeping, side lying is the most preffered position, supine lying is also adviced. A singlepillow under head for head support is allowed. A Butterfly pillow is the best support for a patientof cervical osteoarthritis, as it is flattened in the middle where the head rests and the elevatedends support the head on the sides.

Support

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

Relaxation

Due to pain and spasm of cervical muscle, patient is always in discomfort and uneasiness. So toalleviate these undesirable situations, relaxation techniques are taught in various positions thatis during rest, work or play.

While lying on bed, patient is adviced to loosen his entire body and stretch for few times so as toreduce the muscular tension to a minimum. While relaxing the whole body should be fullysupported by pillows. He is then encouraged to think of something pleasent which will facilitatecomfortable and relaxed sleep.

Surgery may be necessary for a patient suffering from cervical osteoarthritis if he/she hassevere pain that does not improve from other conservative treatments. It should be the lastresort as there is always a risk factor involved.

Calcaneal Spur

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

Heel Spur Causes

Thus calcaneal spur is a late sequale of plantar fascitis. Heel spurs and plantar fasciitis canoccur alone or be related to underlying diseases which cause arthritis (inflammation of the

joints) such as Reiter's disease, ankylosing spondylitis, and diffuse idiopathic skeletalhyperostosis.


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Heel Spur Symptoms

The calcaneal spur may not be always painful.When painful a sharp, stabbing painunder 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.

Heel Spur Diagnosis

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

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

Heel Spur Treatment

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 downfrom bed in morning or after long sitting ).

Relieve pain and inflammation: Use of ultrasound and contrast bath help reduce painand inflammation.

Avoid walking barefoot: Shoes are a must to support the arch of the foot even when athome. Arch Supports and heel cups cushion to the heel, and reduce the weight bearingon 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 tothe intrinsic muscles in warm water in the morning before initiating weight bearing.Strengthening exercises to the intrinsic muscles as sustained toe curling, performedeven with shoes on provide an excellent technique of resistive exercises. Resting onlateral border of the foot with cupping of the foot by curling of toes is effective inmoulding longitudinal arch.

Weight loss: Losing weight can reduce the extra pressure that plantar fascia bears withevery step.

Medications: Pain Relief Medications like analgesics and anti-inflammatory are advisablein acute as well as chronic cases.

For chronic heel pain management or surgical advice consult a podiatrist. Steroids andanesthetic injectables at the site of spur may be advised in severe ceases.


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Genu Varum

Genu Varum is also known as Bow Leg. It is a deformity wherein there is lateral bowing of thelegs at the knee.

This is usually due to defective growth of the medial side of the epiphyseal plate. It is commonlyseen unilaterally and seen in conditions such asRickets, Paget's disease and severedegree osteoarthritis of the knee.

The degree of deformity is measured by the distance between the two medial femoral condyleswhen the patient is lying.

Treatment of Bow legs

Generally, no treatment is required for idiopathic presentation as it is a normal anatomicalvariant 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.

Mild degree of deformity can be treated by wearing surgical shoes with 3/8" outer raised andwith 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 wearcasts or braces following the operation.

Post operative Physiotherapy

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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De Quervain Tenosynovitis

What is De Quervain tenosynovitis? : De Quervain tenosynovitis is an entrapment tendinitis ofthe tendons contained within the first dorsal compartment at the wrist. It is an inflammatorycondition 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:

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

.Etiology of De Quervain tenosynovitis

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

De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen orirritated. The irritation causes the lining (synovium) around the tendon to swell, which changesthe 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 befound in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usuallymost common in middle-aged women.

Pathology of De Quervain tenosynovitis

The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicislongus muscles. These two muscles, which run side by side, have almost the same function: themovement of the thumb away from the hand in the plane of the handso called radialabduction (as opposed to movement of the thumb away from the hand, out of the plane of thehand -palmar abduction). The tendons run, as do all of the tendons passing the wrist, in synovialsheaths, which contain them and allow them to exercise their function whatever the position ofthe wrist. Evaluation of histological specimens shows a thickening and myxoid degenerationconsistent with a chronic degenerative process. The pathology is identical in de Quervain seenin new mothers. De Quervain is potentially more common in women; the speculative rationalefor 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, alongwith tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarelynoted.

Signs of De Quervain's tendinitis:


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Pain may be felt over the thumb side of the wrist. This is the main symptom. The painmay appear either gradually or suddenly. Pain is felt in the wrist and can travel up theforearm. The pain is usually worse when the hand and thumb are in use. This isespecially true when forcefully grasping objects or twisting the wrist.

Swelling may be seen over the thumb side of the wrist. This swelling may occur togetherwith 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.

Examination

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

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

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 thepatient 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 caughtearly enough. Splinting with a thumb-spica splint may be necessary to reduce the movement ofthe wrist and lower joints of the thumb. If these interventions do not work, then a cortisone shotinto the irritated area may be the next course of action. Physical therapy may also be used toretrain movements to avoid or change the method of those daily actions that caused theinflammation.

The final step, if all other interventions fail, is surgery to release the tendons and provide morespace for them to move. Following the surgery physical therapy may still be required to retrainthe movements that caused the injury.

What can a physical therapist do to help in De Quervain tenosynovitis?

In acute stage

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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suggest activity modifications

In chronic stage

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 handcenters 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

Surgical Treatment for De Quervain tenosynovitis

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

Complications

Although de Quervain tenosynovitis features a simple tendon entrapment and the treatment isquick and straightforward, complications can be profound and permanent. Careful attention to

surgical technique at the initial release is paramount to avoiding complications.

Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, oradhesions in the scar can cause neuritis in this high-contact area, greatly limiting hand and wristfunction. This complication is best avoided through careful blunt dissection of the subcutaneoustissue and gentle traction.

Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longusare mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis. Insuch a case, the extensor pollicis brevis tendon may remain entrapped within the septated firstdorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgicalre-exploration may allow a previously overlooked tendon to be released.

Subluxation of released tendons is possible. With wrist flexion and extension, the tendons of awidely released first dorsal compartment snap over the radial styloid. This complication is bestavoided by carefully limiting the release to the thickest mid 2 cm of the first dorsalcompartment or by reconstructing a loose roof to the released sheath. Reconstruction of thesheath with a slip of local tissue may relieve symptoms.

Preventive measures for De Quervain tenosynovitis


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Prevention of overuse injuries commonly requires breaking up sessions of work or practiceinvolving a particular area into shorter periods with more frequent breaks to allow that area torest and avoid the overuse.:>>A proper warm up before doing any lifting, grasping or holding forextended periods may prepare the tendons for the task and prevent some of the strain placedon them.>:Avoidance of activities that cause pain is a common sense prevention method thatoften gets ignored. If a movement causes pain, find another activity or action that accomplishes

the same task without the pain.

Pinched Nerve In Shoulder

Typically, pinched nerve in shoulder occurs when too much pressure is applied to the shouldernerve by the surrounding tissue, such as cartilage, tendons, bones and muscles.Symptomsinclude muscle weakness, numbness, pain and a tingling sensation that radiates along theshoulders 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.

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 sportsinjury. In many cases, a pinched nerve results in severe pain and disability in the shoulder andupper arm. After treating the pain with moist heat, consult your physician. Exercise therapy isone of the first courses of treatment.

What is a pinched nerve?

A pinched nerve is a term that is quite common to hear, but most of us dont really know what itmeans. A pinched nerve in the shoulder is a complaint that you will hear often, a very painfulone 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 apinched 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 discarea in your neck. It usually happens around C6 and C7. This is typically where problems canoccur and result in symptoms like a pinched nerve in the shoulder. The nerves that run throughC6 and C7 travel down through your shoulder blades, and can cause chronic pain and musclesspasms. A pinched nerve in the shoulder that originates in the neck is not always the actualdiagnosis, but it is something you need to look out for, as it is quite typically disguised as ashoulder problem.

The neck is a complex place when it comes to nerves, and neck pain can stem from all mannerof things, including a pinched nerve in the shoulder. Nerves can become trapped in the shoulderitself, due to the cramped conditions in an area called the brachial plexus. The brachial plexushas 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 ofthe chest, shoulder, arms, and hands. Disc herniation in the cervical spine can also causepinched 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 theones who are having pinch nerve in shoulder. People working in constructions carry heavyloads like hollow blocks, sand, rocks, wood are the once having pinch nerve in their shoulder.
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Same for factory workers and delivery men carry heavy loads of their products. They have beenputting pressure on their bodies, especially their shoulders. Other causes of pinch nerve are dueto swelling of some parts of your body because of pregnancy,arthritis, diabetes, family historyand 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 nervecan be the cause. The trouble could be rooted in another medical problem, such as a herniatedspinal disc.

If you have an extracervical ribthis can put more stress on an already cramped area, and anyminor trauma to the shoulder can result in neck pain, arm pain, and even coldness andweakness in the fingers, depending on which nerves have been impacted. Sometimes a fairlyinnocuous repetitive motion which taps on the front of the shoulder can lead to inflammation inthe area and cause a pinched nerve in the shoulder.

Pinched Nerve In Shoulder Symptoms

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

Numbing: Numbness or tingling can occur due to a pinched nerve in shoulder. You might get afeeling that your shoulder is dead, or when you touch it you dont feel as much, there is lesssensation. Pins and needles is another common complaint. It may occur any place betweenyour 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 apinched nerve in shoulder. You may experience it when you are reaching above your head to tryto 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.

C5 - The main result of a pinched C5 nerve root is shoulder pain, weakness in thedeltoid 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 intoyour thumb. Other less common symptoms include weakness in the biceps and wristmuscles.

C7 - The main result of a pinched C7 nerve is pain and numbness radiating down thearm 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.

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 physicianwill isolate the problem by assessing your symptoms and then, most often, sending you for an
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X-Ray, MRI or CT scan. If the nerve at C5 is pinched, however, you are likely to developshoulder pain, numbness, and weakness in the deltoids and bicep muscles. Pain can be bothsharp and acute, or a dull aching pain in the neck or shoulder. Some patients may experience awidespread pain, whereas for others it is isolated to a smaller spot and can produce a burningsensation. Numbness, and a feeling of pins and needles in the shoulder can indicate a trappednerve and lead to muscle weakness and, over time, muscle atrophy (wasting).

Treatment for Pinched Nerve In Shoulder

Stuff To Do At Home

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

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

3. Apply a heat pack onto your shoulders and neck. One of the reasons you have pain isbecause your shoulder muscles might be too tight and therefore compressing the underlyingnerve. Heat can greatly relieve the muscular tension and therefore apply less pressure on thenerve.

4. Massage the neck and shoulder. Make sure that you dont apply too much pressure. Themassage should be light and gentle. Dont try to massage yourself and get a health professionallike a chiropractor, physical therapist or massage therapist to treat you.

5. Use anti-inflammatory drugs (NSAID Non-Steriod Anti-inflammatory drugs). These can giveyou a bit of relief but be sure that you know the possible side effects are. They do not removethe cause of the pain.

6. Apply heat cream or herbs onto the affected area. Again, this doesnt remove the cause ofthe problem but can give you plenty of relief.

After about 10 -12 days, you can start physiotherapy. It helps strengthen and stretch themuscles, 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 notrespond 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 onecause because it increases the pressure on the nerves with the heavy weight in your body, sotry to loose weight. Exercising regularly is a big help, try swimming, jogging or biking. Then letyour body rest after a long work. One cause of pinch nerve is over working.


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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 chestout, and try to lessen the use of very high heeled shoes. These are some tips that can help inimproving pinched nerve in shoulder. But take note that you should always ask your doctorabout these especially when your pinch nerve is severe.

Myositis OssificansProdyut Das

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.

Also known as

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

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 inflammatorychanges are rarely evident. Also in early phase of evolution, formation of bone may not beobserved, so term ossificans is not always applicable.

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 forciblemanipulation will cause a widespread involvement.

What causes myositis ossificans?

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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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 bethe site. Process is peculiar alteration within the ground substance of connective tissue,associated with striking proliferation of undifferentiated mesenchymal cells. Initially there isdegeneration 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 immaturefibroblasts. At the same time, primitive mesenchymal cells proliferate within injured connectivetissue. Intense cellular proliferation of fibroblasts and mesenchymal cells produces a histologicalpicture that may be erroneously diagnosed as fibrosarcoma or myosarcoma. Ground substancebecomes homogeneous or glassy or waxy, suggesting some type of edema. It increases inamount and encloses some of mesenchymal cells, which then assume the morphologicalcharacteristic 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 formationand mineralization changing in mature bone evolves, it progressively extends towards thecentral, severely damaged area. When myositis is not removed and is allowed to mature, itbecomes oriented and covered by a cartilaginous cap, because of muscle action over thelesion. This is called post traumatic osteochondroma and is common in region of knee joint.

Pathophysiology of myositis ossificans traumatica

The specific cause and pathophysiology are unclear - it may be caused by an interactionbetween local factors (e.g., a reserve of available calcium in adjacent skeletal tissue or softtissue 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 totissue with foci of calcification and then to maturation of calcification and ossification.

Myositis Type

In the first, and by far most common type, nonhereditary myositis ossificans (commonlyreferred to simply as "myositis ossificans"), calcifications occur at the site of injuredmuscle, 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 totrauma. It is passive stretching then active exercise, is responsible for bone formation.

The second condition, myositis ossificans progressiva (also referred to as fibrodysplasiaossificans progressiva) is an inherited affliction, autosomal dominant pattern, in which

the ossification can occur without injury, and typically grows in a predictable pattern.IPjoint of thumb, large toe and spine are liable to fuse. All joint motion is finally lost andpatient dies of inter current infection. This condition is very rare.

Symptoms of Myositis include

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


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

Radiographs:

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

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

Bone Scan:

active myositis appears as intense para-osseous accumulation of tracer activity in acutelydamaged muscle on delayed images;

Prognosis:over time, the volume of heterotopic bone will diminish;

Treatment of myositis :

Rest Immobilization Anti-inflammatory drugs physiotherapy management

surgical debridement

Radiation therapy subsequent to the injury or as a preventive measure of recurrence may beapplied but its usefulness is inconclusive.

Treatment is initially conservative, as some patients' calcifications will spontaneously bereabsorbed, and others will have minimal symptoms. In occasional cases, surgical debridementof the abnormal tissue is required, although success of such therapy is limited.

physiotherapy management of myositis ossificans includes

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

Surgical Management


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Growth should not be removed in premature stage as it will likely reoccur. The ossificationbecomes exuberant, infiltrates beyond the original site, and compresses the soft tissues aroundbeyond hope of repair. When after serial x-rays the mass is dense, well delineated, and at astand still, it may be safely removed. It may be possible to prevent myositis by aspirating theoriginal 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 thejoint capsule or tendon sheath. It contains clear gelatinous fluid.

Causes for Ganglion Cyst: The aetiology is yet to be known. Myxoid degeneration of fibroustissue of capsule, ligaments and retinaculae has been suggested. This is sometimes initiated orexcited by injury.

According to some, ganglion arrises from small bursa within the substance of the joint capsuleor the fibrous tendon sheath. This bursa becomes distended possibly following trauma givingrise 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 issurrounded by fibrous capsule and it posseses small pseudopodia.

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.

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

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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Clinical features of Ganglion Cyst: The patient often is a young adult. The most commonpresenting symptom is a painless lump. Occasionally there may be considerable pain, which isoften 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 (asthe 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 sheathof a tendon, the swelling becomes fixed as the tendon is made taut.

Ganglion Cyst Treatment:

Consevative Ganglion Cyst treatment

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 yourhand and wrist to rest, which may help shrink the cyst. As the cyst shrinks, it mayrelease the pressure on your nerves, relieving pain.

A strike on the cyst will cause rupture on the cyst with apparent belief of cure (previouslyit was done with the holy bible in the west). But with this ganglion cyst treatmentrecurrence is common. Massaging the ganglion. Rubbing the ganglion gently but oftenduring the day may help move the fluid out of the sac. Do not smash a ganglion with abook or other heavy object. You may break a bone or otherwise injure your wrist bytrying 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 notsucceeded to claim cure in majority of the cases

Operative Ganglion Cyst treatment

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

After surgery

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, movingthe 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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Therapy is sometimes utilized after surgical and non-surgical treatment. Your therapistwill teach you exercises to mobilize your joints. This may be helpful for reducing swellingand 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 andhand.

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 orrestricted motion. Your doctor can help you decide the best treatment for you

Managing Fibromyalgia an urban ache

What is Fibromyalgia?

Fibromyalgia (FMS) refers to a condition with a constellation of symptoms that includewidespread aching, stiffness, fatigue, and the presence of specific body tender points. Thepresence of pain originates in the muscles and connective tissues of the body. It is a syndromeof unknown etiology characterized by chronic wide spread pain, increased tenderness topalpation and additional symptoms such as disturbed sleep, stiffness, fatigue and psychologicaldistress. While medication mainly focus on pain reduction, physical therapy is aimed atmanaging fibromyalgia consequences such as pain, fatigue, deconditioning, muscle weaknessand 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. Theexact physiological process has not been determined, but it is likely many factors, includingthose beyond the muscles and fibrous tissues, play a role.

Since many patients with joint and ligament pain have been referred to rheumatologists, tocheck whether inflammation is present that would respond to antiinflammatory drugs, thismedical specialty developed criteria for the diagnosis of this illness.

The American College of Rheumatologists (ACR) defined fibromyalgia (FMS) in 1990 as thepresence of-

1) body or joint pain above and below the waist, and on the right and left side of thebody,

2) axial pain (most often neck or low back pain), and 3) 11 out of 18 possible tender points.

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


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examined by clinicians, there is surprisingly little inflammation present for the amount of painthat is experienced. In fact, muscle and ligament examinations from biopsy samplescharacteristically show no unusual patterns of disease or inflammation. About 2-5% of thegeneral population is considered to have FMS. FMS is a common disorder characterized bymultiple 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 jointsthemselves. These tender points hurt when pressed with a finger. Tender points are often notdeep 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 ofFMS, 11 of 18 tender point sites must be painful when pressed. In addition, for a diagnosis offibromyalgia, the symptom of widespread pain must have been present for three months.

FMS trigger points exist at these nine bilateral muscle locations:

Low cervical region: (front neck area) at anterior aspect of the interspaces between thetransverse 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.

Is there a prescription medication that help managing fibromyalgia pain ?

Managing Fibromyalgia Pain for tender points with involves a multifaceted treatment programthat 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, thestandard treatment for managing fibromyalgia (Chronic fatigue syndrome) and tender pointsinvolves medications, daily stress management, exercise, physiotherapy, hydrotherapy using

heat and ice, and rest. Other remedies for symptoms may also be used in managingfibromyalgia.

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 oftender points. As an example, therapeutic massage can manipulate the muscles and softtissues of the body to help ease pain, muscle tension, spasms, and stress.


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Twice daily moist heat applications are also helpful in easing the deep muscle pain andstiffness. 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 controlyour 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 exercisessuch as guided imagery, deep-breathing exercises, or the relaxation response to manage howyou respond to stress.

Staying on a regular bedtime routine is also important. Doing so allows your body to rest andrepair itself. In addition, regular exercise is vital to managing fibromyalgia pain, depression, andother symptoms of fibromyalgia.

A number of factors can make FMS symptoms worse. They include:

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

What Are the Symptoms of Fibromyalgia?

Symptoms of FMS include:

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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FMS symptoms may intensify depending on the time of day -- morning, late afternoon, andevening tend to be the worst times, while 11 a.m. to 3 p.m. tends to be the best time. They mayalso 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 maydisappear for months and then recur.

What causes fibromyalgia?

The exact cause is not known. Patients experience pain in response to stimuli that are normallynot 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 brainnerve chemical serotonin is also relatively low in patients with chronic fatigue syndrome. Studiesof pain in fibromyalgia have suggested that the central nervous system (brain) may be somehowsupersensitive. Scientists note that there seems to be a diffuse disturbance of pain perception inpatients with FMS.

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

Doctors don't know what causes fibromyalgia, but it most likely involves a variety of factorsworking together. These may include:

Genetics. Because FMS tends to run in families, there may be certain genetic mutationsthat 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 coatingaround sensory nerves. Still another hypothesis regarding the cause of fibromyalgiasymptoms proposes that affected individuals suffer from vasomotor dysregulationresulting in sluggish or improper vascular flow.

Diagnosis

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


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objective laboratory tests or medical imaging studies to confirm the diagnosis. While historicallyconsidered either a musculoskeletal disease or neuropsychiatric condition, evidence fromresearch conducted in the last three decades has revealed abnormalities within the centralnervous system affecting brain regions that may be linked both to clinical symptoms andresearch 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, andbehavioral interventions.

Diagnostic Criteria

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

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

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 thi

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