Physiotherapy for Ankylosing Spondylitis
December 20, 2008 | Leave a Comment
Ankylosing spondylitis belongs to a group of disorders called the spondyloarthropathies, a group which also includes psoriatic arthritis, reactive arthritis and arthritis related to inflammatory bowel disease. All these conditions are linked by the genetics of a gene on white blood cells called HLA B27 and by the presence of enthesitis, inflammation at the points where ligaments and tendons insert into bone. This can lead to fibrosis at these sites and then bone formation, causing joint fusion (ankylosis) in some cases.
The commonest spondyloarthropathy is Ankylosing spondylitis, which occurs as a reflection of the occurrence of the HLA B27 gene in the population. The gene occurs much less commonly near the equator and much more commonly in northern latitudes, and this is also the pattern with the development of AS. White race people are more commonly affected with around 0.1 to 1.0 percent overall, varying with latitude. Only 1 or 2 people of a hundred with the HLA B27 gene actually develop AS, but if they have a close relative who has the condition the likelihood rises to 15 to 20%.
Only one female is diagnosed with AS for every three males, and female patients’ symptoms are often much milder and some may be missed as a diagnosis of AS. The most typical presenting group is young men under 40 years old, with under sixteen year olds making up to twenty percent of this group. The symptoms appear on average at twenty-five years of age and the diagnosis is rarely made above fifty years old. AS can look like mechanical back pain if sufficient attention to detail is not made. Strong and persistent stiffness is often an answer to the question of how they are in the morning.
Low back pain is the major diagnostic alternative but AS patients are generally younger and the inflammatory process leads to different symptoms:
Morning stiffness in the lumbar spine, lasting at least 30 minutes or longer Exercise improves the back pain and stiffness Rest worsens the pain and stiffness Pain is usually worse in the second half of the night, after a time of rest Peripheral joints are affected in 30 to 50% of patients Tiredness is common AS has systemic affects from its inflammatory nature which can include feeling unwell, fever and loss of weight.
Physiotherapy examination of the spine in an AS patient usually uncovers significantly reduced ranges of spinal movement from normal, with perhaps a reduced lumbar lordosis and an increased thoracic curve. Neck movements may also be limited in later stages and a reduction in chest expansion noted due to rib joint involvement. Peripheral symptoms occur in around a third of patients and the physio will palpate the tender areas, searching for evidence of enthesitis in the insertions of the Achilles tendon and plantar ligament of the foot. These are areas of high mechanical stress and commonly affected.
Postural analysis of the AS patient is the first thing a physiotherapist notes after the subjective examination, recording spinal abnormalities, flexed knees, rounded shoulders or poking head posture. The ranges of movement of the cervical, thoracic and lumbar spine are measured and a battery of standard measures taken which allows assessment of the disease progression. The hips or other peripheral joints may be affected and these need to be measured also, with the physio likely testing out sites where the enthesis is likely to be painful and inflamed. If the disease is active then the patient may also have joint effusions and may appear unwell, be sweating and not have slept well.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
The Shoulder and Physiotherapy
December 2, 2008 | Leave a Comment
The gleno-humeral joint, known in lay terms as the shoulder, is a vital part of the links in the upper limb and responsible for our ability to place our hands where we can see them to perform activities. Because flexibility is a prime requirement the shoulder is a less stable joint with moderate muscle power and a large range of motion. It is described as a “soft tissue joint”, implying that the joint’s functional ability is dependent on its soft and not its hard components. Physiotherapists are closely involved in treating and rehabilitating the shoulder, dealing with the muscles, ligaments and tendons.
The gleno-humeral joint is made up of the ball of the humerus and the socket of the shoulder blade which is called the glenoid surface. The top of the arm bone, the humeral head, is large and carries many of the tendon insertions for the stability and movement of the shoulder. The socket or glenoid is a relatively small and shallow socket for the large ball but is deepened slightly by a fibrocartilage rim called the glenoid labrum. Above the shoulder is the acromio-clavicular joint, a joint between the outer end of the collar bone and part of the shoulder blade, a stabilizing strut for arm movement.
A great many muscles act on the shoulder joint and on the other joints in the shoulder girdle, the acromioclavicular, sternoclavicular and scapulothoracic joints. The glenohumeral and scapulothoracic joints are acted upon by the major stabilisers and movers in the area, varying from power muscles which allow forceful work to stability muscles such as serratus anterior and the rotator cuff to smaller movement muscles such as deltoid. The muscles must keep the relationship between the shoulder blade and the thorax and ribcage steady and under control for the glenohumeral joint to also enjoy stability and precise movement.
The rotator cuff is a group of four small muscles which originate from the scapula and insert around the ball of the humeral head, the teres minor, subscapularis, infraspinatus and supraspinatus. The cuff tendons form a sheet around the ball of the arm bone and allow forces to be exerted on the humeral head by the shoulder girdle muscles. If the rotator cuff is not functioning normally the more powerful muscles tend to make the humeral head slide upwards on the socket, interfering with normal function and making a person unable to lift their arm up above their head.
As a person ages, the rotator cuff develops degenerative changes in its tendinous structures, causing small tears in the tendons which can enlarge until there is no continuity between the muscles and their attachments. This leads to loss of normal shoulder movement and can be very painful but is not always so and “Grey hair equals cuff tear” is a common saying. Physios work at rotator cuff strengthening, whilst in massive tears the main shoulder muscles can be progressively strengthened to improve function. Surgery is possible for massive, moderate and small rotator cuff tears and physiotherapists manage the post-operative protocols.
The shoulder joint is not typically affected by OA (osteoarthritis) but when it is physiotherapists treat arthritic shoulders by joint mobilisations, muscle strengthening and ranges of motion. Once physio has nothing else to offer, total shoulder replacement is one of the further options, with various surgical techniques involving replacing the humeral ball and the scapular socket either anatomically or in reverse. The shoulder is often called a “soft-tissue joint” as the soft tissues, their strength and balance, are vital to the function of the joint. Post-operative physio management is essential as the correct protocol must be closely followed to ensure success.
Physiotherapists treat many other types of shoulder problems such as impingement, tendinitis, hypermobility, abnormal muscle patterning, fractures and dislocations. Impingement is treated by strengthening the rotator cuff or by subacromial injection or acromioplasty operation, where the end of the acromion can be excised. Tendinitis is treated by direct treatment of the tendon and graded strengthening and hypermobility by stability work and accepting the limitations dictated by the condition. Abnormal muscle patterning is managed by teaching normal patterns functionally and fractures and dislocations by the protocols laid down by the surgeons and trauma physiotherapists.
Physiotherapy Treatment of Shoulder Fractures
November 30, 2008 | Leave a Comment
Humeral fractures occur commonly with up to five percent of all fractures falling into this category, eighty percent of humeral fractures being minimally displaced or undisplaced. Osteoporosis is a contributing factor in many of these fractures and a fracture of the forearm on the same side is a typical presentation. Nerve or arterial damage from the fracture is an important consideration but not common. Typical sites of fractures are the top of the arm (neck of humerus - “shoulder fracture”) and the middle of the shaft of the humerus.
Humeral fractures are typically caused by a fall on the arm, force being transmitted from the elbow or hand or by a fall onto the side of the upper arm. The upper arm is the site of attachment of many of the arm muscles and the pull these exert at the time of injury can displace the fracture. Older people are more susceptible to these fractures with a typical age of around 65 being the peak occurrence, while if this fracture occurs in young people it is due to road accidents or sporting injuries.
A forceful incident is normally required to fracture the humerus and if there is no history of this the physician will suspect a cause such as cancer. The physio examination will show significant pain on attempted movement of the shoulder or elbow, reduced movement of the shoulder, widespread bruising or swelling in the whole arm and in shaft fractures some arm shortening is possible. Checking for nerve damage is important as the radial nerve can be injured especially in shaft fractures, impairing control of wrist and thumb muscles.
Management of Arm Fractures
Acutely the patient is kept still and given adequate analgesia to relieve the initial pain. Fractures of the upper part of the arm bone can mostly be managed without operation if there is little or no displacement but rotator cuff injury could occur if the greater tuberosity is fractured, especially if it is displaced any distance, great force was involved or the patient is older. A collar and cuff sling allows upper humeral fractures to traction themselves straight and in line, while shaft fractures can be braced but are difficult to control.
Displaced three or four part fractures typically require surgery, referred to as ORIF (open reduction internal fixation) and this is more likely in younger people. Older people may have a poorer result in terms of pain and movement so may have surgical replacement of the head of the arm bone. Plating and nailing is usually unnecessary for shaft fractures as they heal well normally. The side effects of humeral fractures include nerve injury in shaft fractures, adhesive capsulitis and avascular necrosis of the head of the humerus. Healing occurs in six or eight weeks and older people may never regain full movement of the shoulder.
Physiotherapy for Shoulder Fractures
Initially the physio assesses the arm, asking the patient about their pain level as this varies greatly, examining the swelling and bruising of the arm. The physiotherapist then checks the available range of movement of the shoulder, elbow, forearm and hand. Any muscle weakness and sensory loss is noted as this may denote nerve damage. If not operated on, a sling is continued with and if the fracture is not too painful or severe, early exercises are started by the physiotherapist. Pendular exercises, with the patient bending over at the waist, are important in the early stages as they allow movement of the shoulder joint without much force.
Three weeks after the fracture bone healing will be well under way so the physiotherapist will instruct the patient in auto-assisted exercises, using the other arm, to help reduce stress on the injury. Unassisted exercises are the next step as the arm becomes stronger, to practice lateral and medial rotation and flexion. At six weeks the bone will be clinically sound so the physio can progress to more vigorous movements with resistance and gentle end-range stretching. Joint mobilisations can be useful to free up the sliding and gliding movements of the joint and strengthening and joint range work continued with Theraband.
How Osteopaths Treat Neck Pain
November 23, 2008 | Leave a Comment
Osteopathic medicine is a type of medicine that considers the entire body and not just a person’s individual or isolated symptoms. Osteopathic medicine is very popular right now, especially for people who suffer from joint and muscle pain. Many people believe that when you have neck pain, one of the best resources you can seek out is an osteopath. Of course, if you’ve never visited an osteopath before, you might be nervous, but you really need not worry. Here is what to expect when you visit an osteopath to treat neck pain.
At first, you’ll probably feel like you are visiting a “regular” doctor. You’ll be given a physical and asked for your complete medical history. After that, your osteopath will perform a few additional tests to help determine the exact cause of your neck pain. He or she might take an X-Ray to find out if you have damaged any of your vertebrae. Don’t be surprised if your osteopath then gives the rest of your body a complete examination as well!
It is important to know that when you visit an osteopath for help with your neck pain, you should leave your “personal space” at home. Osteopathic treatment is hands on!
Your Osteopath might use any of the following methods to treat your neck pain:
Counterstrain technique: Your osteopath puts you into a position that is designed to restore movement to muscles that might be currently restrained or strained.
Muscle Energy technique: Your osteopath gives you exercises that will start with your muscles in precise positions and follow with you moving those muscles in precise movements.
Soft Tissue technique: this technique involves your osteopath putting pressure on the muscles that are near and around your spine. Sometimes the pressure is deep, other times it involves traction or rhythmic stretching.
Thrust technique: your osteopath will use high velocity force to reintroduce movement to your joints or to get rid of any signs of muscle asymmetry, restricted movement, muscle tenderness or tissue changes.
In some cases, osteopaths will also use low level lasers or acupuncture to treat their patients.
An osteopathic visit might sound scary, but there is no reason to be frightened. Most people who visit an osteopath don’t experience any pain. Most of the time osteopathic visits have been reported to be pleasant and relaxing!
A number of people often confuse osteopaths with chiropractors, but it is important to understand that the two professionals, while seemingly similar, are actually quite different! A chiropractor is a professional who wants to treat your spine and joints. Osteopaths want to work with you and help treat your entire body.