Emerging Physios

The Fifth Cervical Vertebra (C5)

2025-06-26T21:13:00.000+05:30

The C5 vertebra is structurally similar to C3 and C4 — a typical cervical vertebra — but it holds increased clinical significance due to the C5 spinal nerve, which is a major motor root for shoulder muscles (especially deltoid and rotator cuff). It plays a key role in neck motion, especially flexion and lateral bending, and lies near the thyroid gland anteriorly.

Key Points

1. Type: Typical cervical vertebra (like C3–C6)
2. Spinal nerve C5: Major motor supply to deltoid, biceps, supraspinatus
3. Motion: Assists in neck flexion and side-bending.
4. Landmark level: Just below the thyroid cartilage
5. Vertebral artery: Still passes through transverse foramen
6. Facet joints: Guide movement and prevent over rotation.

Important Questions & Answers

1. Q: What type of vertebra is C5?
A: A typical cervical vertebra.
2. Q: Which nerve exits at C5?
A: The C5 spinal nerve, which forms part of the brachial plexus.
3. Q: What muscles does the C5 nerve root innervate?
A: Deltoid, biceps, supraspinatus, and partially the diaphragm (via phrenic nerve).
4. Q: What clinical signs may appear in C5 dysfunction?
A: Weak shoulder abduction, decreased biceps reflex, pain/numbness in lateral arm.
5. Q: Is there any organ close to C5?
A: Yes, thyroid gland and recurrent laryngeal nerve lie anteriorly.
6. Q: What movements are supported at C5?
A: Flexion, extension, and lateral bending of the neck.

Clinical Insight

1. C5 dysfunction may lead to:
Shoulder pain (even when shoulder is normal)
Deltoid weakness or atrophy
Referred pain to lateral neck and upper arm

2. Commonly affected by:
Forward head posture
Chronic neck tension (especially in desk workers)
May also be hypertonic from sympathetic activity (linked to thyroid tension anteriorly)

The Fourth Cervical Vertebra (C4)

2025-06-25T21:35:00.001+05:30

The C4 vertebra is a typical cervical vertebra, structurally similar to C3 and C5. It serves as a central support for head and neck movement, playing a role in flexion, extension, and rotation. C4 lies at the level of the thyroid cartilage (Adam’s apple). The C4 spinal nerve plays a major role in neck muscle control and contributes significantly to the phrenic nerve, which powers the diaphragm — essential for breathing.

Key Points

Type: Typical cervical vertebra
Location landmark: Behind the thyroid cartilage
Transverse foramen: Contains vertebral artery
Spinal nerve C4: Contributes to the phrenic nerve → controls diaphragm
Common symptoms: Tightness in neck, shoulder pain, breathing difficulty
Joints: Facet joints allow motion & protect spinal cord

Important Questions & Answers

Q: What kind of vertebra is C4?
Ans: A typical cervical vertebra, similar to C3 and C5.

Q: What landmark is at the level of C4?
Ans: The thyroid cartilage (Adam’s apple).

Q: What nerve exits at the level of C4?
A: The C4 spinal nerve.

Q: What important nerve does C4 help form?
Ans: The phrenic nerve, which controls the diaphragm.

Q: What symptoms may indicate C4 dysfunction?
Ans: Neck pain, shoulder pain, shallow breathing, and reduced neck rotation.

Q: What artery passes through the transverse foramen of C4?
Ans: The vertebral artery.

Clinical Insight
1. C4 lesions may affect the phrenic nerve, leading to diaphragm dysfunction (shallow breathing or hiccups).
2. Can also cause referred shoulder pain and scalene tightness.
3. Gentle cervical mobilization can restore nerve communication and improve breathing or posture.

The Third Cervical Vertebra (C3)

2025-06-17T22:29:00.001+05:30

The C3 vertebra is part of the lower cervical spine and acts as a support link between the upper cervical spine and the rest of the vertebral column. It shares structural features with C4 and C5, forming a stable yet mobile segment. It helps in neck flexion, extension, lateral bending, and rotation. The spinal nerve exiting here (C3) is vital for neck muscle control and contributes to the phrenic nerve, which controls the diaphragm.

Key Features:

Vertebra type: Typical cervical vertebra (like C4–C6). Small body, large vertebral foramen, bifid spinous process.
Transverse foramen: Passage for vertebral artery.
Facet joints: Allow movement and protect spinal cord.
Nerve involved: C3 spinal nerve.
Muscle control: Helps supply neck muscles, trapezius, and part of the diaphragm (via phrenic nerve).
Clinical link: Lesions here affect breathing, neck stiffness, and sometimes referred pain in shoulder.

Questions & Answers

What kind of vertebra is C3?
Ans: A typical cervical vertebra with common features like bifid spinous process and transverse foramen.
What nerve exits at C3?
Ans: The C3 spinal nerve.
Which important nerve does C3 contribute to?
Ans: The phrenic nerve, which innervates the diaphragm.
What clinical symptoms can a C3 lesion cause?
Ans: Neck pain, breathing difficulty, shoulder pain, and muscle weakness in the neck.
Why is C3 clinically important in osteopathy?
Ans: It affects head/neck movement and breathing via phrenic nerve contribution.
What artery passes through the transverse foramen of C3?
Ans: The vertebral artery, which supplies blood to the brainstem.

Clinical Insight
A lesion at C3 can disturb phrenic nerve signaling, causing difficulty in breathing or shallow respiration.
Tightness in trapezius or scalene muscles may signal C3 nerve dysfunction.
Gentle mobilization can improve nerve flow and reduce referred pain to the shoulder or jaw.

The Atlas (C1 Vertebra) & The Axis (C2 Vertebra)

2025-06-14T23:00:00.006+05:30

A. The Atlas (C1 Vertebra)

The atlas is the first cervical vertebra, specialized to support the skull. It has no body or spinous process, allowing greater motion. It forms joints with the occiput (atlanto-occipital joint) and with the axis (atlanto-axial joint). It transmits the vertebral artery and spinal nerve, and its lesions can lead to headaches, dizziness, and visual symptoms.

Key Features:

No body or spinous process.
Articulates with the skull and axis.
Supports nodding and slight rotation.
Important structures: vertebral artery, C1 spinal nerve.
Clinical importance in headache, vertebrobasilar insufficiency

Questions & Answers:

1. Why is it called the atlas?

Ans- It supports the skull, like Atlas held up the sky in Greek mythology.

2. What joint does it form with the skull?

Ans- Atlanto-occipital joint.

3. What unique feature does it lack?

Ans- It has no vertebral body or spinous process

4. What artery passes through the transverse foramen?

Ans- Vertebral artery.

5. Clinical sign of atlas misalignment?

Ans - Headache, neck stiffness, dizziness.

6. Main motion allowed?

Ans- Flexion-extension (nodding).

7. Important related nerve?

Ans- Suboccipital nerve (C1)

B. The Axis (C2 Vertebra)

The axis (C2) is the second cervical vertebra. It is unique because of a bony projection called the dens (odontoid process) that acts like a pivot, allowing the atlas (C1) and skull to rotate side to side ("no" movement). The atlas rotates around the dens, making this the most mobile vertebral joint in the spine.

Key Features:

Function: Supports rotation of the head (side-to-side)
Special feature: Dens (odontoid process)
Joint formed: Atlanto-axial joint (C1-C2)
No intervertebral disc between C1 and C2
Vulnerable to injury, but vital for head mobility
Spinal cord and vertebral artery are closely related — making lesions here serious

Questions & Answers

What is the main function of the dens?
Ans: It serves as a pivot that the atlas (C1) and skull rotate around.
What joint is formed between the atlas and axis?
Ans: The atlanto-axial joint.
What happens if the transverse ligament (which holds the dens) is damaged?
Ans: The dens can press on the spinal cord — a potentially fatal condition.
What movements are allowed at the atlanto-axial joint?
Ans: Rotation (side-to-side head turning).
Why is there no intervertebral disc between C1 and C2?
Ans: To allow free pivot movement and reduce resistance during rotation.
Which nerve is related to C2?
Ans: The greater occipital nerve - it may be involved in tension headaches.

Clinical Insight:

A rotated or misaligned axis can cause:

Vertigo or balance problems
Neck stiffness,
Irritation of the vertebral artery
Headaches (especially at the back of the head)
Gentle manual correction can relieve symptoms and restore head movement.

Ultrasonic Therapy

2020-08-06T00:48:00.004+05:30

INTRODUCTION

Ultrasonic therapy is the therapeutic application of ultrasound waves within the frequency range between 0.7 MHz to 3.3 MHz with energy absorption at a depth of 2 to 6.5 cm of soft tissue. Used to promote tissue healing and decrease pain in both acute and chronic conditions.
Ultrasound is a form of acoustic vibration or mechanical vibration propagated in the form of longitudinal compression waves, at frequencies too high to be heard by the human ear.
Frequency of Sound waves:-

1. Infrasound - less than 20 Hz frequency

2. Audible sound - ranges between 20 Hz to 20000 Hz

3. Ultrasound - above 20000 Hz (0.02 MHz)

Majority of Ultrasound generators are set at a frequency of 1 MHz but some units are set at 3 MHz.
Ultrasonic energy generated at 1 MHz transmitted through the more superficial tissue and absorb primarily in deeper tissues up to 2 to 6.5 cm.
At 3.3 MHz, the energy is absorbed up to 1 to 2 cm of penetrated tissue.

Frequency controls the depth of penetration of ultrasound; 1 MHz ultrasound penetrates approximately 3 times as far as 3.3 MHz.(picture adapted from Cameron, fourth edition)

PRINCIPAL OF ULTRASONIC THERAPY

Ultrasonic therapy transfer high-frequency sound pulse in the body by using a probe to produce the thermal and mechanical effect in the tissues. Recently it was found that it also has the non-thermal effects.

Thermal effect:- The continuous transfer of ultrasound waves from transducer head to tissue generates a considerable amount of heat which absorbed by tissue causing an increase in tissue temperature results in a chemical equilibrium of tissue,which is helpful in the removal of scar, deep tendon healing etc.
Non- thermal effect:- On and off the transfer of ultrasound results in the dissipation of heat during the off-time, causing an increase the intracellular calcium level and cell membrane permeability, facilitate tissue healing, modify inflammation and enhance transdermal drug delivery.

PRODUCTION

Piezoelectric effect:- when certain crystals such as quartz, tourmaline, zirconate titanate and signette's salt are put under stress and released alternatively, a potential difference is produced across their faces and they change their shape. This phenomenon is called the piezoelectric effect.
Reverse piezoelectric effect:- A condition, when crystals are under the influence of high-frequency alternating current, they compress in size and when the current is off they expand.
In Ultrasonic generator, the reverse piezoelectric effect is used, where compression and expansion of the crystal hitting the front metal plate causing vibration and produces ultrasound waves.

The source of high-frequency current is conveyed by a coaxial cable to the transducer circuit and to treatment head or applicator or sound head.

Inside the transducer circuit, high-frequency current is applied to the crystal, that being fused to the metal front plate of the treatment head.

Cross Section of an Ultrasound Transducer: A coaxial electrical cable delivers an alternative current that innervates the piezoelectric crystal, causing it to vibrate via the reverse piezoelectric effect and produce ultrasonic sound waves(picture adapted from Therapeutic Modalities, fourth Edition)

Change in Crystal shape causes vibration of the front metal plate which in turn produce ultrasonic waves.


Piezoelectric Crystals. The reverse piezoelectric effect. The crystal expands and contracts when an electric current is passed through it. (picture adapted from Therapeutic Modalities, fourth Edition)

Strict frequency control of high-frequency current (1 MHz to 3 MHz) ensures a steady and regular rate of deformation.

TRANSMISSION OF ULTRASOUND

Rarefaction and Compression of Molecules. An ultrasound wave passing through the tissues creates alternating periods of low and high pressure. Molecules in the low-pressure areas expand (rarefaction), and molecules in the high-pressure area compress. (picture adapted from Therapeutic Modalities, fourth Edition)

Ultrasonic waves are a series of mechanical compression and rarefaction of air particles in the direction of the waves, hence called the longitudinal wave.
Air does not transmit Ultrasonic waves because of its less elastic nature, as being a longitudinal wave sound needs a medium to travel. So great care is needed to be taken to not leave air between the treatment head and patient.

A. REFLECTION:-

Ultrasound reflection and refraction. (picture adapted from Cameron, fourth edition)

When ultrasound beam passes through one medium to another, there will be a certain amount of reflection occur preventing the complete transmission of ultrasound waves, this reflection depends on the acoustic impedance (z) of the medium.
Acoustic impedance is the ratio between the reflected and transmitted Ultrasound at an interface. How deep an ultrasound beam passes through tissue depends on the resistance provided by the tissue. this physical property of tissue resistance described as acoustic impedance.

1. Reflection at transducer head- skin interface:- when head and skin are not in proper contact, a small air pocket remains between them causing reflection of Ultrasound to the transducer head. Which lead to damage to the piezoelectric crystal and may cause excessive heating of the transducer head and skin.
2. Reflection at the tissue - air interface:- Occur when ultrasound is given to the thin area such as the palm of the hand where Ultrasound goes through the tissue and then meet the air opposite side. Pain felt in the area of the skin opposite the transducer head.
3. Reflection at bone periosteum:- At bone periosteum, 70% of energy is reflected and 30% is absorbed by the bone. As the Ultrasonic energy is absorbed in the periosteum, it quickly heats up causing periosteal pain.

B. REFRACTION:-

When Ultrasonic beam encounters an interface between the two media and transmitted, it may be refracted i.e. deviated from its path.

While travelling from a medium with low velocity to a medium with high velocity, ultrasound beam deviates away from its target path.

C. ATTENUATION

Attenuation: Decreasing ultrasound intensity as the wave travels through tissue. (picture adapted from Cameron, fourth edition)

It describes the gradual reduction of Ultrasound intensity once left from transducer head and reaching towards the target site.
Factors which contribute to attenuation:-

1. Absorption:- Ultrasound is absorbed by the tissues and is converted into heat at a certain depth, depending on the type of tissue, as tissues with high protein content absorb more ultrasonic waves.

This accounts for some 60 to 80% of energy lost from the beam.

2. Scatter (to spread):- When a cylindrical beam of Ultrasound is deflected from its path due to refraction at interface, bubbles or particles of the medium called scattering of the ultrasonic beam.

The overall effect of these is that the Ultrasonic beam is reduced in intensity, the deeper it passes.

This gives rise to the term "Half value distance".

Half value distance:- The depth at which half of the initial energy has been absorbed.

The deeper the energy penetrates into the tissues, it decreases exponentially, as a proportion of it, is absorbed in each unit distance.

The half-value distance for 1 MHz is 6.5 cm and 3 cm for 3 MHz.

D. ULTRASONIC FIELD:-

No beam of Ultrasound emitted from the transducer head come out uniformly even in a homogeneous medium.
The Beam Non-Uniform ratio (BNR) is used to find the average non-uniform nature of Ultrasound beam.
BNR = The spatial peak intensity/The spatial average intensity in the beam.
Beam nonuniformity. (picture adapted from Cameron, fourth edition)
Spatial peak intensity:- The peak output intensity of an ultrasound beam at one point over the area of the transducer head.
Spatial average intensity:- The average output intensity of an ultrasound beam over the area of the transducer head.
At only one point in the centre, the intensity is at its peak, regardless at minimum over the edges of the transducer head.
The lower the BNR, more uniformly the beam travel across the transducer head, prevent high-intensity hot spots and tissue damage.
Near field:- Is the region up to which ultrasound beam converge.
Far-Field:- Is the region from where the ultrasound beam starts diverging.
The depth of the near field varies with the frequency of Ultrasound. The extent of the near field depends upon the radius (r) of the transducer head and the wavelength (ƛ) of the ultrasound beam in the medium. The depth of near field= r²/ƛ


A Schematic Representation of an Ultrasound Beam. Note the irregular intensity of near field and the spatial peak intensity in the far-field. (picture adapted from Therapeutic Modalities, fourth Edition)

C. COUPLING MEDIA:-

Ultrasonic Waves are not transmitted by air, that's why a couplant is used in between transducer head and skin.
Air reflect the ultrasound beam back into the treatment head, which might damage the crystal.
Consequently, the treatment head should not be left switched on, when not in contact with a medium.
No couplant affords perfect transmission of ultrasound waves and only a percentage of the original intensity is transmitted to the patient.

Characteristics of coupling media

Acoustic impedance is similar to the tissue, which does not let the reflection to occur.
High transitivity for Ultrasound, which let the ultrasound to travel deeper.
High viscosity, let the media to stay not to drop off.
Low susceptibility to bubble formation, to decrease the chances of cavitation.
A chemically inactive nature.
Hypo allergic character.
Relative sterility.
Cheap.
Act as a lubricant to allow the treatment head to move smoothly over the skin.

Method of Application

A. Modes

Continuous mode:-
1. Continuous transmission of Ultrasound waves throughout the treatment.
2. This mode produces a thermal effect and used for musculoskeletal conditions such as muscular spasm, joint stiffness, pain etc.
Pulsed mode:-
1. Transmission of ultrasound occurs in intervals, not continuously during the whole treatment.
2. When the transmission occurs it called on time and when it stopped, it called as off time.
3. The pulse mode produces less heat so it is used for soft tissue repair. Eg, Tendinitis.

The proportion of total treatment time expressed as The duty cycle or The mark: space ratio.

a) Marked: Space ratio:- The ratio of time, which express the on and off duration of Ultrasound in pulse mode. Some machine has a fixed ratio of 2:8 while others have variable range. e.g: 1:1, 1:4, 1:8. For a ratio of 1:1 defines that on and off time is 50-50% of total treatment.

b) Duty cycle:- Show's the percentage of on & off time of Ultrasound in the total treatment period. e.g: 20% duty cycle means that only for 20% of total treatment time Ultrasound is on.

Ultrasound Duty Cycle. The amount of time that the ultrasonic energy is produced. The top figure shows a 100% duty cycle. The bottom figure shows the ultrasound that would be emitted during the same period if a 50% duty cycle were selected. (picture adapted from Therapeutic Modalities, fourth Edition)

B. Frequency:-

Attenuation increase with an increase in frequency, that's why low-frequency ultrasound penetrates more deeply in the tissues.

1. 3 MHz frequency penetrates only superficial tissues as it reaches effectively up to 2.5 to 3 cm.

2. 0.75 to 1 MHz frequency penetrate in deep tissue due approximately 5 cm depth.


Relative Depth of Penetration of and 3-MHz Ultrasound. The effects of 1-MHz ultrasound occur more deeply within the tissues than 3-MHz ultrasound, which attenuates in the superficial tissues. (picture adapted from Therapeutic Modalities, fourth Edition)

C. Intensity:-

1. Measured in watts. The power per unit area of the sound head expressed in watts per centimetre square(w/cm²)

2. Intensity applied depends on the nature of the lesion.

For acute and immediate post traumatic:- 0.1 to 0.24 w/cm²

D. Duration of treatment

Amount of ultrasonic energy transmission during the treatment depends on the intensity of ultrasound and duration of treatment, and every condition requires a different amount of ultrasonic energy.
Duration of treatment depends on the Size of the affected area, generally, 1-2 minutes for every cm² id recommended.

Minimum- 1-2 minutes
Maximum- 8 minutes
Average- 5 minutes
For chronic- longer treatment time
For acute - lesser treatment time.

MECHANISM OF ULTRASOUND:-

Ultrasound therapy helps in improving the healing of acute injuries and decrease pain even in

chronic conditions. But how does it work?

By producing the following effects:

A. THERMAL EFFECT:

The absorption of ultrasound waves in the tissues results in oscillation of the particles. this oscillation produces heat, which is proportional to the intensity of the ultrasound waves.
The amount of heat generation within the tissues depends on the heat absorption by tissues and the amount of heat which is not dissipated.
The heat absorption by tissues depends on the following factors which are as:

1. Nature of tissue (Acoustic impedance): The tissue with high protein content absorbs more ultrasound, for example, Bone can absorb 30% of heat due to high protein content.

2. Degree of vascularization: Heat dissipation in the body, depends on thermal diffusion and local blood flow, so when there is less blood supply to some area due to injury or less vascular tissues like ligament or tendon. Heat can not be transmitted by blood flow results rise in local temperature of that area.

3. Frequency of ultrasound: Higher the frequency greater the absorption.

B. NON-THERMAL EFFECT.

Pressure changes applied to tissues by the ultrasound waves produce certain effects without increasing the temperature of the tissues, these are known as Non-Thermal effects.
Non-thermal effects achieve by using the pulsed mode where mark: space ratio is 1:2, 1:4 and 1:8 is seen at minimum.
The physical mechanism which is involved in producing these non-thermal effects are:

a) Cavitation:-

Phenomena of gas bubble formation due to vibration by ultrasonic waves within the tissues, these bubbles become smaller during compression and expands while rarefaction phase of the waves.

1. Stable Cavitation:-

When bubbles oscillate to and fro within the Ultrasonic pressure waves but remain intact.
While oscillating through many cycles, micro-scale eddy currents are produced around these oscillating bubbles known as micro-streaming.
Micro-streaming:- micro-scale eddy currents produced around oscillating bubbles causes reversible permeability changes in cell membrane locally. for example, increase the permeability of calcium ions and enhances cell activity.

2. Unstable or transient Cavitation:-

Occurs when the volume of bubbles increases rapidly and collapse suddenly.
It is dangerous to the tissues as the collapse of the bubbles causes a high-pressure change and great local rise in temperature, leads to the free radical formation and gross tissue damage.
It is avoided by moving the treatment head (to prevent standing waves), using a space average intensities (below 4 watts/cm²) and using a pulsed mode.

Cavitation and microstreaming. (picture adapted from Cameron, fourth edition)

b) Mechanical effect or Micro-massage:-

This occurs when the longitudinal compression waves of Ultrasound beam produces compression and rarefaction of cells and affect the tissue fluid movement in the interstitial space.
Helps in reducing oedema
Combining with thermal effect, this makes it easier to stretch the scars and adhesion by affecting their extensibility.

c) Biological effect:-

Some useful effect of ultrasound in tissue repair after an injury or infection.

Inflammatory:-
Ultrasound interact cells of repair process such as platelets, micro-phages, mast cell by producing platelet permeability and increasing intracellular calcium ions which eventually helps in releasing histamine by degranulation.
Proliferative:-
1. Ultrasound affects the rate of angiogenesis.
2. Enhance the motility and proliferation of fibroblast cells which produces collagen fibres and synthesis protein and eventually leads to wound contraction.
Re-modelling:-
Increase the extensibility and tensile strength of scar by affecting the direction, strength and reducing the cross-linking of collagen fibres.

Schematic Diagram of the Effects of Therapeutic Ultrasound. (picture adapted from Therapeutic Modalities, fourth Edition)

THERAPEUTIC GOALS:

A. THERMAL GOALS:

1. Chronic indurated oedema :

Ultrasound helps in breaking of adhesions formed between adjacent layers, thus removes the chronic oedematous fluid. for example in chronic traumatic oedema in the ankle.

2. Increase soft tissue extensibility:

Ultrasound is applied to the posterior knee in conjunction with an extension stretching force. (picture adapted from Cameron, fourth edition)

Immobilization, inactivity and scarring cause limitation in joint ROM and limitation of function. e.g. shortening Joint capsule, surrounding tendons or ligament.
Using this modality will increase the temperature of soft tissue and it's extensibility, makes it easier to stretch.
As these tissues have a high ultrasound absorption coefficient which makes it, a good modality to use in such condition.

3. Decrease pain:

Stimulates the cutaneous thermal receptors and inhibit pain by the pain gate mechanism as well as enhancing the soft tissue extensibility when using continuous mode.

4. Decrease Plantar warts:

it's a viral cutaneous infection causing skin lesions containing thrombosed capillaries covered by hyperkeratotic epithelial tissue, occurring commonly in plantar surfaces of children or young adults.
Recent studies show that the use of ultrasound modality will decrease these lesions at 0.6-0.8 W/cm², a continuous mode for 7-15 minute with 2-15 treatments.

B. NON-THERMAL GOALS :

Recent injuries and inflammation:- As discussed in biological effects, ultrasound helps in removal of tissue exudates and promotion of tissue repair which leads to inflammation resolution and pain reduction. example sprain and strain.
Calcium resorption:- Ultrasound helps in resorption of calcium deposits from certain tendons such as over supraspinatus tendon.
Bone fracture healing:- Recent studies recommended ultrasound parameters 0.15 w/cm², pulsed 20% duty cycle, 1.5 MHz frequency applied for 15-20 minutes, is useful in efficient fracture healing.
Surgical incision healing/ scar tissue:- Ultrasound is applied on first or second postoperative days for gynaecological surgical wounds and episiotomies in human, have been found to reduce pain, and resolve the haematoma which enhances breaking strength of such wounds.
Herpes Zoster infection pain:- For the treatment of pain resulting from acute herpes zoster low dose ultrasound is recommended.

CONCLUSION

Ultrasound is used as a therapeutic modality in physiotherapy to decrease pain and promote healing in both acute and chronic injuries. Mostly used frequencies in clinical practice are 1 MHz and 3 MHz. Ultrasound waves with 1 MHz frequency penetrate deeper than the 3 MHz.
Apart from frequency, intensity and duration of using ultrasonic waves also vary with the condition.
Ultrasonic waves can produce thermal effects when applied continuously and non-thermal therapeutic effects when given in pulsed mode, it depends on the condition which mode should be used. Generally, in acute injury pulsed mode and in chronic pain continuous mode of ultrasonic therapy is used.
There are specific properties of Ultrasound like reflection, refraction, attenuation and absorption which determines the transmission of ultrasonic waves in turn guide the way of using it in therapeutic setup, by some terms like acoustic impedance, half value distance and BNR etc.
Therapeutic ultrasound produces many thermal and non-thermal effects, which can be used to treat many conditions ranging from acute injuries to chronic pains.

Resources

·         Electrotherapy Simplified – Basanta Kumar Nanda

·         Clayton’s Electrotherapy: Theory and Practice, eighth edition – Forster & Phalastanga

·         Physical Agents in Rehabilitation: From Research to Practice, fourth Edition -Michelle H. Cameron

·         Textbook of Electrotherapy, second edition – Jagmohan Singh

·         Physical Principle Explained – John Low and Ann Reed

·         Therapeutic Modalities, fourth Edition - Chad Starkey

·         Ultrasonic Therapy – Physiopedia

Radiology | An Introduction

2020-06-22T23:11:00.014+05:30

Introduction

Radiology is vital nearly for every sector of health care, including Physiotherapy, as it helps to confirm the provisional diagnosis which a therapist makes after a thorough clinical examination of a patient.

In this blog, we are going to study that there are so many investigations comes under radiology, but for physiotherapist, we are mostly interested in X-ray, CT and MRI, that’s why we have started this blog series and in this blog, we are going to discuss:

Explanation of the basic properties of X rays, how it’s used to produce an image of the body organ.
A thorough discussion about: why bone appears white and air looks black in colour.
In the last, we would clear some important characteristics of these densities, which help us to interpret the x-ray image.

What is Radiology?

Radiology is a branch of medicine that deals with radiant energy to diagnosis and treatment of the disease.
It includes a broad spectrum of imaging techniques, the basic principle of imaging, however, remains the anatomical demonstration of a particular region and related abnormalities, the principle imaging modalities in which physiotherapist show interest are X-ray, CT and MRI.

Firstly, we are going to understand what is x-rays, how it produces images and fundamental concepts which are used to interpret the x-ray images.

What is the X Rays?

X rays are a form of electromagnetic energy, with a wavelength ranging from 0.01 to 10 nanometres, due to this short-wavelength X-ray has certain properties :

X-ray is ionizing radiation: which means X rays can produce ions (charged particles) in the matter and if this ionization occurs in a tissue, it can lead to cellular damage.
The X-ray can penetrate: but not through all the material, it can penetrate through less density matter and high-density matter can absorb it.

How X-ray images are produced?

X rays are produced in the x-ray machine and are exposed to the patient body or structure that we need to see and strike the photosensitive surface(x-ray detector), based on how much x rays reaches the detector after passing through patient, a shadowgram is formed of varying intensities of a grey colour.

Radiographic Densities:

There are five basic densities in the x-ray images based on the densities of the tissues present in our body.

Tissues densities are based on the following characteristics:

1) Atomic Number: higher the atomic number of a matter, the more x rays will be blocked from reaching the film. In the body minerals like calcium has the high atomic number that’s why they absorb x rays and appear white on the x-ray film.
Example: metal (like metal implants, screws etc) and bone.

2) Specific gravity: some tissues have the same atomic number but they appear different on an image, due to different specific gravity, air and soft tissues have the same atomic number, but the air has less specific gravity i.e 0.001, that’s why it appears black whereas soft tissue has specific gravity 1, so it appears more grey on the x-ray image

3) Thickness: thicker the tissue, greater will be x-ray attenuation and whiter would its image.

More dense tissues absorb more x rays and block them to reach the detector, and appear white on the image, such object or tissue is known as Radiopaque/Radiodense.
Less dense tissues allow the x rays to pass through them to reach the detector and appear black on the image, such matter is known as Radiolucent.

It is divided into 5 categories, according to their density:

(a) Metal (Bright white) - The density of metal is very high, so x-rays get absorbed in it and an image appears bright white in colour.

(b) Mineral (White) - Calcium also dense but less dense than metal, so x-rays get absorbed in it and bone appears white in colour, but part of the bone with less calcium appear less radiopaque e,g. osteoporotic bones.

(c) Fluid/Soft tissues (grey) - The density of both fluid and soft tissue is the same but slightly less than bone and higher than fat. So it appears grey colour in a radiograph.

(d) Fat(dark grey) - The density of fat is low than fluid/soft tissue but higher than air. So it appears dark grey colour in the radiograph.

(e) Air (black) - The density of air is very low, so when x-rays pass through air, it gets passed all the way through it and appears black in colour.

Important things while seeing X-ray image

Densities are additive

This means radiographic densities of different tissues on superimposition will show the combined density on the image. For example, a tissue light grey density is superimposed with tissue grey density, but on an x-ray image, we will see the nearly light grey.

Silhouette Sign

On an x-ray image, we can easily see the boundaries of tissue if its adjacent to the tissue with a different density like the boundary of heart shadow (grey) in a chest x-ray can easily be seen as its surrounded by air (black) which is radiolucent.

But on the other hand, if two structures with nearly the same density, then we can't see the boundaries of those structure as they got merged, in medical term it is known as silhouette sign.

Conclusion

Radiology or in general said Medical imaging is an important part of clinical practice and even for the physiotherapist.
This imaging technique plays an essential role to confirm the diagnosis and helps in the differential diagnosis.
Knowledge and skills to interpret radiological images and reports are very important to have better communication with the other doctors/team members/co-workers and give the ability to take better decision to refer the patient if it’s not related to the field of physiotherapy.
So, before directly jumping on the images to guessing which is this structure, we need to learn the basic concept related to imaging technique like how these images are formed? What do you mean by this black and grey colour in the x-ray? And many more questions are going to be answered in this blog series.

Resources

Radiology Fundamentals: Introduction to Imaging and Technology fourth edition.
Radiology Handbook: A Pocket Guide to Medical Imaging, J.S. Benseler, D.O.
Lecture Notes Radiology, Third Edition, Pradip R. Patel.
edX course: Applied anatomy of the locomotor system (Click here)
Physio-pedia (Click here)

Active Knee stabilizers

2020-06-08T00:21:00.071+05:30

Introduction

We have studied the arthrokinematics of the knee joint in our post "how our knee joint work". But to move the knee joint, we need some active and passive stabilizers. In our previous post, we studied "passive knee stabilizers" but we also need "Active knee stabilizers" to move knee efficiently.

So, In this post, we are going to study "Active Knee Stabilizers" and how they guide Knee Arthrokinematics.

Active Knee Stabilizers

Active knee stabilizers are contractile structures, which stabilize our knee joint while movement like muscles, also known as dynamic stabilizers.

Fig 1.1 Showing Front and back of the thigh

Muscles of the knee joint

(A) Knee flexors

There are 7 knee flexors as they cross the knee joint posteriorly are:
Hamstrings(semimembranosus, semitendinosus, biceps femoris) sartorius, gracilis, popliteus and gastrocnemius. ( Fig 1.2 &1.3)

Fig 1.2 Front of thigh showing gracilus and sartorius

Fig 1.3 Back of thigh showing Hamstring group

The semitendinosus, sartorius and gracilis form a common tendon, Pes anserinus(Goose foot). (Fig 1.4).

Fig 1.4 Saggital view of knee showing pes anserinus("Goose foot")

Rather than flexion, some of the muscles produce medial/lateral rotation or valgus/varus moments at the knee joint like:
Semimembranosus, semitendinosus, sartorius, gracilis and popliteus also medially rotate the tibia on the femur.
Biceps femoris, laterally rotate the tibia on the femur.
Biceps femoris, lateral head of gastrocnemius and popliteus produce valgus moments at the knee (resist varus stress at the knee).
Semimembranosus, semitendinosus, sartorius, gracilis and medial head of gastrocnemius produce varus moments at the knee (resist valgus stress at the knee).

(B) Knee extensors

Quadriceps femoris (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius).(Fig 1.5)

Fig 1.5 Front of thigh showing Quadriceps femoris

The resultant pull of the vastus lateralis muscle is 35° laterally, whereas the resultant pull of the vastus medialis muscle is 40° medially, due to it's attachment to the medial and lateral aspects of patella respectively by the reticular fibres. (Fig 1.6)

Fig 1.6 Showing pull of Quadriceps femoris muscle include vastus medialis(VM), vastus lateralis(VL),
vastus intermedius(VM), rectus femoris(RF
(adapted from norkin 5th edition)

The pull of vastus intermedius muscle is parallel to the shaft of the femur.
The net posterior compressive force due to vastus medialis (VM) and lateralis muscle(VL) is average 55°( Fig 1.7 )

Fig 1.7 Showing the posterior compressive force of
VL and VM at 55°
(adapted from norkin 5th edition)

The resultant pull of the quadriceps muscle is 10° to 15° in the lateral direction which is known as quadriceps angle(Q-angle). (Fig 1.8)

Fig 1.8 Front of thigh showing Q-angle

Patella:- The patella act as an anatomical pulley. It adds mechanical efficiency for quadriceps by increasing the moment arm of the quadriceps.

Clinical relevance:-

Any alteration in alignment that increases the Q-angle is thought to increase the lateral patellar compressive forces and if force is more, may also lead to subluxate or dislocate the patella.
Factors lead to increase Q- angle is:- Excessive genu valgum, Tight iliotibial band, Tight lateral retinaculum, medial femoral torsion, lateral tibial torsion, excessive or prolonged pronation in the foot. ( Fig 1.9)

Fig 1.9 Increased medial femoral (femoral anteversion) and tibial lateral torsion will result in a larger Q-angle and an increased lateral force on the patella

Q-angle is slightly greater in females than males, due to wider pelvis.

Role of muscles in arthrokinematic of Knee joint

While weight-bearing knee flexion, semimembranosus and popliteus assist the menisci to deform posteriorly(Fig 1.10) so that menisci remain beneath the rounded femoral condyle as the condyles move on the relatively tibial plateau. The quadriceps contract eccentrically to counterbalance the knee flexion, and maintain the knee joint in equilibrium.

Fig 1.10 Showing attachment of semimembranosus to the medial meniscus, which helps deform menisci posteriorly during knee flexion
(adapted from norkin 5th edition)

While weight-bearing knee extension, the soleus and gluteus maximus assist the knee to produce extension (although they don't cross the knee joint).

How? By pulling the tibia posteriorly on femur due to contraction of the soleus muscle and by posterior shear of the femur on the tibia due to contraction of the gluteus maximus muscle. (Fig 1.11)

Fig 1.11 Showing resultant pull of gluteus maximus and soleus assist in knee extension
(adapted from norkin 5th edition)

While non-weight-bearing knee extension, the quadriceps contraction creates anterior shear of the tibia on the femur which is resisted by the active or passive forces like an anterior cruciate ligament.
While non-weight-bearing knee flexion, hamstring contraction produce posterior shear of the tibia on femur and Popliteus assist the tibia to rotate medially to unlock the knee, posterior translation is resisted by Posterior cruciate ligament.

Summary

Active knee stabilizers are contractile structure (dynamic stabilizers) like muscles.
Knee flexors muscles like Hamstring, Sartorius, Gracilius, Popliteus.
They also resist valgus and varus stress at the knee joint.
Knee extensors muscles like Quadriceps femoris.
Q-angle, the resultant pull of quadriceps femoris muscle.
Increase in Q-angle, due to any malalignment of the body segment, lead to increase lateral compressive force on patella.
Factors lead to increase Q-angle like medial femoral torsion, lateral tibial torsion, Excessive genu valgum, Excessive foot pronation.
They also help in arthrokinamatic of the knee joint (weight-bearing/non-weight bearing).

Reference article

For more in details about the Q-angle, please click the reference link down below.

https://www.physio-pedia.com/%27Q%27_Angle

Resources

Joint structure and function, a comprehensive analysis 5th edition by Pamela K. Levangie, Cynthia C. Norkin
Kinesiology Of Musculoskeletal System, foundations for rehabilitation 2nd edition by Donald A. Neuman

Passive Knee Stabilizers

2020-06-01T01:07:00.173+05:30

Passive Knee Stabilizers are non-contractile structures like the joint capsule, ligaments and menisci etc. Which stabilize our knee joint and help in arthrokinematic of knee joint

In our previous post (click here), we discussed "how our knee joint work". But that was only bony movement and we know that bone can not move by itself, we need some active (muscle) and passive (capsulo-ligamentous) stabilizers which stabilize our knee joint and help in knee joint motion.

In this, we are going to study only about "Passive Knee Stabilizers"

MENISCI

The medial and lateral menisci are fibrocartilaginous structures located within the knee joint.
The medial meniscus is "C" shaped and Lateral meniscus is almost "circular".
The medial meniscus is less mobile due to greater ligamentous and capsular restraints than the lateral meniscus.

Fig 1.1 Superior view of tibia showing menisci and cruciate ligament
(adapted from Neuman, 2nd edition)

The menisci convert the articular surface of the tibia into the concave surface for the convex femoral condyles.

Functions:-

The primary function is to reduce the compressive stress across the tibiofemoral joint by distributing weight-bearing forces (Fig 1.2).
Reduce friction between the tibia and femur
Stabilize the joint during motion
Act as a shock absorber
Improve joint congruency
Facilitate normal joint arthrokinematics
Provide proprioception

Meniscal nutrition and Innervation

The periphery part is vascular(obtain its nutrition through a blood vessel) but the inner part, in contrast, is essential, avascular.
Innervated by free nerve endings(nociceptors) and three different mechanoreceptors (Ruffini corpuscles, panician corpuscles and Golgi tendon organs).

Clinical relevant

Due to the avascular nature of the inner part of menisci, reduce the potential for healing after an injury.
Proprioceptive deficits occur, as a result of injury to the mechanoreceptors within the meniscus.
Removal of menisci(meniscectomies), increase the joint stress (multiplies the forces by six or seven times on the tibial plateau) and may lead to damage of the articular cartilage, which contributes to degenerative changes within the tibiofemoral joint.
The medial meniscus is injured twice as frequently as the lateral meniscus due to relative lack of mobility of medial meniscus, has greater ligamentous and capsular restraints than the lateral meniscus.

Joint capsule

Fig 1.3 Showing both the layers of the joint capsule.

The joint encloses both tibiofemoral and patellofemoral joint.
It's composed of 2 layers:-

a) superficial thick fibrous layer
b) deep thin synovial layer

(A) Synovial layer

secrete and absorb synovial fluid into the joint

Function:- It lubricates the joint and provides nutrition to avascular structures such as menisci.

( B) Fibrous layer

support to a joint is provided by the several capsular thickenings or (capsular ligaments) (Fig 1.4).

Anteriorly, anterior portion of the knee joint capsule is called extensor retinaculum.
Medially, the thickest band ( transverse oriented fibres)within the medial retinaculum is the medial patellofemoral ligament.
Laterally, fibres(transverse oriented fibres) within the lateral retinaculum called a lateral patellofemoral ligament.
The remainder of the retinacular bands includes the obliquely oriented medial patellomeniscal ligament, the lateral patellomeniscal ligament and longitudinally positioned medial and lateral patellotibial ligaments.
Posterior joint capsule reinforced by posteromedially by oblique popliteal ligament, posterior oblique ligament, and posterolaterally by arcuate ligament, lateral collateral ligament, popliteus muscle/tendon (Fig 1.5).

Fig 1.4 Anterior view of knee, showing reinforcement of extensor retinaculum by medially and laterally ligaments. ( adapted from Norkin, 5th edition)

Fig 1.5 A view of the posterior capsule of the knee.
( adapted from Norkin, 5th edition)

Function:- Both the posterior oblique ligament and the arcuate ligament, assist in checking the hyperextension of the knee.

Innervation:- Innervated by both nociceptors as well as mechanoreceptors( Pacinian and Ruffini corpuscles).

Anterior and Posterior cruciate ligament

Fig 1.6 Showing cruciate and collateral ligaments of the knee.

Both ligament cross each other within the intercondylar notch of the femur, Connect tibia to the femur.
Both are the important "passive knee stabilizers", in the sagittal plane.
Both are intracapsular but extra synovial.
Both cruciate ligaments innervated by the mechanoreceptors

(A) Anterior cruciate ligament(ACL)

consist 2 separate bundles:

a) anteromedial bundle (AMB)

b) posterolateral bundle (PLB)

When the knee close to full extension, the PLB is taut & AMB is relaxed.
As the knee flexes, AMB becomes tight & PLB is relaxed.
The shift in the tension between the bundles, allow some portion of the ACL to remain tight at all times (Fig 1.7)

Functions:-

1. The primary function is Resist anterior translation of the tibia on the femur (open chain kinematic) and posterior translation of femur on the tibia (closed chain kinematic).

2. Resist hyperextension of the knee.

3. Resist extreme of valgus, varus and axial rotation.

4. In addition to stabilizing the knee, contribute proprioception to the knee as they contain mechanoreceptors.

5. Guide the natural arthrokinematic of the knee joint.

Fig 1.7 Although the anteromedial bundle(AMB) of the anterior cruciate ligament(ACL) is slack in extension and the posterolateral bundle(PLB) is slack in flexion, there is a continuum between the two so that some portion of the anterior cruciate ligament remains fairly taut throughout the range of motion.
(adapted from Norkin, 5th edition)

(B) Posterior cruciate ligament (PCL)

consist of 2 separate bundles

a) anterolateral bundle (ALB)

b) posteromedial bundle (PMB)

When the knee close to full extension, the PMB become taut & ALB is relaxed.
As the knee flexes, ALB becomes taut & PMB is relaxed.

Functions:-

1. The primary function is to resist posterior shear of the tibia on the femur (open chain kinematic) and anterior shear of the femur on the tibia (closed chain kinematic).

2. Resist extreme of valgus, varus and axial rotation.

3. In addition to stabilizing the knee, contribute proprioception to the knee as they contain mechanoreceptors.

4. Guide the natural arthrokinematic of the knee joint.

Medial and Lateral Collateral ligament

Fig 1.8 Anterior view of knee, showing medial and lateral collateral ligament.

Both ligaments are the important "passive knee stabilizers", in the frontal plane.

(A) Medial collateral ligament (MCL)

a broad structure that crosses the medial side of the knee joint.
It has 2 portions:-

The superficial portion is longer, it arises proximally from the medial femoral condyle travels distally to insert into the medial aspect of the proximal tibia.
A deep portion is shorter, it arises from the inferior aspect of the medial femoral condyle, continuous with the joint capsule travel distally to insert into the medial tibial plateau and rigidly affixed to the medial border of the medial meniscus.

Functions:-

The primary restraint to excessive valgus at the knee.
Resist excessive lateral tibial rotation at the knee.
Secondary role as a restraint to anterior tibial translation.
As it taut in full extension, assist with locking the knee.

(B) Lateral collateral ligament (LCL)

Cross the lateral side of the knee joint.
Proximally arise from the lateral femoral condyle travel distally to the fibular head, where it joins with the tendon of the biceps femoris muscle.

Functions:-

The primary function is to resist varus stress at the knee.
Resist excessive lateral tibial rotation at the knee.
As it taut in full extension, assist with locking the knee.

(C) Clinical Relevant

As Medial collateral ligament(deep portion), attached to the medial joint capsule and medial meniscus, severe injury to medial collateral ligament involve medial joint capsule and medial meniscus also.
Simultaneous Injury to the medial collateral ligament, the medial meniscus and anterior cruciate ligament called "terrible triad"(O' Donoghue triad) of knee joint structure.

Till now, we cover the "passive knee stabilizers" individually and their functions. Now we will study their role in arthrokinematic of the knee joint.

Role of Cruciate ligaments and Menisci in Arthrokinematic of knee joint

Cruciate ligaments

1. During weight-bearing knee flexion, anterior cruciate ligament gets taut and creating an anterior translational force on the femoral condyle (Fig 1.9 A)

2. During weight-bearing knee extension, posterior cruciate ligament creating a posterior translational force on the femoral condyles (Fig 1.9 B)

Menisci

1. During weight-bearing knee flexion, the oblique contact force of the menisci-on-femur(MF) guide the femur anteriorly during flexion, while the reaction force of the femur-on-menisci(FM) deforms the menisci posteriorly on the tibial plateau (Fig 1.10)

2. During weight-bearing knee extension (return to extension from full flexion), the posterior deform menisci return to their neutral position.

Fig 1.10 Schematically represented, the oblique contact of the femur with the wedge-shaped meniscus results in the forces of meniscus-on-femur(MF) and femur-on-meniscus(FM). These can be resolved into vertical (V1 &V2) and shear (shear 1 & shear2) components. Shear 1 assists the femur in its forward glide during flexion, and shear 2 assists in the posterior migration of the menisci that occurs with knee flexion. ( adapted from Norkin, 5th edition)

Conclusion:

In this post, we studied about the Passive Knee Stabilizers.

"Passive Knee Stabilizers" are joint capsule, ligaments and menisci.

Initially, we studied all these, individually what are they? What are there functions?

Like, some increase joint congruency, act as a shock absorber, distribute weight, provide proprioception and the structure which provide frontal and sagittal knee stability.

After that, we studied how these Passive Knee Stabilizers help arthrokinematic of the knee joint,

like During knee flexion, PCL guide femoral condyle to translate anteriorly and menisci deform posteriorly to translate femoral condyle on the relatively fixed tibial plateau.

Reference article

For more in details please click the reference link down below.

https://musculoskeletalkey.com/structure-and-function-of-the-knee/

Resources

1) Joint structure and function, a comprehensive analysis 5th edition by Pamela K. Levangie, Cynthia C. Norkin

2) Kinesiology Of Musculoskeletal System, foundations for rehabilitation 2nd edition by Donald A. Neuman

Posture | An Overview

2020-05-28T17:55:00.056+05:30

Posture (Body alignment) is something that everyone should have to concern because, as in most of the painful conditions, it's all related to the misalign segments of the body, where a person experiences pain or even breathing, the difficulty is all because of the postural defect.

It is better to understand basic details to create a good alignment then copying someone else form.

What is Posture

A position of the body which is required to achieve a functional task by taking less muscle effort and creating maximum stability.

This can be of two types :

1. Static posture: Without doing any movement, how your body handles your body alignment, like sitting, sleeping and standing.

2. Dynamic posture: With functional activity, how your body manages to achieve the correct functional positions, like running, jumping and throwing or bending.

Postural Alignment

Proper body alignment depends on the curvature of the spine. The spine has three natural curvature at the neck, mid-back and lower back.

When any of these curvature increase or decrease or bent in sideways will create a postural misalignment lead to postural defects.

Factors which affect Posture

The chief factors affecting Body alignment:

1. Psychological background:-

A stable and positive mental attitude has a profound effect upon the nervous system and these effect reflected in the alignment of the body part of an individual.

> Joy, happiness and confidence reflect an erect and alert body alignment.

> Unhappiness, sad and the feeling of inferiority reflects a stoop and flexed body alignment.

2. Healthy Body:-

In terms with good health conditions, proper nutrition and appropriate sleep play an essential role for a healthy nervous system, and for the growth and development of bones and muscles.

3. Opportunity for plenty of natural free movement:-

Activities like jumping, running and outdoor activities enhance the opportunity of natural free movement resulting in the healthy development of skeletal muscle growth, which in turn helps to maintain good body alignment.

4. Local factors:-

localised pain, muscular weakness, occupational stresses etc. lead to muscular imbalance lead to altered postural pattern and even the cause of the pain has been removed, this adaptive altered pattern is continued and form a postural defect.

Pain and Posture Relation

People ask me many times, why some individuals with weak and stretched muscles may have no pain, but why the individual with tight and strong muscle shows pain.

I always say that the answer lies in mobility of that individual, as the one with weak muscle have flexible joints and position of the body also change randomly while on the other hand, the one with strong muscle have tightness in the muscle leads to less mobility which can cause painful incidents.

Basic understanding to relate with pain is the effect of constant or repeated smaller stress occurring over a prolonged period which can give rise to the same kind of pain that occurs with a sudden stress/injury.

From a physiotherapist's point of view, there is an important difference exist in between treatment of an acutely painful condition with that of a chronic one. Therapeutic treatment is only beneficial and relieves the pain if applied at the right time. Otherwise, the application of one may not give that much effect.

Posture Assessment

As a physiotherapist, I always look for the following basic principle to detect a faulty body alignment which are:

1. Faulty alignment - which results in undue stress and strain on bone, ligament, joints, and muscles.

2. Joint positions- Indicate which muscle is short and which is elongated.

3. A relationship findings between muscle and alignment of body segment to know if this alignment is habitual.

4. Muscle shortness - which holds the origin and insertion of the muscle close together.

5. Muscle weakness- allowing separation of muscle origin and insertion.

6. Adaptive shortening of the muscle - occur when muscle remains contracted for prolong period.

7. Stretch weakness - which occurs in one joint muscle that remains in an elongated position.

Examining the spine curvature is an important and most reliable way of knowing the postural defect is structural or adaptive.

What does an ideal Posture look like

No posture is said ideal.

Ideal body alignment is only a myth.

Body alignment is considered ideal only when the body can change its shape and alignment based on the functional movement it needs to achieve and the given task can be completed with a maximum output of stability while putting less effort of using muscle work.

With such efficiency, less number of repeated stress occurs and mobility increases.

Always try to change your position in every 15-20 minutes to avoid stresses on the body joint which can lead to adaptive postural changes.

Conclusion

Perfect Postural alignment is a myth any alignment providing maximum output with less muscular effort is considered good body alignment.

Avoid any kind of pressure and load on physical and mental health as both will affect the body alignment.

Avoid any type of sedentary lifestyle where sitting is needed for 8 hours straight, use an alarm clock, set a 20 min timer. when it rings stand up walk a little then come back to work.

Always remember never underestimate the power of good body alignment as it relieves 70% of your muscular pain.

Resources

Muscles: Testing and function with posture and pain, 5th Edition - Kendall
The Principle of exercise therapy, Fourth edition - M. Dena Gardiner.

By Kunwar Karan Singh

(Physiotherapist)

Intervertebral Disc | A Brief Introduction

2020-05-25T16:59:00.000+05:30

What is Intervertebral Disc | Definition of Intervertebral Disc

Intervertebral disc (IVD) are soft tissues present in between the vertebrae in the spinal column, so that we can bend and twist our back smoothly.

Intervertebral means in the between the vertebrae.

There are 23 discs in our spine,

6 discs in the cervical spine

12 discs in the thoracic spine

5 discs in the lumber spine

No disc is present in the sacral and coccyx region as they are fused.

To understand how disc works, we need to know the components of a disc which make it able to perform those functions.

What are Intervertebral discs made of | Composition of Disc:

There are 3 parts of a disc and these three parts are composed of water, collagen, and proteoglycans (PGs) in different proportions along with many cells, including elastin, proteins, proteolytic enzymes, chondrocytes, and other types of collagen.

1. Nucleus Pulposus(like a water balloon): It is a gelatinous mass found in the center of the disc

a) Composition:

i) 70% to 90% of water,

ii) approximately 65% of PGs of the dry weight, these PGs have an ability to attract water molecules because of the presence of glycosaminoglycans, that’s why the nucleus pulposus has more concentration of water.

iii) 15% to 20% of Collagen fibres of the dry weight, there are two types of collagen fibres type I and type II, both of them has a different function; in the nucleus, type II collagen fibres are more than type I collagen fibres, which can resist compressive loads.

b) Function :

i) Resist compressive loads due to predominates type II collagen fibres.

ii) When compressed, it deforms its shape and the increased pressure stretches the walls

of the balloon in all directions due to high water content and act as a shock absorber

2) Annulus Fibrosus: it is a fibrous outer ring around nucleus pulpusos and It is attached to the cartilaginous endplates on the inferior and superior vertebral plateaus of adjacent vertebrae and to the epiphyseal ring region by Sharpey fibers.

a) Composition :

i) 60% to 70% of water.

ii) Only 20% PGs of the dry weight, that’s why less water concentration in annulus.

iii) 50% to 60% of Collagen fibers of the dry weight, with type I collagen is more than type II, which can resist tensile force and present in the outer portion of the annulus.

a) Function:

i) Resist greater proportions of tensile forces as type I collagen predominates in the annulus fibrosus, particularly in the outer portions.

ii) It helps to maintain the integrity of the nucleus pulposus under pressure.

3) Vertebral End Plate: These are the layers of cartilage with thickness 0.6 to 1mm, that cover the superior and inferior surfaces of the vertebral bodies. They cover the entire nucleus pulposus but not the entire anulus fibrosus. They are strongly attached to the anulus fibrosus and only weakly attached to the vertebral body, which is why it is considered to be a component of the disc rather than the vertebral body.

a) Composition :

i) It contains a higher proportion of water closet to nucleus pulposus i.e 70% to 80%

ii) Similarly PGs are also in high proportion like nucleus pulposus.

iii) But apart from the nucleus, it has a higher proportion of collagen fibres closest to the anulus fibrosus and the subchondral bone of the vertebral body and The cartilage of the vertebral endplates is consist of both hyaline cartilage(present toward the vertebral body) and fibrocartilage( present toward the nucleus and able to resist high compressive forces)

b) Function:

i) Tolerate high compressive forces and help in weight transmission, as Hyaline cartilage is found mainly in young discs and Fibrocartilage with increasing age, becomes the major component of the vertebral endplate, with little or no hyaline cartilage remaining, reflecting the need to tolerate high compressive forces.

Nerve supply of the Intervertebral Discs | Innervation of the disc:

Majority of the disc is not supplied by any nerve, which means any injury to disc will not cause pain to us, but some part of the disc does receive nerve supply, which are:

a) Outer one third to one-half of the fibres of the anulus fibrosus receive nerve supply from the vertebral and sinuvertebral nerves which means only from this part we can feel pain.

Blood supply of the intervertebral discs | Nutrition to the disc:

1. Disc are generally avascular which means there is no direct blood supply to provide nourishment.

2. Only the outer, more peripheral rings of the annulus fibrosus contain blood vessels from small branches from metaphyseal arteries, for this reason, most of the disc has an inherently limited healing capacity.

3. Essential nutrients, such as glucose and oxygen reach the deeper cells of the disc by diffusion through these peripheral blood supply.

Why we need Discs | Function of the Intervertebral Discs

1. Spine mobility: Since the disc is present in between the vertebrae, it separates two vertebral bodies, thereby it creates a space between the vertebral bodies and increases the available motion of the spine. This motion depends on the ratio between disc thickness and vertebral body height. The greater the ratio, the greater the mobility. This ratio is greatest in the cervical region, followed by the lumbar region, and the ratio is smallest in the thoracic region.

2. Weight Transmission: Disc helps in the transmission of load from one vertebral body to the next. The size of the disc is related to both the amount of motion and the magnitude of the loads that must be transmitted, that's why the size of lumber disc is largest than cervical as it has to bear the weight of trunk whereas cervical only bear the weight of the neck.

3. Hydrostatic Pressure Distribution: Disc acts as shock absorbers while transmitting body weight and protect vertebral bodies from the excessive pressure that might result from body weight or strong muscle contraction. The high water content of nucleus pulposus play a major role in this mechanism, which can be understood by following steps :

a) Compression forces from body weight and muscle contraction push the end plates inward and toward the nucleus pulposus.

b) Being filled mostly with water and therefore essentially in-compressible, the young and healthy nucleus responds by deforming radially and outwardly against the annulus fibrosus.

c) Radial deformation is resisted by the tension created within the stretched rings of collagen and elastin of the annulus fibrosus.

d) Pressure within the entire disc is thus uniformly elevated and transmitted evenly to the adjacent vertebra. When the compressive force is removed from the endplates, the stretched elastin and collagen fibers return to their original preloaded length, ready for another compressive force.

This mechanism allows compressive forces to be shared by multiple structures, thereby preventing a small spot of high pressure on any single tissue.

How Intervertebral discs vary in the spine | Regional variation of disc:

Just like vertebrae, Discs are also vary in size and composition in different regions of the spine, now we will study how disc in cervical spine differs from thoracic spine disc and lumber spine disc.

A. Cervical Intervertebral Disc:

a) Size:

i) The disc thickness at the cervical region is approximately 3 mm as weight-bearing loads are the lowest in this region and for the same reason the discs are smallest in the cervical region

ii) But the ratio between disc thickness and the vertebral body height is greatest in the cervical region,

This reflects the greater functional needs for mobility in the cervical spine.

a) Structure: composition and structure of nucleus pulpusos and vertebral endplate are similar in all the 3 vertebral regions, but the structure of annulus fibrosus vary in cervical and lumber region. Due to the following characteristics

i) Anulus Fibrosus of the cervical spine :

→ It does not have complete concentric rings that surround the nucleus pulpuses like lumber spine

→ It has a near-crescent shape i.e thick along the anterior rim and progressively tapering to a very thin layer at the disc’s lateral margins.

→ Little or no annular fibers exist at the region of the uncovertebral joints and a small fissure (or cleft) typically extends horizontally inward from each uncovertebral joint, coursing to the deeper regions of the disc.

→ The posterior annulus is separate from the anterior and lateral regions as it is thin and oriented vertically, parallel with the adjacent posterior longitudinal ligament

B. Thoracic Intervertebral disc:

Since there has been little study of the structure of the thoracic spine disc; To know more Click here.
However, the structure is generally held to be similar to discs in the lumbar region, with differences only in size and shape, as mentioned below.

a) Size:

i) Thoracic disc is thinner than those of other regions, especially in the upper thoracic segments.

ii) The ratio of disc size to vertebral body size is smallest in the thoracic region,

which results in greater stability and less mobility for this region.

b) Structure: It’s wedge-shaped, with the posterior height greater than the anterior height, which contributes to the thoracic kyphosis curve.

C. Lumber Intervertebral disc:

a) Size: i) Disc thickness is 9 mm which is the largest (as are the vertebral bodies) because weight-bearing loads are the greatest in lumber region.

ii) The ratio of disc size to vertebral body size is on the second position, as it is less than the cervical region and more than the thoracic region, this reflects the greater functional needs for mobility like in the cervical region.

a) Structure: except Anulus Fibrosus, the structure of the nucleus and vertebral endplate are the same as other regions.

i) Anulus Fibrosus :

→ Collagen fibers of the anulus fibrosus of lumber spine are arranged in sheets called lamellae, primarily of 15 to 25 concentric lamellae, which physically entrap the liquid-based central nucleus.

→ Collagen fibers in these adjacent lamellae are oriented in opposite directions at 120 degrees to each other and about 65 degrees from the vertical, This structural arrangement offers significant resistance against inter-vertebral distraction (vertical separation), shear (sliding), and torsion (twisting).

→ The shape of each disc in lumber region is not purely elliptical but concave posteriorly. This provides a greater cross-sectional area of anulus fibrosus posteriorly and hence an increased ability to resist the tension that occurs here with forward bending.

Conclusion:

→ IVD are the soft tissue present in between the vertebral bodies, which helps to transmit body weight, act as a shock absorber, and increase the mobility of the spine by increasing inter-vertebral space.

→The main component of disc is nucleus pulposus which acts as a shock absorber helps in weight transmission, Annulus Fibrosus is a kind of outer covering of the nucleus and resist tensile forces generating due to nucleus deformation while load transmission and Vertebral Endplate is the interface between the disc and vertebral body.

→ Similarly like vertebrae, discs also vary in structure and shape in the cervical and the lumber region of the spine but not much variation is seen in the thoracic discs.

→ Cervical disc are smallest in thickness but, disc thickness: vertebral body height ratio is greatest in the cervical region whereas in lumber region, disc is largest in thickness but thickness height ratio is less than the cervical region.

Sources:

Joint Structure and Function: A Comprehensive Analysis Fourth Edition.
Kinesiology of the Musculoskeletal System Foundations for Rehabilitation 2e 2010 - Neumann.
Youtube video is taken from Physiotutor, do share the video and subscribe them on youtube. Click here

By Sonali Tushamer (Physiotherapist)

Accessory Movements

2020-05-22T21:19:00.000+05:30

As we all know that in our body , Most of the movements occurs at joint which we are able to see like Flexion/Extension, Abduction/Adduction, Rotations....

But there are some movements also occur at each joint which we are unable to see, Want to know about it? Let's see....

Accessory Movements :- The movements which occur between the joint surfaces also known as Arthrokinematic .These movements include roll, spin and slide.

These movements are not voluntary controllable by an individual.
To occur these movements, one joint surface is relatively stable and serves as a base for the motion , whereas the other surface moves on this relatively fixed base.

1) Roll :- A roll refers to the rolling of one joint surface on another joint surface as a tire rolling on the road.

Direction of rolling is describe by the direction of movements of the bone.
Multiple points along one articular surface contact multiple points on another articular surface.

eg :-In standing, while knee flexion femoral condyle posteriorly roll on relatively fixed tibial condyle.

2) Slide :-It's a pure translatory motion, refers to the sliding of one component over another as when a braked wheel skids.

Direction of slide/glide depend upon the shape of the articular surface(convex/concave)
A single point on one articular surface contacts multiple points on another articular surface.

eg :-In standing, while knee flexion femoral condyle slide/glide anteriorly on relatively fixed tibia.

3) Spin :- It's a pure rotatory motion, refers to rotation of the one articular surface against the articular surface of another bone as a toy top rotating on one spot on the floor.

A single point on one articular surface rotates on a single point on another articular surface.

eg :-At the elbow , the head of the radius spins on the capitulum of the humerus during supination and pronation of the forearm.

Now the question arise that:-
1) Is these movements depend on any factor or not?

Yes, the type of accessory motion that occur at a particular joint depend on the shape of the articulating surfaces.

Convex - Concave rule

1) When Concave surface is moving on relatively fixed convex surface, Rolling and Sliding occur in same direction of movement of bone.eg :-In high sitting, while knee flexion tibia (concave) roll and glide posteriorly on relatively fixed femur(convex).

2) When Convex surface is moving on relatively fixed concave surface, Sliding occur in opposite direction and Rolling occur in same direction of movement of bone. eg:-In standing, while knee flexion femur(convex) roll posteriorly and slide antetiorly on realtively fixed (concave) tibia.

Conclusion:-

In this topic we almost cover the movements which are occuring between the articulating joint surfaces. In which direction this movements is occurring(same/opposite) with respect to the bone movement. Factor on which they movements depends like joint surface such as convex/concave.

Now again here a question arise, Why these movements are important?

If you know the answer or wanted to know the answer, you can comment below
OR
If you have any query regarding this topic please comment below

Youtube:

Reference Article:

To know more in depth you can also go through this link reference.
https://lukedelorenzo.wordpress.com/2011/07/27/arthrokinematics-an-important-biomechanical-concept/amp/

RESOURCES :-

1) Joint structure and function, a comprehensive analysis 5th edition by Pamela K. Levangie, Cynthia C. Norkin

2) Kinesiology Of Musculoskeletal System, foundations for rehabilitation 3rd edition by Donald A. Neuman

3) Therapeutic Exercise, Foundations and techniques 6th edition by Carolyn Kisner, Lynn Allen Colby

BY MANISHA GOLA (PHYSIOTHERAPIST)

Cryotherapy | Application of Cold.

2020-05-18T22:00:00.001+05:30

While doing his daily activity little Sam twisted his ankle and experience sharp pain. His mother Miranda applied an ice pack on his ankle and within 5 minutes pain is reduced.

This makes Sam amazed and curious that 5 minutes before he experienced a sudden pain which is now tolerable. But how?

Like Sam sometimes we all get curious that how this little calm cold piece gives sudden change on the injury to reduce the pain, well it’s not only ice but also the use of low temperature frozen gel pack and vapour coolant spray give the same effect.

But how does this happen? Well there is a little interesting science behind it. Let’s see what is it.

Latent heat: A concept that says a form of energy released or absorbed by a substance during a change in it physical state that occur without changing it temperature.

While applying ice on skin, the skin radiates a considerable amount of energy to change ice into water during this process, body loses heat results in the cooling of the skin, while ice is absorbing the heat emitting from body and changing it structure into liquid but not changing it temperature.

Conduction: Transfer of heat between two object that are in direct contact with one another. It happens when skin comes in contact with warm or cold object.

Latent heat producing two type of responses in human body:

1. Circulatory Response: In response to cold, body try to reserve heat by constriction(shrinking) it blood vessels. This homeostatic response allows the part to become cold. After a while, a short period of vessel enlargement cause dilation(expand) of blood vessel and then a short interval of dilation and constriction of the vessel is seen.

2. Neural Response: There is a large number of thermal receptors present in the skin. In which the amount of cold receptors is larger in quantity than the warm receptors.When the cold is applied these cold receptors activates and send signals to the spinal cord.

Large number of cold receptors decrease nerve conduction velocity of both sensory and motor nerves of warm receptors and have a greater effect on small diameter fibre than large diameter fibre.

Effects of Cold Pack Application:

1. Reduction of pain: One of the oldest technique in relieving pain is using ice. The mechanism involved in the activation of a large number of thermal receptors generating signal and blocking other pain signals travelling towards the spinal cord.

In response to such strong signals, mid brain stimulates to release Beta endorphin which gives temporary relief.

During this period if therapeutic exercise will be done under the observation of qualified physiotherapist, muscle strengthening, and transient pain relief also be achieved.

2. Reduction of spasticity: Cold decreases spasticity for a temporary period of time. On application, it decreases the activity of afferent spindle and Golgi tendon organ activity.

A 30 min of application of ice decrease the spasticity lasting for 1-1.5 hours.

During the temporary decrease of spasticity, therapeutic activity under a qualified physiotherapist carried on to increase muscle strength and endurance.

3. Reduce muscle spasm: Spasm is a state of muscle response to injury or pain, in manifesting as an increase in muscle tone in a specific area with the apparent aim of limiting movement and further damage. Sometimes it produces in more than needed itself causing pain and resulting in more spasm.

In such condition, cold decrease the muscle tone and abnormal manifestation by inhibiting the signal via thermal receptors.

4. Reduce swelling: After an injury, there is an abnormal demand for metabolic reaction resulting in acute inflammation causing swelling in response to heat.

Cold reduces the metabolic reaction rate and reduces inflammatory changes.

Multiple sclerosis patient symptoms get aggravated in hot climates or with excessive activities. Cryotherapy is found effective in these cases.

Technique of application

Application of ice vary upon the effect required:

1. Cold pack: Crushed ice flakes placed inside a towel folded into an appropriate shape then placed over the injured surface.

2. Ice Towel: A towel dip in cold water is covered in plastic sheath, placed on bed over which patient lie down or covers the injured part directly touching the skin applied directly to the skin. Must be taken under the observation of qualified therapist as chances of ice bite is more in this condition but very effective.

3. Immersion: A technique where only a injured part is immersed in a bucket full of ice. Only arm and legs can be immersed in this process. Very effective but have many disadvantages must be taken under the guidelines of doctor/therapist.

4. Ice massage: A pack of ice cover in cloth or towel massaging on injured part. A useful method as it does not require any machine. the freezer compartment of a domestic refrigerator is sufficient, making this technique useful in small departments, in-ward, and home.

Contraindication:

1. Peripheral Vascular Disease: Condition where impairment in circulation over a particular area. eg, atherosclerosis As vasoconstriction may cause further decreasing circulation.

2. Vasospastic Disorders: in condition like Raynaud’s disease(A condition where smaller arteries supplying blood to your skin narrow, limiting blood circulation causing numbness and cold in some areas of your body like fingers and toes) associated with excessive vasospasm should not be treated as already decreasing circulation will further decrease.

3. Cold Sensitivity/Urticaria: A small number of patients are always there who suffer from the condition of urticaria. Their condition aggravated due to the release of histamine from mast cells, causing local weal formation, itching, and development of erythema.

4. Cardiac Condition: In a patient with 6 months after myocardial infarct, ice treatment must be avoided. The initial application of ice causes a sudden drop in blood pressure, thus causing an increase in heart rate. thus a weak heart is not able to meet this demand.

Precautions:

1. Open wound: the application may delay the healing by impairing circulation and metabolic rate.

2. Cardiac Disease: Caution should be taken while treating patients with cardiac disease. The left shoulder and heart have the same parasympathetic supply, cryotherapy should not be applied over the left shoulder as it may inhibit cardiac function in cardiac patients.

3. Skin hypersensitivity: Some people are intolerable to cold in the form of numbness, pain, or colour changes.

4. Psychological: Some patient gets terrified with ice especially the elderly.

Conclusion:

Little Sam now understood a lot about the nature of ice and is happy that this little thing can do so much in just 5 to 15 minutes of application and there are lots of application ways to get much greater relief.

Now he noticed why his grandpa hates cold water and like warm surfaces.

I hope like little Sam you reader too got valuable knowledge regarding Ice.

Youtube: To know more about application of ice, please see the link below also.

Sources:

1.Electrotherapy Simplified – Basanta Kumar Nanda

2.Clayton’s Electrotherapy: Theory and Practice 9^th edition – Angela Forster and Nigel Palastanga

BY KUNWAR KARAN SINGH

(PHYSIOTHERAPIST)

HOW OUR KNEE JOINT WORK?

2020-05-15T13:31:00.000+05:30

Before to understand how our knee joint work, first we have to understand:-

1) where knee joint is present?

2) what are the components which made knee joint?

Let's start with some Introduction:-

Knee joint is present in lower limb.
Knee joint is the complex joint.
Component involve in knee joint

Femur (Thigh bone)
Tibia (Leg bone)
Patella (Knee cap)

It's made up of 2 joint

Tibiofemoral joint (tibia articulate with femur)
Patellofemoral joint (patella articulate with femur)

There are many structures which protect the knee joint like Ligaments, Capsule, Menisci

A. COMPONENTS

a) FEMUR (thigh bone):It is the longest bone of the body.

PARTS:

Proximal part: head, neck, greater trochanter, lesser trochanter, intertrochantric line, gluteal tuberosity.
Middle part (Shaft)
Lower part: medial condyle, lateral condyle, intercondylar fossa, central groove(patellar groove)

b) TIBIA (leg bone):Also known as shin bone

PARTS:

Proximal part: Medial condyle, Lateral condyle, Medial and lateral tibial plateau, Intercondylar eminence, tibial tuberosity.

Middle part (Shaft)

Distal part:medial mallelous

c) PATELLA (knee cap): It's an inverted triangle with it's apex directed inferiorly.

Posterior surface have :-

Medial facet
Lateral facet
Vertical ridge
Odd facet

B. KNEE JOINT

It involve 2 joints:-

(1) Tibiofemoral joint:

When both tibial plateau articulate with both femoral condyle it made Tibiofemoral joint.

(2) Patellofemoral joint:When posterior surface of patella articulate with central groove of femur it made Patellofemoral joint.

C. STRUCTURES

a) LIGAMENTS

1) Anterior cruciate ligament( ACL):Prevent anterior translation of tibia on femur

2) Posterior cruciate ligament(PCL): Prevent posterior ranslation of tibia on femur

3) Medial collateral ligament(MCL): Prevent valgus force (abduction)at knee

4) Lateral cruciate ligament(LCL): Prevent varus force(adduction) at knee.

b) MENISCI

1)Medial meniscus

2)Lateral meniscus

Act as shock absorber
Reduce friction between tibia and femur
Distribute weight bearing forces

c) CAPSULE

It enclose the both tibiofemoral and patellofemoral joint.
It's grossly composed of :-

1) superficial fibrous layer

2) thin deep synovial layer

D. MOVEMENTS
The main movement which occur at knee joint is :-

1. Flexion
2. Extension

But both Abduction/Adduction, Medial/Lateral rotation also occur in knee joint but to a lesser extent which we are unable to observe at knee joint but they are necessary for normal functioning of tibio-femoral joint.

**As we almost discuss the main components which will help us to understand the main content of this topic...." HOW OUR KNEE JOINT MOVE"(Arthrokinematic of knee joint)

TIBIOFEMORAL JOINT

a) Now here we discuss about how our knee joint work?

b) How one joint surface move on another joint surface?

c) What are the movements occur between the joint surfaces?

d) Joint surface movements depend upon:-

1) Is the movements occur in closed kinematic chain or open kinematic chain?

2) Is Convex surface is moving on concave surface or Concave surface is moving on convex surface?

(A) CLOSED KINEMATIC CHAIN(weight bearing)
When femur is moving on relatively fixed tibia. eg:- Squatting.

1) FLEXION:- Femur roll posteriorly and glide anteriorly on relatively fixed tibia (According to concave - convex rule)

2)EXTENSION :- Femur roll anteriorly and glide posteriorly on relatively fixed tibia (According to concave - convex rule).

(B) OPEN KINEMATIC CHAIN( Non weight bearing)

When tibia is moving on relatively fixed femur eg :- High sitting knee flexion/Extension.

1) FLEXION :- Tibia glide and roll posteriorly on relatively fixed femur (Acc. to concave - convex rule).

2) EXTENSION :- Tibia glide and roll anteriorly on relatively fixed femur (Acc. to concave - convex rule)

SCREW - HOME MECHANISM

To complete knee flexion/Extension there is little rotation of tibia on femur occur.

(A) Open kinematic chain( Non weight bearing)
While knee extension (last 30° of knee extension) there is lateral rotation of tibia occur on femur to complete knee extension. It's referred as Automatic rotation or Screw home mechanism.

Now, to flex the tibia on femur, the tibia rotate 1st medially to unlock the knee as laterally rotated tibia can't flex.

(B) Closed kinematic chain (Weight bearing)

While knee extension (last 30° of knee extension) the femur rotate medially on fixed tibia to lock the knee.

While knee flexion, initially the femur rotate laterally on fixed tibia to unlock the knee.

PATELLOFEMORAL JOINT

a) It's one of the most in-congruent joint in the body.

b) Due to in-congruence of the patella, the contact between the patella and femur changes throughout the knee Range of motion (ROM)
c) In fully extended knee, patella lies on the patellar groove on femur.

d) Contact between both surface during knee movements

-Fully Extension= Only the inferior pole of the patella is making contact with femur

-10°-20° of knee flexion= Inferior margin of both the medial and lateral facets of patella

-As flexion progress(45°)=most of the part of lateral and medial facet of patella make contact

-At 90°= All portion of patella make contact with femur except odd facet

-Beyond 90° =Patella migrate inferiorly, odd facet make contact with the medial femoral condyle for the first time

-At full flexion=Patella lodge in the intercondylar groove, only lateral and odd facet make contact.

Summery:

Through this knowledge now we are able to understand how our knee joint move.

In Closed kinematic chain:-

a) Femur move on relatively fixed tibia.
b) Rolling and gliding occur in opposite direction.
c) Locking of knee, done by medial rotation of femur on tibia and unlocking done by lateral rotation of femur on tibia.

In Open kinematic chain :-
a) Tibia move on relatively fixed femur.
b) Rolling and gliding occur in same direction.
c) Locking of knee done by lateral rotation of tibia on femur and unlocking done by medial rotation of tibia on femur.

Resources:

1) Joint structure and function, a comprehensive analysis 5th edition by Pamela K. Levangie, Cynthia C. Norkin

2) Kinesiology Of Musculoskeletal System, foundations for rehabilitation 3rd edition by Donald A. Neuman

YOUTUBE:

If you want to know more you can check these link below also:

BY MANISHA GOLA (PHYSIOTHERAPIST)

Identify Vertebra in the Vertebral column

2020-05-13T20:28:00.000+05:30

Human vertebral column consist of total 33 vertebrae and vertebral column is divided into 5 regions.

Which are cervical region/spine, Thoracic region/spine, Lumber region/spine, sacral and coccygeal region/spine.

Before studying the difference between these vertebra of 5 region, we must know the basic structure of a typical vertebra. You can easily understand the different part of a vertebra by seeing figure below:

In these figures, different parts of vertebra are labelled, based on these parts you are able to differentiate the vertebra of different region of spine, these are :

1. Vertebral body : Block of trabecular bone

2. Padicle : connect the vertebral body to the posterior elements

3. Lamina : constitutes the central portion of the arch connect both the pedicles

4. Superior and inferior articular process aka Zygapopyhseal articular process : these are projections which make joints with the vertebra above and below.

5. Transverse process : Lateral projections of bone that originate from the laminae

6. Spinous process : Posterior projection of bone that originates from the central portion of the lamina

7. Vertebral foramen ; not labelled in the figure, it’s the opening surrounded by vertebral body, pedicles and lamina, though this opening spinal cord passes.

How the vertebra differ in each region

Cervical Vertebra

1. Vertebral body: Small rectangular shape.

Have unicate processes

2. Pedicle : halfway between superior and inferior facet

3. Lamina : thin and curved

4. Zygapophyseal Articular Processes : smooth and flat articular facet ; in midway between Frontal and horizontal plane

5. Transverse processes: short has anterior and posterior tubercles groove for the spinal nerves. Transverse Foramen

6. Spinous processes : are short, extend horizontaly with some processes being bifid (i.e. double)

7. Vertebral foramen/canal: relatively large and triangular in shape.

Thoracic Vertebra

1. Vertebral body : equal transverse and anteroposterior diameters

Anterior height is greater than posterior height.

Two demifacets (half facet) for articulation with the ribs.

2. Pedicle : face generally in the frontal plane, with a mild forward slope that averages about 15 to 25 degrees from the vertical.

3. Lamina : Short, thick, and broad.

4. Zygapophyseal Articular Processes: face generally in the frontal plane, with a mild forward slope that average about 15 to 25 degrees from the vertical.

5. Transverse processes: Processes are large with thickened ends. Possess paired oval facets for articulation with the ribs.

6. Spinous Processes: T1–T10 slope inferiorily. T11 and T12 have a triangular shape.

7. Vertebral Foramen/canal: Small and circular.

Lumber Vertebra

1. Vertebral body : massive, with a transverse diameter greater than the anterio-posterior diameter and height.

2. Pedicle: Short and thick

3. Lamina : Short and broad.

4. Zygapophyseal Articular Processes: oriented nearly vertically, with a moderate-to-strong sagittal plane bias.

5. Transverse processes : Processes are long and slender and extend horizontally

6. Spinous Processes : Broad, thick, and extend horizontally.

7. Vertebral Canal: Triangular in shape, Larger than the thoracic but smaller than the cervical.

Just before the viva:

I know its not easy to remember all the 7 characteristic feathers of a each region, that is why, I am gonna tell you a simpler way to answer the question:
Which vertebra is this? when your examiner ask you in the viva.
Just keep these 3 points in your mind about each vertebra, which will make you pass your viva in the med school. These are mentioned in the picture below about Body, Spinous Process and Vertebral Foramen of different region of Vertebral Column.

Now you can easily tell the difference between the vertebrae of different region of spinal column.

Youtube:

Sources:

Joint Structure and Function: A Comprehensive Analysis Fourth Edition.
Kinesiology of the Musculoskeletal System Foundations for Rehabilitation 2e 2010 - Neumann.

By Sonali Tushamer (Physiotherapist)

COLD OR HEAT? WHICH PACK AFTER INJURY

2020-05-11T20:15:00.000+05:30

Why does it matter:

Both Heat and ice reduce the pain but in different ways as Heat can reduce pain by relaxing muscle fibres.

Ice suppress the nerve stimulation of affected area. So, which pack you should apply after injury, to understand this you should know what changes does heat and cold to your body.

How does it work :

· Cold reduces blood flow (Vasoconstriction) and inflammation producing activity on the site of injury thus result in reduction of inflammation of affected site, which in turn decrease pain due to inflammation.
· Heat increases the blood flow (Vasodilation) and metabolic rate which enhance inflammation after injury, increased blood flow removes waste product (debris) from the injury site and improve healing process.

Then what so much of good thing about ice, Ice is good in recent injury where it slows down the inflammation process and save you from unbearable pain like for 2-3 days after sprain (ligament injury).

Now you must be confuse isn't the Heat is bad for you but it will be in recent (acute) injury but not in chronic(old) injury, it’s the best medium to heal that injured part that is after 2 – 3 days of injury.

Time Duration:

· Always remember generally after injury use ice pack, as it is said earlier acute (recent) injury requires less blood supply so that it will reduce the chances of inflammation.
· In general use cold pack in between 2-3 Days of injury. Also helps in reducing pain sensation.Now after 3-4^th day, Go with the hot pack as your injured part is healed up and stiffed and to reduce muscle pain which is generating due to immobilisation.

· For Ice apply only for 10 -15 minutes. Not to use directly on skin but to wrap a towel between ice and skin. A small time for application is to avoid the chances of frost bite.

· For Heat apply for 15 - 20 min not more than that and always first touch the heat pad to skin to check that you are not using too hot for the affected part as at the time when you are using the pack the sensation might be low because of thickness of muscle. So it’s better to know the optimal temperature and wrap it under towel and then place it above the affected area.

Which one is a better option:

This question in general depends on the condition of injury as it is a recent or 3-4 day old injury.

Ice therapy used to:

· Reduce pain

· Reduce spasticity

· Reduce muscle spasm

· Reduce swelling

· Promote Repair

· Promote excitatory stimulus when muscles are inhibited.

Heat therapy used to:

· Increased metabolic activity
· Increased blood flow
· stimulation of neural receptors in the skin or tissue
· Muscle relaxation
· Increased activity of sweat glands.

When not to use ice:

· Psychological

· Cardiac Condition.(6 month after a myocardial infarct ice condition should be avoided)

· Peripheral nerve injury

· Vasospastic Disease

· Peripheral vascular disease

· Cold sensitivity.

Heat not to use in:

· Damaged skin

· Open wound

· Allergic Rash

· Skin Condition

· Impared skin sensation

· Defective arterial blood supply

Advisory note:

During first 3 day’s of your injury use ice. After passing those 3 day’s go with heat.Ice cause tightness, stiffness and vasoconstriction, giving a great time period for ligament to heal to optimal period.Heat comes after ice to cure that stiffness and bring back vasodilatation. But using heat immediate after injury will aggravate the pain and inflammatory condition.

Conclusion:

Both Ice and Heat have their own terms of benefit with respect to the condition.If the injury is acute the Ice is a better option but when the injury is chronic Heat is a good option.you can never judge one without knowing the conditional effect of each one on the injured part.So its better to know the character of effect of both the packs.

I Hope now you must be able to understand that whenever you twist your ankle why your Therapist/Doctor ask you to Apply the Ice pack over the hot and after three days of application ask you to go with hot pack.

Suggestion:

If you like you can also read this research article "The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner"

https://www.preventworkinjury.com/wp-content/uploads/2014/10/Heat-vs-Cold-Therapy.pdf

By Kunwar Karan Singh (Physiotherapist).

Emerging Physios

The Fifth Cervical Vertebra (C5)

The Fourth Cervical Vertebra (C4)

Important Questions & Answers

Q: What kind of vertebra is C4?Ans: A typical cervical vertebra, similar to C3 and C5.

Q: What landmark is at the level of C4?Ans: The thyroid cartilage (Adam’s apple).

Q: What nerve exits at the level of C4?A: The C4 spinal nerve.

Q: What important nerve does C4 help form?Ans: The phrenic nerve, which controls the diaphragm.

Q: What symptoms may indicate C4 dysfunction?Ans: Neck pain, shoulder pain, shallow breathing, and reduced neck rotation.

Q: What artery passes through the transverse foramen of C4?Ans: The vertebral artery.

Clinical Insight1. C4 lesions may affect the phrenic nerve, leading to diaphragm dysfunction (shallow breathing or hiccups).2. Can also cause referred shoulder pain and scalene tightness.3. Gentle cervical mobilization can restore nerve communication and improve breathing or posture.

Clinical Insight

1. C4 lesions may affect the phrenic nerve, leading to diaphragm dysfunction (shallow breathing or hiccups).2. Can also cause referred shoulder pain and scalene tightness.3. Gentle cervical mobilization can restore nerve communication and improve breathing or posture.

The Third Cervical Vertebra (C3)

Questions & Answers

Clinical InsightA lesion at C3 can disturb phrenic nerve signaling, causing difficulty in breathing or shallow respiration.Tightness in trapezius or scalene muscles may signal C3 nerve dysfunction.Gentle mobilization can improve nerve flow and reduce referred pain to the shoulder or jaw.

The Atlas (C1 Vertebra) & The Axis (C2 Vertebra)

Questions & Answers

Clinical Insight:A rotated or misaligned axis can cause:

Ultrasonic Therapy

PRINCIPAL OF ULTRASONIC THERAPY

Radiology | An Introduction

What is Radiology?

What is the X Rays?

How X-ray images are produced?

Radiographic Densities:

Active Knee stabilizers

Active Knee Stabilizers

Muscles of the knee joint

Passive Knee Stabilizers

Passive Knee Stabilizers are non-contractile structures like the joint capsule, ligaments and menisci etc. Which stabilize our knee joint and help in arthrokinematic of knee joint

In our previous post (click here), we discussed "how our knee joint work". But that was only bony movement and we know that bone can not move by itself, we need some active (muscle) and passive (capsulo-ligamentous) stabilizers which stabilize our knee joint and help in knee joint motion.

MENISCI

Joint capsule

Anterior and Posterior cruciate ligament

Medial and Lateral Collateral ligament

Conclusion:

Posture | An Overview

What is Posture

Postural Alignment

Factors which affect Posture

1. Psychological background:-

2. Healthy Body:-

3. Opportunity for plenty of natural free movement:-

4. Local factors:-

Pain and Posture Relation

Posture Assessment

What does an ideal Posture look like

Conclusion

Resources

Intervertebral Disc | A Brief Introduction

How Intervertebral discs vary in the spine | Regional variation of disc:

Accessory Movements

Cryotherapy | Application of Cold.

HOW OUR KNEE JOINT WORK?

Identify Vertebra in the Vertebral column

How the vertebra differ in each region

COLD OR HEAT? WHICH PACK AFTER INJURY

Suggestion:

Q: What kind of vertebra is C4?
Ans: A typical cervical vertebra, similar to C3 and C5.

Q: What landmark is at the level of C4?
Ans: The thyroid cartilage (Adam’s apple).

Q: What nerve exits at the level of C4?
A: The C4 spinal nerve.

Q: What important nerve does C4 help form?
Ans: The phrenic nerve, which controls the diaphragm.

Q: What symptoms may indicate C4 dysfunction?
Ans: Neck pain, shoulder pain, shallow breathing, and reduced neck rotation.

Q: What artery passes through the transverse foramen of C4?
Ans: The vertebral artery.

Clinical Insight
1. C4 lesions may affect the phrenic nerve, leading to diaphragm dysfunction (shallow breathing or hiccups).
2. Can also cause referred shoulder pain and scalene tightness.
3. Gentle cervical mobilization can restore nerve communication and improve breathing or posture.

1. C4 lesions may affect the phrenic nerve, leading to diaphragm dysfunction (shallow breathing or hiccups).
2. Can also cause referred shoulder pain and scalene tightness.
3. Gentle cervical mobilization can restore nerve communication and improve breathing or posture.

Clinical Insight
A lesion at C3 can disturb phrenic nerve signaling, causing difficulty in breathing or shallow respiration.
Tightness in trapezius or scalene muscles may signal C3 nerve dysfunction.
Gentle mobilization can improve nerve flow and reduce referred pain to the shoulder or jaw.

Clinical Insight:

A rotated or misaligned axis can cause: