Lectures in Physical Therapy

Duchenne muscular dystrophy

noreply@blogger.com (dr/azza) — Fri, 1 Apr 2011 12:19:00 +0200

Definition:it is one of genetic determined myopathy that are characterized by steady progressive degeneration and weakness of the muscle.it is x linked disease and is insidious in its onset.

clinical presentation:

1-Delayed motor development.

2-Walking is clumsy and there is frequent falling.

3-Walking with wide BOS with waddling and lurching gait.

4-Walking on tips of foot.and relactance of walking and running.

5-As weakness increase , gower sign appear: as child climb him self for raising due to weakness of the back and abdominal muscle, calf, iliopsoas,iliotibial band and knee flexors.

6-Using wheel chair for ambulation.

7- Affection of respiration.

8-Positional deformity as scoliosis.

7-Obesity due to lack of activity and mobility and sitting on wheel chair.

By progression:

1- there is shortening in specific muscles.

2- Weakness and deposition of fibrous tissue.

Shortening of specific muscle help sitting before weakness but he can not maintain the upright posture.

Management:

Goal: maintainance of child functional and ambulant as much as possible.

Evaluation:

1- Functional ability assessment:what he can do from his ADL activity according to his age:

At 6-7 years : he can walk and run.

At 9-10 years:child can walk with assisstance due to deterioration of the muscles.

Examples for functional assessment.

For upper limb: 1- bilateral abduction and elevation of both arms or one.

2- raise hand just above head.

3- mouthing only.

For lower limb:1-walking and ascending stairs without assistance.

2 -walking and ascending stairs mild assistance.

3-walking and ascending stairs with moderate assistance.

4-use wheel chair for mobility.

5-just getting off or raising from wheel chair.

2-Muscle power assessment: manual muscle test,we do group muscle test to avoid exhuation,

it is applied for the following muscles:1-upper and lower fibers of trapezius.

2- serratus anterior.

3- pectoralis .

4-abdominal.

5-gluteus maximus and medius.

6- rhomboids.

7-triceps.

8-iliopsoas.

9-quadriceps.

10-tibialis anterior.

11-latissimus dorsi.

3- ROM assessment: active and passive range of motion.

limited active range of motion refers to muscle weakness.but if there is limitation in both active and passive range this refers to muscle tightness.

Prolonged sitting on wheel chair leads to limitation of range of hip extension ,knee extension,ankle dorsiflexion and elbow extension.

4- Flexability assessment: is used for test for tight muscles as

a- Iliopsoas muscle: thomas test.

b-Ilio tibial band: obar test.

c- Hamstring and calf muscles.

5- Muscle tone assesment:we can use gower test :patient sitting and therapist stand behind him and hold child shoulder from under axilla then elevate shoulder. there is increase in the upward displacement with sudden release , the shoulder drop sudden not gradually.

6-Gait and wheel chair assessment:

a- By observation: we can see pattern of walking as walking on tip of toes with wide BOS.

b-wheel chair: if he can do his activities as transfere and the distance that patient can travel and the amount of energy expenditure.
7-Pulmonary function assessment: to evaluate vital capacity and oxygen consumption.
Respiratory failure is the common cuase of deathdue to weakness of the respiratory muscles and accumulation of secretions which lead to infection.
treatment:
1- To prevent deformity:a- ROM exercise for all jointsin the early stage

b- Stretching exercise for hamstring and calf muscles.

c- Application of braces as AFO and KAFO.

d- Strengthening exercise .

2- To maintain functional ability: this can be achieved through proper exercises which must be:

a- functional exercise.

b- aerobic exercise.

c- exercise for large group of muscles.

d- child must talk rest to avoid fatigue.

3- Family support: parents are depressed and feel guilt and furstration so we must help them to accept this problem and avoid giving false hope for them .

4- Pain control: proper exercise help reducing pain through prevention of deformity and delay appearance of complication.

For child who sits on wheel chair must change his position periodically and change position of the propelling hand every 6months.

For child who is bed ridden ,we must use air matress to avoid development of pressure ulcers also we must do respiratory care in the form of breathing exercise and posture drainage.

5- To control obesity: it develops as child in put is more than the out put and decrease his activity level .so we advice for proper diet and exercise program and avoiding food with high caloric value.

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Congenital hip dislocation

noreply@blogger.com (dr/azza) — Thu, 31 Mar 2011 16:03:00 +0200

Incidence: it occurs by 2 or 3 children per 1000 live births. it is common in female than male by ratio 5:1.

Etiology: there is many factors that may lead to this congenital anomaly:

1) Ligamentous laxity around hip joint result from familial mesenchymal tissue disorders and cartilagenous limbus which form the rim of the acetabulum that is inverted inside the acetabulum.

2) The head of the femur is flattened.

3) Breech presentation during delivery.

4)Shallowing of the acetabulum.

5)Sever hypotonia with generalized joint laxity.

The dislocated femoral head is directed superior and posterior to the acetabulum leading to :

1)Elongation of the ligamentum teres .

2)Contraction of psoas, adductor,and hamstring muscles.

3) Separation of the gluetus medius from the ilium.

4) Stretching of the joint capsule.

Clinical presentation:

1) Skin fold on the gluteal and adductor region .

2) Limitation of passive hip abduction.

3) Old child who begins to ambulate show positive trendelenburg sign.

4) Child with bilateral CHD has waddling gait.

Diagnosis:

1) Plain X- ray:we can see shallowing of the acetabulum and shape of the femoral head.

2) CT ultrasonic : is used for intra utrine investigation.

Special tests for hip instability in infants.

1) The ortolani test: chid lies supine with his hip and knee are flexed.

Grasp: the therapist hold legs at the femoral condyles with his index and middle finger on the lateral aspect of the thigh on the greater trochanter.

both legs are rotated through full arcs of external rotation and abduction.

the normal hip can be brought into 90 degree of abduction but the dislocated hip blocks usually at 30 to 40 degee of abduction and external rotation.

2)Piston test: child lies supine with hip flexed 90 degree and adducted and the knee is flexed . the therapist grasp thigh with the opposite hand and the infant pelvis is supported with the other hand then move thigh up and down through its axis.

Normally , the hip is felt stable without telescoping of the limb.

If there is dislocation , the axial compression cuases the leg to be short so that telescoping is obvious.

3)Barlow's test: child is supine with his hips and knees are flexed.

the therapist grasp the normal side of the pelvis with the opposite hand to this side and the examined hip is held between tip of middle and thumb .

the hip is adducted if it is dislocated it can be pushed out of the back of the joint and reduced by pressure on the greater trochanters.

treatment

1) Reduction of the joint with minimal soft tissue injury .the child is put in quadriped position and use splint that keep hip in abduction . it may be one of the following:

a- Traction :weight traction can be used to reduce dislocation . the hip is moved gradually in wide abduction in either extension or flexion.

b- Splinting:

1-Frejka pillow. 2-Von Rosen splint.

3-Denis brown hip splint. 4-Pavlik harness.

5-Plaster hip spica.

2) physiotherapy:

1- Mobilization in warm water is very useful.

2- weight bearing activity as standing and walking.

3- Walking using crutch is better than using walker as it allow active hip and knee flexion.

4- Using tread mill for strengthening and endurance.

Surgical management:

1-Closed or open reduction may be done with or without musclotenotomies.the hips are placed in abduction and immobilized with plaster which is maintained for 9 months depending on child age and type of surgery .

2- Pelvic osteotomy : is used for children between 18 months and 10 years of age . they are immobilized in plaster hip spica for up to 8 weeks.

3- Steel triple osteotomy : is done for children with age of 12 years and older child . they require 120 weeks for immobilization in hip spica

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Shoulder - Reverse TSA Standard of Care

noreply@blogger.com (dr/azza) — Sun, 27 Mar 2011 20:09:00 +0200

Standard of Care: Reverse/Inverse Total Shoulder Arthroplasty

Case Type / Diagnosis:

The reverse or inverse total shoulder arthroplasty (rTSA), first described by Grammont et al.
11
has only recently gained popularity and FDA approval as a treatment option for patients
requiring a shoulder replacement for the treatment of glenohumeral (GH) arthritis when it is
associated with irreparable rotator cuff damage, complex fractures, as well as for a revision for a
previously failed conventional TSA in which the rotator cuff tendons are deficient/absent.
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dawnload

varicose vien

noreply@blogger.com (dr/azza) — Sun, 27 Mar 2011 18:02:00 +0200

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spina bifida

noreply@blogger.com (dr/azza) — Sun, 27 Mar 2011 17:46:00 +0200

Definition.

It is one of the congenital anomalies in which there is developmental defect in the spinal column

due to failure of fusion of the vertebral arches leading to protrusion of the spinal cord or its membranes .

Brief pathology.

During the intrauterine life, the neural plate is formed at the eighteenth day of the gestation, this neural plate divide into neural tube and neural arch. The neural tube forms the central nervous system (brain and spinal cord). The neural arch forms the peripheral nervous system. This defect appear within first few weeks of gestation, as the neural plate has cranial part which close at the day of 26 of gestational life ,if this closure not occur this will lead to encephalomyopathy which lead to death. The caudal part close at the day of 28 of the gestation, spina bifida result from failure of closure of this part.but wether the cuase is genetic or environmental is unknown.

Types of Spina bifida

1- Spina bifida oculta: there is defect only in the neural arch without neural tissue involvement, there is skin changes and hairy patches.

2-Spina bifida cystica:it include two types:

a)Meningocele: the vertebral arch un fused , there is herniation of the meninges , part of the cord or nerve roots may present in sac but conduct impulse normally.

b)Myelomeningocele: sac contain neural elements that protrude through the spinal defect. The overlying skin is thin andleaks of spinal fluid. There may be secondary infection,neurological and orthopedic problems and hydrocephalus

clinical picture : it will differ according to the affected level . the most common affected is lumbosacral region. it may include:

1- Fflaccide paralysis.

2- Muscle weakness and wasting.

3- Decreased or absent tendon reflexes.

4- Decreased or absent extroceptive and propioceptive sensation.

5-Rectal and bladder incontinance.

6-Hydrocephalus.

7-Sever vasomotor changes.

pt examination.

1) By sight:we can see on the back of the patient one or more of the following:

a)Tuft of hair.

b)Subcutaneous lipoma.

c)Localized sac.

d)Increased head size.

e)Deformity of the lower limb .

2)By palpation:a)bony defect

b)Subcutaneous lipoma.

c) Loss of sensation.

d)Muscle bulk.

3)Measurement and tests:

1-Tape measurement:a) round measurement for head circumferance and muscle contour.

b)Long measurement for lower limb.

2-Range of motion: child with age less than 3 years can not obey to command so we use test for tightness as indicator for limited range of motion.

3-Muscle test: we can do functional muscle test with the following grades:

a-Functional : child can performs the task completely.

b-Sub functional: it start from inability to do task completely to the ability to do flicker contraction in the muscle.

c-Non functional: inability to perform the task.

Exercise for the upper limb:children with spina bifida need to compensate motor control of their legs and trunk. they use their arms as assistance for daily living activities:a- transferring from seat to bed and toilet.

b-Helping children without trunk stability to sit.

c- Standing up from the floor or from wheel chair.So, exercises to strengthen the arms are important part of the treatment as press up with pillows under the knees and feets.

poor sitting balance:many children with spina bifida have poor sitting balance and there is many factors lead to this problem as 1-Weak trunk muscles.

2- Paralyzed lower limb.

3- Lack of sensation.

We can deal with this problem through:

1-Strengthening exercises for back extensors and balance exercise as sitting astride the legs of the therapist or stride aroll.

2- Special seats or wheel chairs are molded to provide adequate support for the trunk .
Pt modalities can be used in the management of the symptoms that result from spina bifida

1- In patient with partial paralysis an extensive program of physical application should be applied aiming to improve muscle power and to increase physical abilities of the patient.
2- Electric appliances may be used to relieve pain, induce relaxation or to improve function.
3- Passive movement and passive stretch should be used to prevent and correct contracture and deformities .
4- Active exercise to prevent muscle imbalance and to keep the gained range during passive manibulation.
5-Hydrotherapy is very effective when skin is intact.
6-Gait training by using braces.
Orthoses:
Many patients who have lower lumber lesion and in whom there is power 5 of the quadriceps and 4 of the medial hamstring have the potential to walk with ankle / foot orthoses with or without external aids. the factors affecting ambulatory status are related expenditure and control of obesity. two orthoses have been introduced reciprocating gait pattern and to enable standing.these are reciprocating gait orthoses and hip guidance orthoses . apre-requisite fitting such an orthoses is that there is no more than 20 degree flexion in the hip, the knee and the foot can be rendered in plantigrade position.

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Musculoskeletal Physical Examination

noreply@blogger.com (dr/azza) — Sun, 27 Mar 2011 17:19:00 +0200

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Subjects, Materials, and Methods

noreply@blogger.com (dr/azza) — Sun, 27 Mar 2011 15:54:00 +0200

In this part of the study the materials and methods were presented under the following headings:

Subjects:

Forty children with acute lymphoblastic leukemia, their ages ranged from 6: 12 years. These children were selected from the National Cancer Institute. These children randomly subdivided into two equal groups (twenty patients for each);

Group (A) = (Exercise Program Group):

This group was composed of 20 children with acute lymphoblastic leukemia and represented the group who received the exercise program for 12 weeks in addition to perform the traditional medical intervention.

Group (B) = (Control Group):

This group was composed of 20 children with acute lymphoblastic leukemia and represented the control group who did not receive any form of physical therapy intervention but this group was instructed and encouraged to remain active during their cancer treatment approach.

Criteria of Patient Selection:

The patients had the following criteria:

a- Inclusive Criteria:

· The age of the patients ranged from 6: 12 years.

· All patients had the same medical care and have no evidence impairment of cardiac, pulmonary, renal, and hepatic function.

· All patients received a good explanation of treatment and measurement devices.

· Each child was evaluated by his/her oncologist before and every 2 weeks during training period.

· The examination included a thorough physical evaluation and complete hematological and biochemical blood analysis.

b- Exclusive Criteria:

Children were excluded from the study for any of the following cases:

· Children who underwent bone marrow transplantation because in this subpopulation of children with ALL treatment complication, side effects, and tumor recurrence are frequent which would compromise training adherence .

· Children with a history of antecedent neurological developmental of genetic disorder and those currently receiving physical therapy intervention will be excluded.

· Severe anemia (hemoglobin <8 g.dl-1).

· Neutrophil counts lower than 0.5x10µL-1.

· Platelet count lower than 50 x 10µL-1.

· Or anthracyclin–induce cardiac toxicity.

Equipment and Tools:

The main equipment and tools used in this study were classified into two types:

1-Measurement Tools:

The measurement tools were:

1. a-Oxygen pro (zan-germany) cardio pulmonary exercise testing unit with the following parts: Fig (4)

· Computer unit fed with software required for the control of the treadmill load, and manipulation and analyze the measured parameter as well, in addition to thermal printer to out the variables measured in the study. Fig (5).

· Gas analyzer with flow (triple valve) sensor.

· Treadmill, Fig (7).

· A rubber mouthpiece (which is connected to the flow sensor and a face mask.

· Weight and Height scales: it was used to measure weight and height of each subject involved.

Fig (5): A Computer Unit with a Thermal Printer.

Fig (7): A Motor-Driven Treadmill.

1. b-Hand-Held Dynamometry: was used to assess the muscle strength of both upper and lower body.

The muscle test has been done through using Hand-held Dynamometry (manufactured by instrument company 3700 sagamore parkway north lafaytte, in 47904 U.S.A). Hand-Held Dynamometry system is a hand-held device used objectively quantifying muscle strength. It is small enough to held in one hand easily read.

The device has six function buttons and LCD screen that control the menus and allow the selection of options and as following: Fig. (8)

· On/Off switch: that used to activate the device when switch to the '' on ''position.

· Reset button: the reset button is located on the top of the device; it is placed for easy access the thumb regardless of right or left operation. The reset button clears the display of all data and sets the zero point for the measurements.

· Range button: the range button toggles between high and low measurement rang. An H or L is displayed on the main measurements screen to indicate the device range setting. Changing the range cause the device to automatically reset and clear all time and force values.

· Scroll/LB/KG: the lb/Kg button has dual functionality depending on which screen is accessed. In the main measurement screen, the lb/Kg button toggles the force measurement scale between pounds and kilograms. An indicator on the main measurement screen shows which scale is selected. When a menu or data display screen is active, this button becomes a scroll button. The scroll button was used to select option by advancing a cursor from on option to the next. The scroll button was also used step through data.

Fig.(8 ): The hand-Held Dynamometry Used in this Study Showed the Function Buttons and Main Measurement Screen.

1- On/off switch. 2- Reset button.

3- Range button. 4- Scroll LB/KG button.

5- Enter/Store button. 6- Menu button.

7- LCD screen.

· Enter/store button: the enter/store button has dual functionality depending on which screen is accessed. In the main measurement screen, the button was used as store button. Pressing the store button stores the current test data in the device memory. Only the peak force and peak time were stored in memory. When the menu screen are accessed, the button is used as an enter button the enter button is used to activate setting and menu option. It was also used to clear some error and warning messages.

· Menu button: the menu button was used to enter the main menu the main menu was used to select the device option and access the submenus.

· The LCD screen on the front section of device used to display force and time.

The main measurement screen showed all of the current measurement information. This screen was shown whenever a measurement was in progress. This screen was also the default start- up display.

¨ Peak force: the peak measurement force was displayed in large numbers on the upper left of the main measurement screen. This value was the peak pounds or kilograms applied during a test. Force values were displayed tenths of pound or kilogram.

¨ Peak time: the peak time value is displayed in the second on the button left of the screen under the peak force. This number is the time during the test when the peak force occurred. Time value was displayed to hundredths of second.

¨ Instaneous force: the instaneous force value was displayed on the upper right on the main measurement screen this value was the force applied to the device at any time.

¨ Running time: the running time value was displayed on the lower right of the main measurement screen .this value showed the total time that force has been applied after a test had ended; this showed the total length of the test in seconds.

¨ Range indicator (H or L): the range shows if the device is set in the high or low measurement setting. If in Kg's the high range would 0Kg-1361Kg, and the low rang would 0Kg-22.6Kg. If in lbs, the high rang would 0lbs-300lbs, and the low range would 0lbs-50lbs. the range indicator was the upper most indicators in the center of the main measurement screen.

¨ Scale 3 indicator (lb or KG): the scale indicator shows if the device is set in pound or kilograms. The scale indicator was the second indicator in the center of the main measurement screen.

¨ Low battery indicator: the low battery is present when a law battery condition exists. The low battery indicator was third indicator in the center of the main measurement screen.

¨ Time unit label: the time unit label indicate is the –S- on the button center of the main measurement screen. This label indicated that the time measurements were in seconds, this label did not change.

1. c- Iowa Fatigue Scale

It was used to measure the degree of fatigue in this children and QoL. It is a self report questionnaire developed by Department of Family Medicine, University of Iowa College of Medicine to measure the degree of fatigue and its progression. It is consisted of many questions about the quality of life and its affection by fatigue. The 11 item scale contains four subscales: cognitive, fatigue, energy and productivity. Patients with a higher fatigue score are much more likely to have lower health status, greater depression and more somatic symptoms, (Appendix I) (Hartz et al., 2003).

Therapeutic Tools:

· Strength training include exercise engaging the major muscle groups (bench press , shoulder press , leg extension , leg press , leg curl , abdominal crunch , low back extension ,arm curl ,elbow extension ).

· Stretching exercise of the muscles involved in the previous exercise was stretched.

· Aerobic exercise consisted of pedaling a cycle ergometer, running and walking on treadmill.

Procedures of the Study:

A verbal explanation about the important of the study procedure, main aim and conceptual approach was explained to every patient.

The procedure of this study was divided into two main procedures:

Measurement Procedures:

· Before starting the study a consent form was taken from each parent of participant as an agreement to be included in the present study. Also before initiating the treatment program the following task was performed :

· The children's hemoglobin level and plat let count was obtained from the medical record to observe changes in physical stability.

· Each subject was examined medically in order to exclude any abnormal medical problem which previously mentioned.

· Measurement was taken pre-test assessment and post test assessment and 12 week later after the intervention program as follow ;

(1)Procedures of Cardiopulmonary Exercise Test:

Prior to the study each subject was instructed:

· Not to eat at least 2 hours before exercise testing.

· Not to do unusual physical activities for at least 48 hours before testing.

· To dress appropriately for exercise especially with regard to footwear.

· Exercise testing was performed according to the recommendation and guidance of the American heart association ( AHA) (Fletcher et al .,2001)

On the testing day:

The cardiopulmonary exercise testing was electronically calibrated by click upon the icon of calibration at the computer monitor. Before starting Gas-calibration, the following steps were checked in advance:

· Zan testing unit had been ON for a minimum warm up time of 20 min.

· Gas bottle was opened

· Gas-suction tube removed from flow sensor and connected to calibration nipple (Cal) on front panel of Zan Testing Unit (it is recommended that Gas-calibration must be carried out before every measurement).

· Calibration was started with (Enter); the flow of Calibration-Gas was clearly audible. As Calibration was ok, the results wer saved with (Enter) (the recommended composition for calibration gas is: 5%Co2, 15.9%O2). At the end, Gas bottle was closed and Gas-Suction tube was removed to flow sensor.

· The subjects were measured for height and weight, and then the computer unit was fed up the subjects' demographic parameters.

1. Age (date of birth)

2. Sex male or female

3. Weight in(Kg)

4. Height in (cm)

Exercise Test:

· A clean and sterilized facemask was applied and fitted to the face of the participant and connected to the flow to the sensor. The expired air was obtained from a valve connected to a mouthpiece and then was analyzed for VO2 volume. Data was delivered to a computer and was integrated to calculate O2 consumption.(fig 9)

· After a 3 min standing rest period, the participant was asked to walk for 5 min at 0% grad for warm up.

· Maximum oxygen consumption (VO2max) determined for each participant by maximum exercise testing according to Bruce protocol.

· Participants were verbally encouraged to continue the test until exhaustion.

· A cool-down period of 5 min was allowed and then the test was terminated.

Fig (9): The Child was Asked to Run on Treadmill Until Exhaustion.

Bruce Protocol:

The starting speed of the Bruce protocol is 1.7 mph and 10% grade, and progressing to increased treadmill speed and grades every 3 minutes until exhaustion as shown in (table 1) (Hillegas and Sadowsky,2001)

Table (1): Bruce Treadmill Protocol

Stage	Time(min)	Speed(mph)	Grade	MET
I	3	1.7	10%	4-5
II	3	2.5	12%	6-7
III	3	3.4	14%	8-10
IV	3	4.2	16%	11-13
V	3	5.0	18%	14-16
VI	3	6.0	20%	17-19

Criteria for terminating exercise testing:

Absolute:

1- Drop in systolic blood pressure (persist below baseline, despite an increasing in workload).

2- Development of chest pain.

3- Signs of poor perfusion (cyanosis or pallor).

4- Subject's request to stop.

Relative:

5- Fatigue, shortness of breath, leg cramps or claudicating pain.

6- General appearance.

7- Hypertensive response (systolic pressure > 250 mm hg and /or diastolic blood pressure >115mmhg) (Fletcher et al., 2001).

Maximum oxygen consumption (VO2max) (ml/min/Kg) was obtained through breath-by breath gas exchange analysis. VO2max was considered to be attained if subject reported a feeling of fatigue and if one of the following criteria was reached:

a) Failure of VO2 to increase despite of increased work rate.

b) Respiratory exchange ratio( RER)> 1.1

c) Maximal heart rate within 10 beats/min of age-predicted maximum (220-age).

(2)Muscle Strength Assessment Procedures:

a- Knee Extensor:

The hand-held dynamometry was one instrument used to test knee extensor muscle performance. All subjects were tested by the same tester. Subjects were seated at the edge of a treatment table and positioned at about 90^ohips flexion and 80^o knee flexion; lower leg vertical to floor; foot not touching floor. The hand-held dynamometry was position two finger widths above the lateral malleolus on the anterior of tibia. Subjects' were asked to stabilize their pelvis by holding onto the edge of the treatment table. A make test was used , in which the tester matches the muscle force generated by the subject, as contrasted with a break test, in which the tester attempts to exceed the force generated by the subject.

Four warm-up contractions were performed, with subjects instructed to gradually increase their knee extension force over 3 seconds. Subjects were instructed to give approximately 50% effort in the first three warm-ups and a maximal contraction on the fourth worm-up. Four maxima trials were then performed, with the peak force of the fourth contraction recorded.

B-Elbow Flexor:

Subjects were seated at the edge of a treatment table. Subjects were asked to hold onto the edge of the treatment table by the other hand to stabilize the trunk. The examined elbow should be held against the patient's side to avoid shoulder movement and put the elbow in supination of the forearm with the elbow at a right angle. The hand-held dynamometry was positioned at the distal end of the forearm above the wrist (to avoid twisting the wrist). The subject was asked to flex his/her elbow while the pressure was in the direction of extension.

A make test was used , in which the tester matches the muscle force generated by the subject, as contrasted with a break test, in which the tester attempts to exceed the force generated by the subject.

Four warm-up contractions were performed, with subjects instructed to gradually increase their elbow flexion force over 3 seconds. Subjects were instructed to give approximately 50% effort in the first three warm-ups and a maximal contraction on the fourth worm-up. Four maxima trials were then performed, with the peak force of the fourth contraction recorded. Fig (11)

Fig. (11): Procedure of Measuring Elbow Flexor Muscle Strength through Hand-Held Dynamometry.

3-The QoL and Fatigue assessment procedure:

Each child was instructed to complete answer the list of question with an assistant from his/her parents. The evaluation was carried out before and at the end of rehabilitation. (Appendix I)

Therapeutic Procedures:

All the children in the exercise group followed a 12 weeks training program consisting of three weekly session with a duration ranging from 90 min (in the first few weeks of the program ) to 120 min ( by the end of the program ) each session started and end with a low- intensity 15 min warm up and cool –down period consisting of walking on treadmill at very light work load and stretching exercise involving all major muscle groups the core portion of the training session is divided into strength and aerobic exercises.

· Strength training included 11exercise engaging the major muscle group (bench press ,shoulder press ,leg extension ,leg press, leg curl ,abdominal crunch ,low back extension ,arm curl elbow extension ,seated raw , and lateral pull-down).for each exercise the children perform one set of 8-15 repetition (total of approximately 20-s duration )

· Rest period of 1-2 min separate the exercises.

· Stretching exercises of the muscles involved in the previous exercises were performed during the rest period between exercises

· The load was gradually increased as the strength of each child improved.

· Aerobic exercise consisted of pedaling a cycle ergo meter, running, walking and aerobic games involving large muscle group (i.e. jumping exercise, ballgames group games, etc).

· The duration and intensity of the aerobic training was gradually increased during the 12 week period so that the subject start with at least 10 min of aerobic exercises at 50% of age predicted maximum heart rate (HR_Max), (calculated as 220 minus age minus rest heart rate) and progress to at least 30 min of contentious exercise at ≥ 7o% HR_maxby the end of the 12 weeks program (San Juan et al., 2007).

Statistical Procedures:

- In this study, the obtained data were recorded on the evaluative sheet.

- These data were transferred into IBM card using IBM personal computer with statistical program.

The statistical procedures were focused to the following phases:-

1-Data Collection Phases: -

The data regarding to the patients’ age, sex, height, weight; collected before entry of the study. The data regarding to (IGA) had been collected before initiation of experiment (pre), and post-treatment.

The data collection was performed at the same sequences and procedures for all patients in the two groups of the study (exercise and control groups).

2-Data Analysis: -

The collected data was analyzed statistically to obtain the following statistical tools:

(a)Descriptive Statistics:

· In this study, the descriptive statistics in form of mean and standard deviation were calculated for all patients in both groups of the study to determine the homogeneity and central deviation. The mean is the sum of the observations on the number of the observations. The stander deviation is the squire root of the variance and it is expressed in the unit of the original measure. Variance is a measure of the variability around the mean within a data set.

(b) Analytic Statistics:

The analysis and comparison of the data were made by these tools of statistics.

· Paired T-test was used to compare the dependent variable

· Cardiopulmonary endurance and physical fitness ,

● Muscle strength (elbow flexor and knee extensor),

· Fatigue and Quality of life (QOL) ,

In children receiving chemotherapy in ALL, within each group (i.e. pre-treatment and post-treatment to the individuals in both groups) to detect level of significant.

● Unpaired T-test was used to compare the dependent variable (

§ Cardiopulmonary endurance and physical fitness ,

§ Muscle strength (elbow flexor and knee extensor),

§ Fatigue and Quality of life (QOL) ,

and independent (age, sex, height, weight of children) Variables between both groups to detect level of significant.

● Sign test was used to compare the data obtained, within each group (i.e. pre-treatment and post-treatment to the individuals in both study and control groups) to detect level of significant.

Sign test: - It is a non-parametric alternative to the one sample t-test; it is designed to test a hypothesis about the location of a population distribution. It is most often used to test the hypothesis about a population median, and often involves the use of matched pairs. It can be applied when the observations in a sample of data are ranks

· Mann-Whitney test was used to compare the data obtained between the exercise and the control group.

Mann-Whitney test: - It is a non-parametric alternative to the independent samples t-test. Like t-test Mann-Whitney tests the null-hypothesis that two independent samples come from the same population. Rather than being based on parameters of a normal distribution like mean and variance, the Mann-Whitney statistic are based on ranks. The Mann-Whitney statistic is obtained by counting the number of times an observation from the group with the smaller sample size precedes an observation from the larger group.

● Both descriptive and analytical statistics were used to examine, describes and analyses the collected data to detect if there was inter-group or intra-group difference before and after treatment.

● Each hypothesis was tested separately by the using the appropriate statistical tools. The data analysis and the level of significance were set at the level of 0.05....

http://ptlectures.blogspot.com

Forearm_Supination_&_Pronation

noreply@blogger.com (dr/azza) — Sat, 26 Mar 2011 20:45:00 +0200

Exercise for burn

noreply@blogger.com (dr/azza) — Sat, 26 Mar 2011 01:41:00 +0200

Exercise for burn

Exercise with positioning and splinting is the essential part of a burn patient's rehabilitation program.

Problems that counter the exercise in a burn patients.

1- Extensive wound

2- Extreme pain

3- Fear of causing additional tissue damage.

Goal of exercise.

A- ultimate goal of burn rehabilitation/

is to assist the patient to return to society at the most optimal functional level as possible compared to their pre-injury status.

B- Specific goals.

1- Reduce edema and promote circulation.

2- Prevent scar tissue contractures and deformities

3- Preserve muscle strength and joint mobility/

4- Promote maximal function independence/

Factor affecting the establishment of a burn patient exercise program.

1- Goal to achieve. 2- Phase of recovery. 3- Intent of exercise.

4- Patient medical status. 5- Age of patient. 6- Social support.

7- Frequency of treatment. 8- Location of burn. 9- Extent of burn.

10- Precaution and contraindication. 11- Types of exercise.

1- Phase of recovery.

Acute or pre-grafting phase the aim is to preserve ROM and strength and decrease the intensity of exercise due to pain.

In post acute phase increase the intensity and prefer functional and independency exercise as the pain decrease.

2- Intent of exercise.

Aim of exercise determines the type of exercise design the therapeutic methods to match with goal will be achieved.

3- Patient medical status.

Differential Diagnosis in Neurology and Neurosurgery

noreply@blogger.com (dr/azza) — Sat, 26 Mar 2011 00:02:00 +0200

This book is dedicated to the Greek national benefactress
Mrs Theoula Carouta
for generously supporting to the department of neurosurgery,
to my university professors
N. Matsaniotis, S. Moulopoulos, Gr. Skalkeas, K. Stefanis
and to my neurosurgical instructors
F. J. Gillingham, E. R. Hitchcock, M. Salcman, G. Sloughter,
H. J. Hoffman, C. Tator, and J. T. Hoff
who have greatly influenced my professional career....

dawnload

Knee_Extension

noreply@blogger.com (dr/azza) — Fri, 25 Mar 2011 21:02:00 +0200

Stability Ball Side Turns - Obliques core Exercise

noreply@blogger.com (dr/azza) — Fri, 25 Mar 2011 17:11:00 +0200

recent_advances_in_physiotherapy

noreply@blogger.com (dr/azza) — Fri, 25 Mar 2011 14:54:00 +0200

Book Description:
Like Partridge: Neurological Physiotherapy: Bases of Evidence for Practice, each chapter in Recent Advances in Physiotherapy features a case report provided by a team of clinicians based on details from a real patient. This book of recent advances provides readers with a way of keeping up-to-date with recent work in the discipline of physiotherapy, based on the evidence for current practice.....

dawnload

Nerve Injuries and Nontraumatic Disorders

noreply@blogger.com (dr/azza) — Fri, 25 Mar 2011 14:44:00 +0200

Nerve Injuries and Nontraumatic Disorders

The classification of nerve injuries proposed by Seddon (1943) was generally accepted but rarely used. He divided such injuries into three groups as follows:

1.Neurapraxia, designating minor contusion or compression of a peripheral nerve with preservation of the axis-cylinder but with possibly minor edema or breakdown of a localized segment of myelin sheath. Thus transmission of impulses is physiologically interrupted for a time, but recovery is complete in a few days or weeks.

2.Axonotmesis, designating more significant injury with breakdown of the axon and distal wallerian degeneration but with preservation of the Schwann cell and endoneurial tubes. Spontaneous regeneration with good functional recovery can be expected.

3.Neurotmesis, designating a more severe injury with complete anatomical severance of the nerve or extensive avulsing or crushing injury. The axon and the Schwann cell and endoneurial tubes are completely disrupted. The perineurium and epineurium also are disrupted to varying degrees. Segments of the latter two may bridge the gap if complete severance is not apparent. In this group significant spontaneous recovery cannot be expected.

A more useful classification was described by Sunderland in 1951. This classification is more readily applicable clinically, each degree of injury suggesting a greater anatomical disruption with its correspondingly altered prognosis. In this classification peripheral nerve injuries are arranged in ascending order of severity from the first to the fifth degree. Anatomically the various degrees represent injury to (1) myelin, (2) axon, (3) the endoneurial tube and its contents, (4) perineurium, and (5) the entire nerve trunk (Table 81-1).

ETIOLOGY OF PERIPHERAL NERVE INJURIES

Peripheral nerves may be injured by metabolic or collagen diseases, malignancies, endogenous or exogenous toxins, or thermal, chemical, or mechanical trauma. Only injuries caused by mechanical trauma are considered here. Every patient having injured a limb or limb girdle should be evaluated for possible musculoskeletal, vascular, and peripheral nerve damage (Table 81-5).

Primary injury of a peripheral nerve results from the same trauma that injures a bone or joint. In some instances, however, the neural injury is caused by displaced osseous fragments, by stretching, or by manipulation rather than by the initial injuring force. Secondary injury results from involvement of the nerve by infection, scar, callus, or vascular complications. These complications may be hematoma, arteriovenous fistula, ischemia, or aneurysm.

The radial nerve is the one most commonly injured. Of humeral shaft fractures, 14% are said to be complicated by injury of this nerve. Of radial nerve injuries, 33% are associated with fracture of the middle third of the humerus, 50% with fracture of the distal third of the humerus, 7% with supracondylar fracture of the humerus, and 7% with dislocation of the radial head.

The ulnar nerve is injured in about 30% of patients with combined skeletal and neural injury involving the upper extremity. This injury is most commonly associated with fractures about the medial humeral epicondyle, but it is often secondary to the formation of callus about the elbow.

The median nerve is injured in only about 15% of combined skeletal and neural injuries of the upper extremity. It is injured most commonly in dislocation of the elbow or secondarily in the carpal tunnel after injury of the wrist or distal forearm.

Axillary nerve stretch injuries occur in approximately 5% of shoulder dislocations.

The peroneal nerve is injured most commonly at the fibular neck in fracture of the tibia and fibula or dislocation of the knee.

Branches of the lumbosacral plexus are injured in less than 3% of pelvic fractures; it is reportedly injured in 10% to 13% of posterior dislocations of the hip. The tibial nerve may be injured in fractures of the proximal tibia and injuries about the ankle.

Peripheral nerve injuries should be carefully excluded in every patient with an acute extremity injury. Equal diligence should be applied in evaluation after surgery, manipulation, casting, and recovery from skeletal injury to detect secondary neural injury.

CLINICAL DIAGNOSIS OF NERVE INJURIES

Immediately after a severe injury to an extremity, recognition of a peripheral nerve injury is not always easy. Pain often is so severe that cooperation by the patient is limited at best. Here the preservation of life and limb is always the first objective. However, when possible, some simple tests should be made to detect injuries of major nerves of the extremity. In the upper extremity, for instance, loss of pain perception in the tip of the little finger indicates ulnar nerve injury. Loss of pain perception in the tip of the index finger indicates median nerve injury, and inability to extend the thumb in the hitchhiker’s sign usually indicates radial nerve injury though the extensor tendons may be severed and render this test invalid. Similarly, in the lower extremity loss of pain perception in the sole of the foot usually indicates sciatic or tibial nerve injury, whereas inability to extend the great toe or the foot indicates peroneal or sciatic nerve injury. As with the radial nerve, injury to the tendons or muscle bellies may render these tests useless. However, they may be carried out quickly and usually serve as effective screening procedures.

In evaluating peripheral nerve lesions, a precise knowledge of the course of the nerve, of the level of origin of its motor branches, and of the muscles that these branches supply is essential. Knowledge of the more common anatomical variations in nerve supply is extremely helpful. Furthermore, one must be familiar with the various zones of sensation, as well as with the areas in which sweating may be diminished or absent and in which skin resistance may be increased. Evaluation of motor loss is highly important. This can be accurate only if one can palpate or see the tendon or muscle belly under consideration. If one relies on analysis of movement alone as an indication of intact nerve supply, errors will be made because of substitution and trick movement

DIAGNOSTIC TESTS

Electromyography. Immediately after section of a peripheral nerve the electromyogram will demonstrate normal insertion activity (Figure 81-9). There will be no muscle response after stimulation of the nerve proximal to the site of injury. During the interval between 5 and 10 days after section, early denervation changes may be seen. Within 5 to 14 days positive sharp waves consistent with denervation are seen (Figure 81-10). Within 12 days denervation fibrillation potentials may be seen. No motor unit potentials are evident during attempted volitional contraction of the muscle, confirming the clinical finding of paralysis involving the muscle being

tested. Electromyography immediately after injury is valuable to demonstrate residual innervation or retained motor unit potentials during attempted volitional contraction that could be so minimal as to be undetected clinically. Retained motor unit potentials found under these circumstances suggest that complete interruption of the supplying nerve did not result from the injury. In such a situation anomalous innervation must be excluded.

Nerve conduction studies. Stimulation of a peripheral nerve by an electrode placed on the skin overlying the nerve will readily evoke a response from the muscle or muscles innervated by that nerve. This response can be seen, palpated, or measured electromyographically.

The techniques of both peripheral nerve stimulation studies and electromyography are exceedingly useful in separating hysterical or functional problems and malingering from organic illness that they might mimic.

Tinel sign. The Tinel sign is elicited by gentle percussion by a finger or percussion hammer along the course of an injured nerve. A transient tingling sensation should be experienced by the patient in the distribution of the injured nerve rather than at the area percussed, and the sensation should persist for several seconds after stimulation. It should be tested for in a distal to proximal direction. A positive Tinel sign is presumptive evidence that regenerating axonal sprouts that have not obtained complete myelinization are progressing along the endoneurial tube. With progressive regeneration, the positive response fades proximally, presumably because of progressive myelinization along the more proximal part of the regenerated segment. Distal progression of the response along the course of the nerve in question can be measured, and the rate of this progression has been used by some to establish prognosis or suggest the need for exploration.

Sweat test. Sympathetic fibers within a peripheral nerve are among the most resistant to mechanical trauma. The presence of sweating within the autonomous zone of an injured peripheral nerve reassures the examiner to a degree, suggesting that complete interruption of the nerve has not occurred. Preservation of sweating can be determined very simply, as pointed out by Kahn, by observing beads of sweat through the +20 lens of an ophthalmoscope. The time-honored sweat test (iodine starch test) consists of dusting the extremity with quinizarin powder. Sweating is induced by various means. The powder remains dry and light gray throughout the denervated area and assumes a deep purple color throughout the area of normal sweating. The triketohydrindene hydrate (Ninhydrin) print test as recommended by Aschan and Moberg is another method of assessing sweat patterns in the hand.

Skin resistance test. The skin resistance test is another method of evaluating autonomic interruption; in it a Richter dermometer is used. The autonomous zone with absence of sweating demonstrates an increased resistance to the passage of electric current. The adjacent innervated areas have a normal resistance, and further decreased resistance in these areas can be elicited by high external temperatures that will not affect the denervated area. The area outlined by the Richter dermometer roughly approximates the autonomous zone of the nerve in question.

Electrical stimulation. Electrical stimulation through the intact skin has been used in one form or another by many investigators and clinicians for a long time. Faradic stimulation often is of little value because normally innervated muscles may fail to respond to this current. Additionally, if response to faradic stimulation is still present after 3 weeks, then the muscles in most instances are capable of voluntary contraction and no additional information is obtained by the study. Galvanic stimulation is useful in determining chronaxy and the strength-duration curve. These determinations frequently give early evidence of denervation after nerve injury and are useful in following the evolution of reinnervation, which is less readily assessed by other methods.

GENERAL CONSIDERATIONS OF TREATMENT

As in any other injury, initial management of the patient with peripheral nerve damage should begin with careful assessment of the vital functions. When indicated, appropriate actions to prevent cardiopulmonary failure and shock should be taken and systemic antibiotics and tetanus prophylaxis should be provided. Once the extent of any injury to the major viscera has been determined and appropriate resuscitative measures have been started, the injury to the peripheral nerve should be evaluated and the specific nerve deficit should be carefully assessed.

An open wound in which a peripheral nerve has been injured should be thoroughly cleansed and debrided of any foreign material and necrotic tissue, using local, regional, or general anesthesia. If the wound is clean and sharply incised, if the condition of the patient is satisfactory, and if a repair can be carried out in a quiet and unhurried setting with adequate personnel and equipment, immediate primary repair of the nerve is preferred. On the other hand, if the general medical condition of the patient does not permit adequate repair or if circumstances otherwise cause an undue delay, we prefer to perform the neurorrhaphy during the first 3 to 7 days after injury; in this instance the wound first is covered with a sterile dressing and is observed for evidence of sepsis.

When open wounds are caused by blasting, abrading, or crushing agents and when contamination with foreign material is severe, the wound is thoroughly cleansed and debrided and a sterile dressing is applied. If the ends of the nerve can be identified, they are marked with sutures such as those of stainless steel that can be easily identified later. In the absence of a significant nerve gap, loose end-to-end apposition prevents retraction of the nerve segments and makes later repair easier. In the presence of a segmental gap in the nerve, suturing the ends to the soft tissues prevents their retraction. Soft tissue coverage of the wound consistent with the management of the injured part is carried out, and the nerve is repaired at a later date when the soft tissues have healed, usually between 3 and 6 weeks after injury.

A closed injury in which a peripheral nerve has been damaged requires careful assessment of residual function and documentation of discrete deficits. After the initial pain has subsided, and the wound has healed, early active motion of all joints of the involved extremity should be started. When necessary, gentle passive exercises that avoid disrupting nerves and tendons may be instituted. All joints of the extremity must be kept supple, and soft tissue contractures must be avoided. Exercises help keep the soft tissues of the extremity in a better physiological state so that when the nerve has regenerated, rehabilitation is easier. The specific effects of electrical stimulation of muscles remain unclear. Regardless of the details of the treatment program the patient must become actively involved in it to prevent contractures and to strengthen muscles with intact innervation. Similarly an extremity with a peripheral nerve injury should not be immobilized indefinitely. Dynamic and static splinting to support joints and to prevent contractures should be used intermittently.

When closed fractures are complicated by peripheral nerve deficits, to await reinnervation seems reasonable, and early surgical exploration usually is avoided. Then the progress of return of function in the injured extremity is evaluated with periodic electromyograms, nerve conduction velocities, and frequent clinical evaluation. Conversely, if the nerve deficit follows manipulation or casting of a closed fracture in the absence of a prior nerve deficit, early exploration of the nerve is favored.

FACTORS THAT INFLUENCE REGENERATION AFTER NEURORRHAPHY

Several important factors that seem to influence nerve regeneration are (1) the age of the patient, (2) the gap between the nerve ends, (3) the delay between the time of injury and repair, (4) the level of injury, (5) the condition of the nerve ends, and (6) the experience and techniques of the surgeon. The first five of these are discussed here.

GENERAL CONSIDERATIONS FOR SURGERY

Indications. In the presence of a traumatic peripheral nerve deficit exploration of the nerve is indicated as follows:

1.When a sharp injury has obviously divided a nerve, early exploration is indicated for diagnostic, therapeutic, and prognostic purposes. Neurorrhaphy may be carried out at the time of exploration or may be delayed.

2.When abrading, avulsing, or blasting wounds have rendered the condition of the nerve unknown, exploration is required for identification of the nerve injury and for marking the ends of the nerve with sutures for later repair.

3.When a nerve deficit follows blunt or closed trauma and no clinical or electrical evidence of regeneration has occurred after an appropriate time, exploration of the nerve is indicated. This is also true when a nerve deficit complicates a closed fracture. In this instance it has been our practice to observe the patient for evidence of nerve regeneration for an appropriate time, depending on the nerve and its level of muscle innervation. Then if regeneration has not occurred, we favor exploration. In situations in which a nerve has been intact before closed reduction and casting of a fracture but a significant deficit is found immediately after, we explore the nerve as soon as feasible.

4.When a nerve deficit follows a penetrating wound such as that caused by a low-velocity gunshot, the part is observed for evidence of nerve regeneration for an appropriate time. If there is no evidence of regeneration, exploration is indicated.

Conversely, delay in exploration of a nerve injury is indicated if progressive regeneration is evidenced by improvement in sensation, motor power, and electrodiagnostic tests and by progression of the Tinel sign.

Time of surgery. It has been the time-honored policy to advise primary suture when possible. This is logical when one considers what happens to the distal end of the nerve, motor end plates, sensory nerve endings, muscles, joints, and other tissues of the denervated extremity. The controversy concerning whether primary or secondary nerve repair is better remains unsolved. Primary repair carried out in the first 6 to 8 hours or delayed primary repair carried out in the first 7 to 18 days is appropriate when the injury is caused by a sharp object, the wound is clean, and there are no other major complicating injuries. Ideally such repairs should be performed by an experienced surgeon in an institution where adequate equipment and personnel are available. The development of magnification devices, new instruments, and new techniques and the modification of a variety of small instruments for use in nerve surgery have improved the technique of early repair. Primary repair should shorten the time of denervation of the end organs, and fascicular alignment should be improved because minimal excision of the nerve ends is required.

BRACHIAL PLEXUS

The brachial plexus is formed by the union of the anterior rami of C5, C6, C7, C8, and T1.

Upper plexus injury (Erb) involves the segments innervated by the C5 and C6 nerve roots with or without dysfunction of the C7 root. Typically the limb is extended at the elbow, flaccid at the side of the trunk, and adducted and internally rotated. Abduction is impossible because of paralysis of the deltoid and supraspinatus muscles, and external rotation is impossible because of paralysis of the infraspinatus and teres minor muscles. Active flexion of the elbow is impossible because of paralysis of the biceps, brachialis, and brachioradialis muscles. Paralysis of the supinator muscle causes pronation deformity of the forearm and inability to supinate the forearm. Sensation is absent over the deltoid muscle and the lateral aspect of the forearm and hand.

Lower plexus injury (Klumpke) can be diagnosed by finding segmental sensory and motor deficits involving C8 and T1 with or without C7 dysfunction. Associated Horner syndrome should alert the examiner to the possibility of an avulsing injury of the lower plexus, and myelography and electromyographic studies may be necessary to exclude such an injury. In addition to penetrating wounds, many lower plexus injuries are caused by difficult births, falling on the outstretched arm, or trauma from crutches. The primary dysfunction is apparent in the intrinsic musculature of the hand along with paralysis of the wrist and finger flexors. The sensory deficit is along the medial aspect of the arm, forearm, and hand.

RADIAL NERVE

The radial nerve, a continuation of the posterior cord of the brachial plexus, consists of fibers from C6, C7, and C8 and sometimes T1. It is primarily a motor nerve that innervates the triceps, the supinators of the forearm, and the extensors of the wrist, fingers, and thumb. This nerve is injured most often by fractures of the humeral shaft. Gunshot wounds are the second most common cause of radial nerve injury.

After repair of the radial nerve the prognosis for regeneration is more favorable than for any other major nerve in the upper extremity, primarily because it is predominantly a motor nerve and secondarily because the muscles innervated by it are not involved in the finer movements of the fingers and hand.

The following muscles supplied by the radial nerve can be tested accurately because their bellies or tendons or both can be palpated: the triceps brachii, brachioradialis, extensors carpi radialis, extensor digitorum communis, extensor carpi ulnaris, abductor pollicis longus, and extensor pollicis longus. Injury to this nerve results in inability to extend the elbow or supinate the forearm and in a typical wristdrop. The inexperienced examiner, however, often may be misled by the patient’s ability to extend the wrist merely by flexing the fingers. The examiner therefore should be discriminating because analysis of movements may often result in error in evaluating the function of a nerve. The triceps is not seriously affected by injuries of the nerve at the level of the middle of the humerus or distally. In injuries of the nerve at its bifurcation into the deep and superficial branches the brachioradialis and the extensor carpi radialis longus continue to function; thus the arm can be supinated and the wrist can be extended.

Sensory examination is relatively unimportant, even when the nerve is divided in the axilla, because usually there is no autonomous zone. When present, the autonomous zone usually is over the first dorsal interosseus muscle, between the first and second metacarpals.

ULNAR NERVE

The ulnar nerve is composed of fibers from C8 and T1 coming from the medial cord of the brachial plexus. It may be divided at any point along its course by missile wounds or lacerations. When it is injured in the upper arm, other nerves or the brachial artery because of their proximity also may be injured. In the middle of the arm the ulnar nerve is relatively protected, but in the distal arm and at the elbow it often is injured by dislocations of the elbow and supracondylar and condylar fractures. An ulnar nerve deficit complicating a fracture or dislocation may be caused by the initial trauma, by repeated manipulations of the osseous injury, or by scar formation developing sometime after injury. The nerve is injured most commonly in the distal forearm and wrist

Interrupting the ulnar nerve proximal to the elbow is followed by paralysis of the flexor carpi ulnaris, the flexor profundus to the little and ring fingers, the lumbricals of the same fingers, all of the interossei, the adductor of the thumb, and all of the short muscles of the little finger. Occasionally when a nerve is completely divided at this level, the intrinsic muscles of the hand function normally because of anomalous innervation of these muscles by the median nerve. In these instances the fibers that supply the intrinsic muscles may be incorporated in the median nerve down to the middle of the forearm where they leave the median nerve to join the ulnar nerve (Martin-Gruber anastomosis). Complete division of the ulnar nerve at the wrist usually causes paralysis of all ulnar-innervated intrinsic muscles unless an anatomical variation connects the median and ulnar nerves in the palm (Riche-Cannieu anastomosis). Usually when the nerve is divided at the wrist, only the opponens pollicis, the lateral or superficial head of the flexor pollicis brevis, and the lateral two lumbricals remain functional.

The sensory examination usually is straightforward, although anatomical variations may cause confusing sensory findings. One need examine only the middle and distal phalanges of the little finger, which make up the autonomous zone of the ulnar nerve (Figure 81-26). Complete anesthesia to pinpricks in this area strongly suggests total division of the nerve. If one is in doubt about the sensory examination, skin resistance studies or an iodine starch test will be useful.

In patients suspected of having cubital tunnel syndrome, a positive percussion test over the ulnar nerve at the level of the medial epicondyle and a positive elbow flexion test are strongly suggestive of a significant compressive neuropathy. With the elbow fully flexed, the patient will complain of numbness and tingling in the small and ring fingers, often within 1 minute. Nerve conduction studies are helpful and should demonstrate slowing in the ulnar nerve velocities across the elbow, although normal velocities may be maintained during early involvement. Electromyography may demonstrate fibrillations in the ulnar innervated intrinsic muscles.

MEDIAN NERVE

The median nerve, formed by the junction of the lateral and medial cords of the brachial plexus in the axilla, is composed of fibers from C6, C7, C8, and T1

Median nerve injuries often are caused by lacerations, usually in the forearm or wrist.

The muscles of the forearm and hand supplied by the median nerve that can be tested with relative accuracy are the pronator teres, flexor carpi radialis, flexor digitorum profundus (index), flexor pollicis longus, flexor digitorum sublimis, and abductor pollicis brevis. Substitution movements caused by action of intact muscles may cause confusion during the examination. The works of Sunderland provide an excellent review of these movements and the methods of recognizing and preventing them. Usually if the forearm can be actively maintained in pronation against resistance, the pronator teres is intact. If the wrist can be actively maintained in flexion and a contracting flexor carpi radialis is palpated, this muscle is intact. Similarly if the interphalangeal joint of the thumb can be maintained in flexion against resistance with the wrist in the neutral position and the thumb adducted, the flexor pollicis longus is functioning. The flexor digitorum sublimis to each finger is examined separately while the remaining fingers are held in full passive extension.

Variations in the sensory supply of the median nerve also may be confusing, but usually the volar surface of the thumb, of the index and middle fingers, and of the radial half of the ring finger and the dorsal surfaces of the distal phalanges of the index and middle fingers are supplied by the median nerve. The smallest autonomous zone of the median nerve covers the dorsal and volar surfaces of the distal phalanges of the index and middle fingers (Figure 81-32). The iodine-starch test or triketohydrindene hydrate print test may be helpful in diagnosis. Autonomic changes such as anhydrosis, atrophy of the skin, and narrowing of the digits because of atrophy of the pulp also are valuable signs of sensory deficit

SCIATIC NERVE

Of the muscles innervated by the sciatic nerve that can be tested accurately, those supplied by the tibial component include the hamstrings, the gastrocsoleus, the tibialis posterior, and the long flexors of the toes; those supplied by the peroneal component include the tibialis anterior and the long extensors of the toes (deep peroneal nerve) and the peroneus longus and the peroneus brevis (superficial peroneal nerve). Testing of the intrinsic muscles of the foot, except the extensor digitorum brevis, is impractical. An extremity in which the sciatic nerve has been divided may develop an equinus deformity of the foot, clawing of the toes, and atrophy of the muscles innervated by the nerve, depending on the level of the injury. Profound weakness of flexion of the knee, inability to dorsiflex the foot or extend the toes, inability to plantar flex and evert the foot, and inability to flex the toes may be seen. When the peroneal part is involved, the sensory loss is primarily over the lateral aspect of the leg and dorsum of the foot. When the tibial nerve is involved, the sensory deficit is primarily over the plantar aspect of the foot. Anesthesia on the plantar surface may result in chronic ulceration. Autonomic disturbances and chronic pain may follow an injury to the sciatic or tibial nerve. The sciatic nerve is difficult to stimulate in situ because it is so deeply located. Stimulation is significant only when it causes contraction or pain. Electromyography is of considerable help in evaluating this nerve

The autonomous zone of the sciatic nerve (Figure 81-36), includes the area over the metatarsal heads and over the heel, the lateral and posterior aspects of the sole of the foot, and the dorsum of the foot as far medially as the second metatarsal, as well as a narrow strip up the lateral aspect of the leg.

TIBIAL NERVE

The tibial nerve, composed of fibers from L4, L5, S1, S2, and S3.

The muscles supplied by this nerve that may be accurately examined were described in the discussion of the sciatic nerve. The autonomous zone of the tibial nerve (including the medial sural cutaneous branch) varies but generally includes the sole of the foot (except the medial border of the instep), the lateral surface of the heel, and the plantar surface of the toes. Because the nerve is deep in the popliteal fossa, stimulating the nerve in this area is not always dependable, and consequently electromyography is indicated. The tibialis posterior, flexor digitorum longus, and flexor hallucis longus are supplied by branches of the tibial nerve after the nerve passes deep to the arch of the soleus muscle. The flexor digitorum longus and flexor hallucis longus may be difficult to test, but the tendon of the flexor hallucis longus may be palpated posterior to the medial malleolus as it passes to cross the medial aspect of the plantar arch. Atrophy of the intrinsic muscles of the foot may allow palpation of the flexor digitorum longus tendons; otherwise this muscle may not be palpable for testing. The autonomous zone of the tibial nerve as it passes deep to the soleus muscle is smaller than that of the nerve as it passes through the popliteal fossa because the sural nerve is excluded. Although electromyography may be necessary for evaluating injury to the tibial nerve beneath the soleus, the nerve may be stimulated with relative ease at the posterior aspect of the medial malleolus.

TENDINITIS AND BURSITIS

In the evaluation of patients with tendinitis of the lower extremity, a careful history of work conditions and exercise routines is necessary. Overuse (repetitive activity) or overload (sudden increase in activity) often accentuates tendinitis. Tendinitis from these causes usually responds to relative rest, ice, the use of a Neoprene sleeve, antiinflammatory medications, and alterations in work or exercise habits. Mechanical abnormalities, leg length inequality, leg malalignment, or foot abnormalities (such as excessive supination or pronation) may respond to the use of properly fitted orthotics. Muscle imbalance should be treated with appropriate flexibility and strengthening exercise programs.

Bursae are sacs lined with a membrane similar to synovium; they are usually located about joints or where skin, tendon, or muscle moves over a bony prominence, and they may or may not communicate with a joint. Their function is to reduce friction and to protect delicate structures from pressure. Bursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances: (1) acute or chronic trauma, (2) acute or chronic pyogenic infection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or rheumatoid arthritis. There are two types of bursae: those normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion, an osteochondroma, or kyphosis of the spine).

Adventitious bursae are produced by repeated trauma or constant friction or pressure. Kuhns showed that adventitious bursae lack a true endothelial or synovial lining and that the same pathological changes can be found in adventitious bursae as in normal ones: infection, tumors, enlargements, and fibrosis.

Treatment is determined primarily by the cause of the bursitis and only secondarily by the pathological change in the bursa. Surgery is not required in most instances. Systemic causes, such as gout or syphilis, and local trauma or irritants should be eliminated, and, when necessary, the patient’s occupation or posture should be changed. One or more of the following local measures usually are helpful: rest, hot, wet packs, elevation, and, when necessary, immobilization of the affected part. Surgical procedures useful in treating bursitis are (1) aspiration and injection of an appropriate drug, (2) incision and drainage when an acute suppurative bursitis fails to respond to nonsurgical treatment, (3) excision of chronically infected and thickened bursae, and (4) removal of an underlying bony prominence.

The usual principles of treating infections are employed in treating those of bursae. The responsible organisms should be identified when feasible, and the infection should be treated with appropriate systemic antibiotics. Aspiration of the bursa and injection of the appropriate antibiotic may be indicated in addition to the supportive measures just described; a compression dressing should be applied after aspiration. Occasionally surgical drainage is necessary.

Traumatic bursitis often will respond favorably to aspiration and injection of an appropriate steroid preparation and the usual nonoperative treatment.

Adventitious bursae that develop as a result of repeated trauma usually have a much thicker fibrous wall than do normal bursae and are more susceptible to inflammatory changes. This type of bursa is treated by removing the cause, for example, excising an osteochondroma or correcting a bunion; at the time of operation the bursal sac usually is excised. Only those bursae that most often require surgical drainage or excision will be described.

Prepatellar bursitis.

Tibial collateral ligament fibrositis and bursitis

Fibular collateral ligament bursitis

Infrapatellar bursitis.

Popliteal cyst (Baker cyst)

Medial gastrocnemius bursitis.

Bursitis associated with gluteus maximus muscle

Subgluteal bursitis.

Trochanteric bursitis.

Ischiogluteal bursitis

ELBOW INJURIES: ELBOW TENOPATHIES

Tennis elbow, a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonathletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence.

The diagnosis of tennis elbow is made by localizing discomfort to the origin of the extensor carpi radialis brevis. In actuality, the origin is covered by the adjacent extensor carpi radialis longus and extensor communis origin and usually is found just distal to the midpoint of the lateral epicondyle. Pinching with the wrist in extension usually reproduces pain at this site.

OSTEOCHONDROSIS OR EPIPHYSITIS

The terms osteochondrosis and epiphysitis designate disorders of actively growing epiphyses. The disorder may be localized to a single epiphysis, or occasionally may involve two or more epiphyses simultaneously or successively. The cause generally is unknown, but evidence indicates a lack of vascularity that may be secondary to trauma, infection, or congenital malformation.

EPIPHYSITIS OF TIBIAL TUBEROSITY (OSGOOD-SCHLATTER DISEASE)

Surgery rarely is indicated for Osgood-Schlatter disease; the disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeks. Krause, Williams, and Catterall, in a review of the natural history of untreated Osgood-Schlatter disease in 69 knees in 50 patients, found that 76% of patients believed they had no limitation of activity, although only 60% could kneel without discomfort. Two distinct groups were identified: (1) those who before treatment had roentgenographic fragmentation and who had either separated ossicles or abnormally ossified tuberosities at follow-up and (2) those who before treatment had soft tissue swelling without roentgenographic fragmentation and who were asymptomatic at follow-up. Krause et al. concluded that symptoms of Osgood-Schlatter disease resolve spontaneously in most patients and that those who continue to have symptoms are likely to have distorted tibial tuberosities associated with fragmentation of the apophysis on initial roentgenograms. Lynch and Walsh described premature fusion of the anterior part of the upper tibial physis in two patients with Osgood-Schlatter disease who were treated nonoperatively, and they recommend screening for this rare complication.

LEGG-CALVÉ-PERTHES DISEASE

Irritable hip syndrome occurs only twice as frequently in boys as in girls, whereas Legg-Calvé-Perthes disease occurs three times more frequently in boys than in girls. The average age of patients with irritable hips is 3 years, and the average age of those with Legg-Calvé-Perthes disease is 7 years. Children with irritable hips have an average duration of symptoms of 6 days, whereas those with Legg-Calvé-Perthes disease have symptoms present for an average of 6 weeks.

Once the diagnosis is established, the primary aim of treatment of Legg-Calvé-Perthes disease is containment of the femoral head within the acetabulum. If this is achieved, the femoral head can reform in a concentric manner by what Salter has termed ‘‘biological plasticity.’’ Containment in most patients who continued weight-bearing has been satisfactorily achieved by abduction and internal rotation devices such as the Newington or Toronto brace and Petrie casts, and by abduction alone in the Scottish Rite brace. Because the prognosis cannot be established accurately, all children with total head involvement, regardless of age, should be treated actively.

Lloyd-Roberts, Catterall, and Salamon classified patients with this disease into groups according to the amount of involvement of the capital femoral epiphysis: group I has partial head or less than half head involvement, groups II and III have more than half head involvement and sequestrum formation, and group IV has involvement of the entire epiphysis. Furthermore, they noted that, especially in group II, III, and IV patients, certain roentgenographic signs described as ‘‘head at risk’’ correlated positively with poor results. These head-at-risk signs include (1) lateral subluxation of the femoral head from the acetabulum, (2) speckled calcification lateral to the capital epiphysis, (3) diffuse metaphyseal reaction (metaphyseal cysts), (4) a horizontal physis, and (5) Gage sign, a radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis. They recommend containment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs. Contraindications include an already malformed femoral head and delay of treatment of more than 8 months from onset of symptoms. Surgery is not recommended for any group I children or any child without the head-at-risk signs.

We have used the Scottish Rite brace, popularized by Purvis and others because of its ability to place the legs in abduction and slight flexion (Figure 24-19). We realize that this brace does not provide maximum containment because it does not internally rotate. In fact, roentgenograms made with the brace on actually show some external rotation; however, the brace does allow some activities of daily living and psychosocially is more acceptable to the child and his parents than some other devices.

Contraindications to bracing include (1) a noncompliant patient, (2) parents or patient to whom the brace is psychosocially unacceptable, and (3) bilateral involvement at different time intervals, requiring prolonged brace wear. In any of these circumstances surgery may be indicated.

Frozen Shoulder

In 1945, Neviaser introduced the term adhesive capsulitis and described pathologic changes in the synovium and subsynovium. Till now unknown etiology.

Etiology: Recent reports suggest that adhesive capsulitis may be caused by biochemical changes in the joint capsule resulting in progressive fibrosis and motion loss.

Several factors have been associated with it: female gender, age greater than 40 years, trauma, diabetes, prolonged immobilization, thyroid disease, cerebral or cardiac infarction, and the presence of autoimmune disease.

The enhancement resulted from increased blood flow in and around the synovial tissue-recently reported MRI visualization of thickening of the joint capsule and synovium.

Diagnosis: It is defined as a painful and stiff developed in an otherwise healthy person 40 to 70 years of age. A duration of more than 1 month prior to examination

TREATMENT

The treatment is dependent on the stage of the disease and the symptoms.

Treatment protocols vary from benign neglect to supervised physical therapy, intra-articular corticosteroid administration, and early surgical intervention.

Traditional manipulative treatment of patients with joint contracture relies on forces applied with a long lever arm, risking fracture, especially in osteoporotic patients.

Intra-articular corticosteroids

The literature support the hypothesis that adhesive capsulitis is an inflammatory and fibrotic condition.

In the early stages, a hypervascular synovial hyperplasia is present that results in eventual fibrosis of the subsynovium and capsule.

Early treatment with it may provide a chemical ablation of the synovitis, thus limiting the subsequent development of fibrosis and shortening the natural history of the disease.

Non-steroidal anti-inflammatory drugs NAIDS

They have some effect in diminishing inflammation and oedema, in the past, ibrufen and diclofenac are used commonly for arthritis.

NAIDS has been shown to be effective both as an analgesic and as an antiinflammatory drug but also has side effects, especially on the gastrointestinal system, and should be used with caution and for a limited period in most cases.

Steroids such as hydrocortisone and prednisone are sometimes used in local injection to avoiding the severe general side effects.

New techniques for manipulation promise to lessen the risk of fracture, and the development of improvements in post-manipulation pain control, such as catheters for continuous local anesthesia, may improve patient outcome.

The treatment remains varied

The positive improvement in patient function noted with home-based physical therapy;

The intra-articular corticosteroid.

There remain significant gaps in our understanding of the etiology of frozen shoulder, which must be answered to best provide appropriate and efficacious treatment for these patients.

Carpal tunnel syndrome

Carpal tunnel syndrome results from narrowing of the carpal tunnel. This narrowing may be secondary to a previous fracture, osteoarthritis or synovial thickening in pregnancy or conditions such as rheumatoid arthritis.

The patient complains of an aching wrist, often worse at night when the arm is warm, together with variable numbness in the radial three and a half fingers and weakness and wasting of the thenar muscles.

TREATMENT: Rest with a simple detachable splint and anti-inflammatory drugs may give some relief but division of the flexor retinaculum of the wrist is often necessary.

Pharmacotherapy of Obesity

noreply@blogger.com (dr/azza) — Thu, 24 Mar 2011 02:08:00 +0200

The growing recognition of the health risks of obesity coupled with the difficulties in treating it successfully by lifestyle modification predicates a need for effective drug treatment. The history of drug treatment in the second half of the 20th century is, however, one of disappointment and concern over drug toxicity. However, the advances in our understanding of the mechanism of weight control, together with improved ways of evaluating anti-obesity drugs, has resulted in two effective compounds, sibutramine and orlistat, becoming available for clinical use. Sibutramine has actions on both energy intake and expenditure and had been shown to enhance weight loss and weight maintenance achieved by diet, in simple obesity as well as when accompanied by complications of diabetes or hypertension. About 50–80% of patients can achieve a >5% loss, significantly more than if patients receive the same lifestyle intervention with placebo. Orlistat, which acts peripherally to block the absorption of dietary fat, has had similar results in clinical trials; a recent study (XENDOS) has just reported results which show that the enhanced, albeit modest, weight loss achieved with orlistat delays the development of diabetes over a 4-year period. A number of other compounds are expected to complete or enter clinical trials over the next decade. There is considerable optimism that we will soon have the pharmacological tools needed to make the treatment of obesity feasible...

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Practicing Neurology

noreply@blogger.com (dr/azza) — Thu, 24 Mar 2011 01:55:00 +0200

n this new edition, Practicing Neurology: What You Need to Know, What You Need to Do, the latest volume from our Current Clinical Neurology series, Rahman Pourmand takes readers through the process of treating neurological conditions from evaluation to emergencies. For each condition, Pourmand provides basic facts, key definitions, step-by-step instructions for conducting a concise physical examination, neurologic signs to watch for, treatment strategies, and the prognosis...

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essentials_of_physical_medicine_and_rehabilitation

noreply@blogger.com (dr/azza) — Thu, 24 Mar 2011 01:32:00 +0200

Book Publisher: Hanley & Belfus

(15 December, 2001)

A major, new work in physical medicine and rehabilitation that is both practical and authoritative, this text provides easily accessible information on the diagnosis and management of musculoskeletal disorders and other common conditions requiring rehabilitation. Each topic is presented in a concise, focused, and well-illustrated two-color format featuring a de******ion of the condition, discussion of symptoms, examination findings, functional limitations and diagnostic testing, with a focus on procedures, rehab interventions, and treatment...

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Physical Medicine and Rehabilitation Board Review

noreply@blogger.com (dr/azza) — Thu, 24 Mar 2011 00:57:00 +0200

By Sara D., Ed. Cuccurullo

Publisher: Demos Medical Publishing

Number Of Pages: 848

Publication Date: 2004-10

"This book is a must for all residents undergoing training in the field of Physical Medicine and Rehabilitation."
Physical Medicine and Board Review" is necessary reading for all residents in Physical Medicine and Rehabilitation as well as practicing physiatrists. The book concentrates on board-related concepts in the field of Rehabilitation Medicine...

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Screening Notes: Rehabilitation Specialist’s Pocket Guide

noreply@blogger.com (dr/azza) — Thu, 24 Mar 2011 00:27:00 +0200

»Book Publisher: F. A. Davis Company

(09 June, 2006)

From Inside the eBook
INTRO Organizational Sequence of This Manual Tabs Across the Life Span Â¦ Alerts & Alarms Â¦ Pediatrics Â¦ Adolescence Â¦ Adult Â¦ Pregnancy Â¦ Geriatric Within Each Tab Â¦ Musculoskeletal Â¦ Neuromuscular Â¦ Cardiovascular/Pulmonary Â¦ Integumentary Â¦ Gastrointestinal Â¦ Hepatic Â¦ Endocrine Â¦ Urogenital Â¦ Additional information What is a RED Flag? Age may also place a person at a higher risk for the development of certain pathologies. The clinician is encouraged to obtain a thorough history, complete a review of systems, clear adjacent structures, & then attempt to provoke the symptoms reported by the client...

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Pelvis - Posterior Pelvic Pain

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 19:10:00 +0200

There are three types of back pain identified with pregnancy: posterior pelvic pain (PPP), high
back pain and low back pain with or without radiculopathy. Studies have indicated that 47-49%
of pregnant women experience some form of back pain during their pregnancy...

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High Risk Pregnancy

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 19:08:00 +0200

Standard of Care: High Risk Pregnancies
Inpatient Physical Therapy Management of the Patient with High Risk Pregnancy
Requiring Bedrest

Case Type / Diagnosis:

This standard of care applies to the acute care management of any woman with a high risk
pregnancy requiring bedrest to prevent fetal loss or extreme premature delivery or to control
maternal medical conditions. This may include patients with the following diagnoses:

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General - Marfan Syndrome

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 19:04:00 +0200

Marfan Syndrome is an autosomal dominant disorder of connective tissue with manifestations
variably involving the cardiovascular, ocular, musculoskeletal, and other systems. It affects
approximately 1 in 5000 people...

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Chris Comfort's Swiss Ball Exercises

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 17:10:00 +0200

Elbow-Radial Tunnel Syndrome

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 16:44:00 +0200

Standard of Care: Radial Tunnel Syndrome

Case Type / Diagnosis / Anatomy:

Radial tunnel syndrome (RTS) was first reported as a unique clinical syndrome in 1956. RTS has
also been called radial pronator syndrome. It is a pain syndrome that is distinct from lateral
epicondalgia and is a syndrome arising from compression of the posterior interosseous nerve
(PIN), which results in refractory lateral elbow and forearm symptoms.
15
This compression
occurs in the proximal forearm where the radial nerve splits into the PIN (main trunk) and the
sensory branch of the radial nerve (minor trunk). Compression can occur either before or after
this split. Radial nerve anatomy around the elbow is highly variable. The radial tunnel originates
near the level of the radiocapitellar joint where the nerve lies against the joint capsule. The
tunnel’s medial border is the brachialis muscle proximally and the biceps tendon distally. The
roof and lateral border of the tunnel is comprised of the extensor carpi radialis longus (ECRL)
and the extensor carpi radialis brevis (ECRB). The tunnel continues to the distal border of the
supinator. There are five sites of potential compression of the PIN:

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Shoulder - Subacromial decompression

noreply@blogger.com (dr/azza) — Wed, 23 Mar 2011 16:06:00 +0200

Indications for Treatment:
Subacromial impingement with rotator cuff tendinitis is a very common condition seen by both
orthopedic surgeons and physical therapists.
3, 12, 16
Impingement syndrome refers to a
pathological condition in which the suprahumeral structures are compressed against the
anteroinferior aspect of the acromion and/or the coracoacromial ligament.
3, 11, 16, 24
The
structures most often involved are the rotator cuff tendons, the long head of the biceps and the
subacromial bursa.

Rotator cuff syndrome is a term that is often used to describe the process
when both rotator cuff tendinitis and impingement are thought to be occurring simultaneously.

There are four major causes of rotator cuff tendinitis: external impingement, internal anatomical
impingement, functional overload and intrinsic tendinopathy.

Rotator cuff tears can occur
either traumatically or by the result of the degenerative process of tendinopathy.

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