Nishar Basha's Blog

SET POINT THEORY

2018-05-05T13:59:00.002+05:30

Set Point is the weight range in which your body is programmed to function optimally. Set Point theory holds that one’s body will fight to maintain that weight range.
Everyone has a set point and, just as you have no control over your height, eye color or hair color, you also have no control over what your set point will be. Your body is biologically and genetically determined to weigh within a certain weight range.

Set Points vary for each individual person. That is why it’s not a good idea to go by the weight charts that you see in medical books or hanging in your doctor’s office. For instance, a woman with a small frame may have a set point range between 120-130 lbs, but another woman with the same height may have a set point range between 130-140 lbs. Their set points may be different, but those are the weight ranges their bodies will fight to maintain. Scientists estimate that the average person has a set point range of about ten to twenty pounds, meaning at any given time, there is a ten-to-twenty-pound range at which your body will be comfortable and not resist attempts to change
Everyone who has ever tried dieting knows just how hard it is to lose weight and keep it off. In the first few weeks of dieting, weight is usually lost, but it is almost always gained back. Many people become frustrated because after a few weeks of dieting, they usually stop losing weight or start gaining it back, even though they are still restricting their food intake. That is a sign that the body is trying to fight to retain it’s natural weight.
When you go below your body’s natural set point, both appetite and metabolism adjust to try to return you to your set point. Your metabolism may slow down to try and conserve energy. Your body will start to sense it’s in a state of semi-starvation and will try to use the few calories it receives more effectively. You may start to sleep more, your body temperature will drop, which is why you hear so many people who suffer from anorexia nervosa complaining of being so cold, and after too much weight loss many women experience the loss of their menstrual cycle. Basically when a woman’s weight gets too low, her reproductive system shuts down because her body could not handle a pregnancy. When body fat is lost, appetite will likely increase. Many people who diet also experience uncontrollable urges to binge. That is because their bodies are asking for more food than is being provided in order to function properly.
Just as your metabolism will slow down when you go under your body’s set point, it will also increase if you go above it. The body will try to fight against the weight gain by increasing its metabolic rate and raising its temperature to try and burn off the unwanted calories.
The above description is an oversimplification as the processes that maintain hunger, digestion, and metabolism are incredibly complex and not entirely understood.
There is no test available to tell you what your body’s natural set point is. However, you can find your own set point. by listening to your body and eating normally and exercising moderately. If you have been dieting for years, it can take up to a year of normal eating for your body’s metabolism to function properly and return you to the weight range that is healthy for you.
Learning to accept the fact that your body needs to be at a certain weight is a good way to stop the vicious cycles of dieting. The more you try to go below your body’s set point range, the harder your body will fight to retain it’s natural weight. Engaging in a healthy eating and exercise routine, will allow your body to go to the weight it wants and needs to be at. Learning to love and accept who you are, will help you to accept your body’s natural set point. It is unfortunate that we live in a society that is obsessed with thinness, but we have to stop believing that thinness equals happiness. If we can all accept each other for who we are, no matter what size we are, people will be much happier, except, of course, for the diet industry, because they would be finally out of business!

3 Basic Energy Systems Provide Secrets; Allow Trainers' To Perfect Goal-Oriented Exercise!

2018-04-01T10:07:00.001+05:30

During exercise, your body relies on three basic energy systems: the anaerobic a-lactic system, the anaerobic lactic system, and the aerobic system. Depending on the sports played, athletes rely on one system more than the others.

An understanding of the involved energy systems in a particular sport gives valuable information about the strength qualities necessary in that sport. This information gives the personal trainer or strength coach clues on how to conduct the strength training.

The Three Basic Systems

1. Anaerobic A-Lactic (ATP-CP) Energy System

shot-putters

gymnasts

2. Anaerobic Lactic (Glycolytic) Energy System

American football skill positions

baseball players

soccer players

judokas

middle distance runners

sprinters

3. Aerobic Energy System

The aerobic system is the most utilized of the three. It provides energy for low intensity activities that last anywhere from two minutes to a few hours. Unlike the other two systems, the aerobic system requires oxygen and takes much longer to overload. Sports and activities that use continuous sustained efforts such as long distance swimming, crew (rowing) and sea kayaking rely on the aerobic system.

In reality, most sports use a variety of energy systems, or at least the power (time to reach peak output) and the capacity (duration that peak output can be sustained) of the system. The only real exceptions are Olympic weight lifting and certain field events, such as hammer or shot put. Which is energy system is most prevalent in a given sport dictates the training intent.

Reference: Bindu Nambiar (bodybuilding.com)

SPASTICITY VS RIGIDITY

2018-02-11T20:24:00.000+05:30

1.Spasticity is an increased resistance to the passive movement of a joint due to abnormally high muscle tone (hypertonia) which varies with the amplitude and speed of displacement of a joint.

1.Rigidity is an increased resistance to the passive movement of a joint which is constant throughout the range of joint displacement and not related to the speed of joint movement; resistance is present in both agonist and antagonist muscles.

2.Spasticity is usually uni-directional, and is velocity and amplitude dependent.

2.Rigidity is bi-directional, and is non velocity or amplitude dependent.

When it Happens: The important of such differentiation is that spasticity is typically caused by damaged to the corticospinal tract, while rigidity is usually extra-pyramidal in origin.

How to Assess and Differentiate:

A simple way to assess spasticity is by fast flexion or extension of selected joint, typically the elbow or knee, to elicit a sudden increase in tone. This demonstrate the velocity dependent nature of spasticity. Another phenomenon known as clasp-knife phenomenon, describe a sudden release of tone after an initial hypertonia of selected joint movement when the examiner passively move the joint to the extreme, this demonstrate the amplitude nature.

To test for rigidity, passively move the joint in both direction, a relatively uniform rigidity in both agonist and antagonist muscle group is known as lead-pipe rigidity; if there is tremor superimposed with background increase of tone – cogwheel rigidity. These rigidity is commonly seen in Parkinson’s disease.

Importance of Closed vs Open Kinematic Chain in Clinical Practice

2018-02-02T20:46:00.002+05:30

I often hear the terminology open-packed and close-packed joint positions used in the clinic. In general, clinicians know to mobilize in the open-packed position and avoid manipulation in a close-packed position, but what else should we know about these terms? Is there any other clinical significance to the open vs close-packed positions?

Open-packed Position
•Position with the least amount joint surface congruency
•Capsule and support ligaments are lax
•Accessory motion or joint play is maximized

Close-packed Position
•Position with the most amount of joint congruency
•Capsule and supporting ligaments maximally tight
•Accessory motion is minimized

How Should PT's Interpret Open vs Close-Packed Clinically?

As I mentioned above, it is important to start your joint assessment and treatment in the open-packed position. Since the joint has the most available room for movement, mobilizations are best tolerated in this position. For example, the open-packed position of the knee is 25 degrees of flexion. The close-packed position is full extension. At 25 degrees of flexion the knee is loose- one can assess varus and valgus ligament stress testing or check tibial IR/ER mobility in this position. Biomechanically, the knee is 'unlocked.' Following an injury, the body favours this position because there is space for swelling and other fluid to accumulate within the joint. As the patient's ROM improves, pain decreases, and the swelling subsides, the clinician can start to mobilize the joint in other positions of flexion and extension as needed.

Additionally, understanding the open and closed packed positions is essential when performing manipulations. We want to manipulate a joint in the open-packed position, but often times we cannot target a specific joint unless we lock out or close-pack the surrounding joints. For example, when performing a prone SIJ distraction manipulation, the hip needs to be placed in extension, abduction, and internal rotation. These three movements are the close-packed position of the hip joint. You must lock out the hip so you do not manipulate it when you are targeting the SIJ.

Each joint has a different open and close packed position and being able to quickly recall that position will make you a more efficient clinician. If you do not understand the open and close-packed positions of regional joints, the specificity of your techniques will decrease.

Thanks to Jim

Source: https://www.thestudentphysicaltherapist.com/featured-articles/importance-of-open-closed-packed-positions

Which is better for shoulder diagonals: Thera-Band or Dumbbells?

2017-09-14T21:00:00.001+05:30

Shoulder rehabilitation often includes Thera-Band® exercises. One popular exercise is the “PNF” diagonal shoulder exercise from the Proprioceptive Neuromuscular Facilitation concept. The PNF diagonal exercise includes tri-planar motion of the shoulder against resistance; the resistance provided can be manual, dumbbell, or elastic band resistance. Few researchers have investigated the EMG activation levels of shoulder muscles during PNF diagonal exercises.

Researchers at the University of Cincinnati in Ohio assessed the activation of scapular muscles in 21 healthy subjects. The subjects performed 4 diagonal patterns (D1 Flexion, D1 Extension, D2 Flexion, and D2 Extension) with both a 3 pound dumbbell and a blue Thera-Band resistance band. For the band exercises, the subjects were seated using a length of band equal to the distance between the floor and their greater trochanter as measured when the subject was standing.
The results showed that both Thera-Band and dumbbell exercises provide similar levels of EMG activity, which is consistent with findings of other researchers who compared EMG levels during isotonic and elastic resistance (Andersen et al. 2010). The serratus anterior, an important scapular stabilizer, remained moderately active in each exercise with no significant difference between exercises (42.5 to 50% of maximal).

When evaluating an exercise for suitability in rehabilitation, it’s important to consider not only the absolute activation but the activation relative to other muscles including agonists and antagonists. The trapezius is prone to muscle imbalance. The upper portion is prone to tightness and the lower portion is prone to weakness according to Janda. Shoulder patients, particularly those with impingement, often exhibit scapular muscle imbalance.

The D2 Flexion pattern had the highest activation levels for the middle and lower trapezius compared to the other patterns; the D1 and D2 flexion patterns also had more upper trapezius activation than their extension movement counterparts. While the Thera-Band resisted D2 Flexion exercise produced higher levels of middle and lower trapezius activation compared to dumbbell resistance, the Thera-Band resistance also produced higher levels of upper trapezius activation compared to the dumbbell.

In contrast to D2 Flexion, the D2 Extension exercise with Thera-Band had the lowest levels of upper trapezius activation. It also had the most desirable ratio of upper to lower trapezius activation (0.9), meaning the lower trapezius was activated at a higher level than the upper trapezius.
As with other surface EMG studies on healthy subjects, these results should be used with caution in patient populations. The authors chose blue Thera-Band resistance, which may not be appropriate in early stages of rehabilitation. It would have been valuable for the authors to report on the eccentric phase of the exercise, or during different phases of the exercise due to the large arc of motion.
The authors concluded that the D2 Flexion pattern with either dumbbell or Thera-Band resistance provides the greatest activation of scapular muscles, and the D2 Extension pattern with Thera-Band provided the best ratio of upper and lower trapezius activation.

REFERENCE: Witt D, Talbott N, Kotowski S. Electromyographic activity of scapular muscles during diagonal patterns using elastic resistance and free weights. Int J Sports Phys Ther. 2011 Dec;6(4):322-32.

Ultrasound Therapy Dosage Chart

2017-09-12T22:08:00.001+05:30

Ultrasound (US) is a form of MECHANICAL energy, not electrical energy and therefore strictly speaking, not really electrotherapy at all but does fall into the Electro Physical Agents grouping. Mechanical vibration at increasing frequencies is known as sound energy. The normal human sound range is from 16Hz to something approaching 15-20,000 Hz (in children and young adults). Beyond this upper limit, the mechanical vibration is known as ULTRASOUND. The frequencies used in therapy are typically between 1.0 and 3.0 MHz (1MHz = 1 million cycles per second).

1 MHZ

3MHZ

Exercises & Yoga Poses for Your Back Pain

2017-09-12T20:56:00.001+05:30

Our aim with these planned series of back straightening exercises is to give you with an exercise program, which when practiced regularly, will help you get rid of round back and discomfort in the spine and give you an optimal posture. If you are diagnosed with a spinal or back injury, consult with your doctor if this exercises are suitable for you.

Cat and Camel or Cow Pose

Initial position. Start with your hands and knees on the exercise mat. Your knees should be directly below your hips and your palms under the shoulders. Keep your pelvis and spine in a neutral (straight) position, by engaging your abdominal muscles to support your spine.

● Pull your abdominal muscles in as you arch your back up like a stretching cat and simultaneously let your head and tailbone drop down toward the floor;
● Return to the initial position;
● Extend the upper part of the spine upwards, supporting it with your abdominal muscles. In the beginning, at this point you can return to the starting position. Later on, as you advance in the exercise, supplement it by moving your tailbone and hips up as well. Make sure your neck is a long extension of your spine and don’t let the head fall back;
● Return to starting position. Repeat 5 times.

Back Extension

Initial position. Lie on your stomach and put your forehead on the exercise mat. Place your arms at your sides and press your palms on the thighs. Straighten your elbows. Put your legs together drawing out the toes slightly.

● Exhale. Gradually lift the head, chest and upper abdomen from the mat, keeping the feet and hands in the initial position;
● Inhale. Slowly lower the trunk and head to the initial position. Repeat the exercise 10 times.
* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Back Stretching

Initial position. Sit on the mat and straighten your back. Stretch your legs in front of you and place them apart – slightly wider than shoulder width. Toes are pointing upward (dorsiflexion). Lean straightened hands on a mat near the pelvis.

● Pull your abdomen in and at the same time tilt your head forward, bending your upper back and stretching your arms in front of you. Glide your hands forward on the mat, between your legs;
● Straightening your body, return to the initial position. Repeat the stretch 5 times.
* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Supplementary Exercise for Back Stretching

In a supine position (on your back, face up), bring your knees to your chest. Hold the stretching position with medium to strong intensity. Avoid sharply increasing the intensity of the stretching. Keep the chest straightened, shoulders relaxed and the shoulder blades together. Breathe freely.

Heel Kick

Initial position. Lie on your stomach and leaning on the arms, lift the upper torso. The forearm should be placed so that the angle between the shoulder and the body was about 90 degrees. The hands are clenched into fists and touching each other. Legs are extended and closed, toes slightly pointed.
● Inhale. Lift both legs about 5 cm from the floor. Vigorously bend one leg at the knee, trying to touch the buttocks with the heel;
● Exale. In the same energetic movement straighten your leg at the knee, bending the other one and going for the buttocks. Repeat the exercise 20 times (10 per leg).

* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Double Impact

Initial position. Lie on your stomach, putting your chin on mat. Bend your elbows and bring your hands behind your lower back. The hands should lie on the sacrum. Lift both legs approximately an inch (2-3 cm) from the mat. Straighten your knees and gently pull the toes.

● Vigorously bend your knees, trying to bring the heels towards the buttocks, as shown in the illustration;
● Lift the chest off the mat, straighten your arms at the elbows, turning the back of the hand towards the feet. Simultaneously, straighten your knees, trying to lift them as high as possible off the floor. Hold the position briefly then return to the initial position. Repeat 6 times.
* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Swimming

Initial position. Lie on your stomach, stretch your arms in front of you, palms facing downwards. Slightly lift the chest, arms and legs of the mat. Keep the legs and toes extended.
● Raise your right arm and left leg;
● Then raise the left arm and right leg, while returning their opposite to their initial position. Continue the exercise for 10 exchanges. The exchange of the opposite limbs is quick, but smooth.

* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Stomach Rolls

Initial position. Lie on your stomach, bend your knees and bring them on your hip. Take hold of the feet with your hands, as shown in the figure. Now, lift the head, chest and knees on the mat.
● Breathing in, roll forward onto your belly, as shown in the figure;
● Breathing out, roll in the opposite direction, from your stomach to the pelvis. Repeat the exercise 10 times.

* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Diving Swan

Initial position. Lie on your stomach and leaning on the arms, lift your chest off the mat. Elbows should be pushed forward and placed wider than shoulders and the hands should be touching. Legs and toes are extended.

● Breathing in, straighten the elbows and raise them to the sides on level with the shoulders and then raise your chest even higher. At the same time, lift slightly both legs off the mat;
● Breathing out, roll forward onto your belly, as shown on the last illustration;
● Breathing in, roll back into the intended position. Repeat 5 times, accompanying the rolls forward with exhalation, and the rolls back with inhalation.
* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Diving Swan Alternative Variant

Diving Swan can also be performed by raising his hands above the head rather than keeping them wide apart, as shown in the illustration above. The same hand position is maintained on the reverse roll as well. This increases the load of spine extensor muscles, but also helps to maintain a uniform curvature of the spine during the rolls.

* Please make sure to start from the 1st exercise and only after perfecting it work your way up to the more demanding ones to ensure a gradual progression and avoid any injuries.

Female Specific Red Flag Symptoms in Low Back Pain

2017-08-08T20:26:00.002+05:30

Running: How to Safely Increase Your Mileage

2017-08-06T12:19:00.002+05:30

Published: Journal of Orthopaedic & Sports Physical Therapy, 2014 Volume:44 Issue:10 Pages:748–748 DOI:10.2519/jospt.2014.0506

Do you want to start a running program? Are you already a runner and want to increase your miles? Are you recovering from an injury and trying to return to running? If you are working to accomplish any of these goals, you have probably wondered how to increase your running miles safely so that you are not hurt. Running-related injuries are very common, and training errors are the leading cause of preventable injuries. Most training injuries are the result of “too much, too soon, too fast, too quick.” Although preventing running injuries is complicated and scientists still have a lot to discover, one rule familiar to many runners is the 10% rule, which states that you should not increase running mileage more than 10% each week. A study published in the October 2014 issue of JOSPT puts the 10% rule to the test.

Although runners, coaches, and health care providers commonly use the 10% rule, more science is needed to understand its role in injury prevention. Researchers followed 873 new runners for 1 year; during this period, 202 runners had a running-related injury. The researchers compared runner injuries based on each participant's weekly increase in running distance: less than 10%, 10% to 30%, and more than 30% in the 2 weeks prior to injury. Runners who increased their mileage by more than 30% had a higher injury rate than those who increased their mileage by less than 10%. Runners who ran farther faster were at higher risk for patellofemoral pain (runner's knee), iliotibial band syndrome, medial tibial stress syndrome (shin splints), patellar tendinopathy (jumper's knee), greater trochanteric bursitis, and injury to the gluteus medius or tensor fascia latae (see illustration). However, other types of injuries were not linked to the 10% rule, such as plantar fasciitis, Achilles tendinopathy, calf injuries, hamstring injuries, tibial stress fractures, and hip flexor strains. The authors suggest that these injuries may be related to other training errors.

Practical Advice:-

A sudden increase in weekly running distance by more than 30% over a 2-week period may put runners at increased risk for developing running-related injuries. The lowest injury rates were found in new runners who increased their weekly mileage by less than 10% over 2 weeks. However, other running injuries may be linked to running pace, increasing running speed, sprint training, or other training errors. If you are starting a running program, your physical therapist can help customize a safe running progression to meet your needs. For more information on a personalized running program, contact your physical therapist specializing in musculoskeletal disorders and running-related injuries.

RUNNING-RELATED INJURIES. A sudden increase in weekly running distance by more than 30% over a 2-week period may put runners at increased risk for developing patellofemoral pain (runner's knee), iliotibial band syndrome, medial tibial stress syndrome (shin splints), patellar tendinopathy (jumper's knee), greater trochanteric bursitis, and injury to the gluteus medius or tensor fascia latae.

Williams Flexion Exercise

2017-08-04T08:22:00.002+05:30

Williams flexion exercises focus on placing the lumbar spine in a flexed position to reduce excessive lumbar lordotic stresses. Exercises are designed to (1) strengthen the abdominal, gluteal, and quadriceps muscles, and (2) stretch the erector spinae, hamstring, and tensor fasciae latae muscles and iliofemoral ligament.

INTRODUCTION

Williams flexion exercises — also called Williams lumbar flexion exercises, Lumbar flexion exercises or simply Williams exercises — are a set or system of related physical exercises intended to enhance lumbar flexion, avoid lumbar extension, and strengthen the abdominal and gluteal musculature in an effort to manage low back pain non-surgically. The system was first devised in 1937 by Dr. Paul C. Williams(1900-1978), then a Dallas orthopedic surgeon.

RATIONALE

Williams believed that the basic cause of all pain is the stress induced on the inter-vertebral disc by poor posture. He theorized that the lordotic lumbar spine placed inordinate strain on the posterior elements of the inter-vertebral disc and caused its premature dysfunction. He was concerned about the lack of flexion in daily activities in the accumulation of extension forces that hurt the disc.

GOALS OF WILLIAMS FLEXION EXERCISES

The goals of these exercises are to open the intravertebral foramina and stretch the back extensors, hip flexors, and facets; to strengthen the abdominal and gluteal muscles; and to mobilize the lumbosacral junctions.

CORE EXERCISES

Williams believed that the back pain was the result of human evolution in movement from a quadruped to an upright position, proposing that the standing position was the cause of back pain because it placed the low back in a lordotic curve. Williams advocated seven exercises to minimize the lumbar curve

1- Pelvic tilt exercises:

Lie on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor, without pushing down with the legs. Hold for 5 to 10 seconds.

2- Partial sit-ups:

The athlete lies in "hooklying" position (supine with knes bent and feet flat). With hands behind his or her head, the athlete elevates the upper torso until the scapulae clear the resting surface and stress is placed on the rectus abdominus. After returning to the start position, the sit-up is repeated for a prescribed number of repitions.

3- Knee-to-chest:

Single Knee to chest. Lie on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.

Double knee to chest. Begin as in the previous exercise. After pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly lower one leg at a time.

4- Hamring stretch:

Lying supine, the athlete places both hands around the back of one knee. The athlete straightens his or her knee and pulls the thigh toward his or her head so the hip goes into flexion. Williams believed that flexible hamstrings are necessary to accomplish full flexion of the lumbar spine. Although tight hamstrings limit lumbar flexion in standing with knee straight, we now know that tight hamstrings actually tilt the pelvis posteriorly and promote trunk flexion.

5- Standing lunges:

This exercise actually results in some extension of the lumbar spine when performed properly. Nonetheless, it is a good stretching exercise for the entire lower extremity, especially the iliopsoas, which may be a perpetrator of low back pain if it is abnormally tight or in spasm.

The athlete begins the forward lunge in a standing position with the feet shoulder width apart. He or she then takes a big step forward with the right leg and plants the foot out front, keeping the body relatively straight. The knee should stay over your ankle and not extend out over the toes to minimize stress on the knee joint.

6- Seated trunk flexion:

This exercise is performed by sitting in a chair and flexing forward in a slumped position. Maximum trunk flexion is obtained and direct stretching of the lumbosacral soft tissue structures occurs.

7- Full squat:

William's squat position is with the feet placed shoulder width apart, the hip and knees are flexed to the maximum available range of motion, and the lumbar spine is rounded into flexion. Upon reaching maximum depth, the athlete "bounces the buttocks up and down" 15 to 20 times, with 2 to 3 inches of excursion on each bounce, then repeats 3 to 4 times.

In modern era Williams flexion exercises are specifically used in medical conditions like Spinal Stenosis, Spondylolisthesis, and facetal locking where spinal extension is painful.

For years, the Williams Flexion Exercises were the main stay of most low back pain prevention and care programs. They certainly accomplished the goal of flattening the lumbar spine and were advocated by physical therapists who worked with sports and industrial injuries. Although the success was limited, William's comprehensive program helped advance the idea that strong abdominal muscles are needed to prevent low back pain and improve core strength.

References For Williams Flexion Exercises

Therapeutic Exercise for Musculoskeletal Injuries 4th Edition By Houglum, Peggy A.
Athletic Training and Sports Medicine By Chad Starkey, Glen Johnson
Clinical Decisions in Therapeutic Exercises , Planning and Implementation ... By CTI Reviews
Orthopaedic Physical Therapy Secrets - E-Book By Jeffrey D. Placzek, David A. Boyce
The Shoulder and the Overhead Athlete edited by Sumant G. Krishnan, Richard J. Hawkins, Russell F. Warren

Cerebral Palsy-Advanced Interventions

2013-09-19T22:51:00.003+05:30

Cerebral palsy includes various kinds of disability, such as difficulty in coordinate and alternative movements, abnormal movements and postures, and difficulty in keeping the body in antigravity postures or upright posture. Hence, manifestations of cerebral palsy are not all the same. Since these motor impairments are due to damage of the central nervous system, extraordinary difficulties have been clinically presented in the control of hypertonicity, in facilitation of the paralyzed muscles, and in restoring balance. These motor disabilities are summarized into hypertonicity including Spasticity, rigidity, athetosis involuntary movement, paralysis (weakness) of the propulsive and antigravity muscles, and difficulty in maintaining equilibrium.

Recently, various types of Spasticity-control methods are being advocated. However scientific they are, there are many problems including grave disadvantages.

Physiotherapy and occupational therapy inhibits hypertonicity, and facilitates voluntary movement and equilibrium. These therapies seem to have played an important role in controlling these factors. However, hypertonicity and fixed deformities in cerebral palsy children more than 3 years old are too complex to treat. It is almost impossible to alleviate hypertonicity permanently with therapeutic exercises alone. It has been mentioned in the books that parents must aware that Spasticity of their children will be forever. Therapy alone cannot control Spasticity with long lasting effect.

Stereotaxic thalamotomy is a Neuro-surgical procedure, which was used to control rigidity and involuntary movements due to cerebral degeneration. The main indications of this procedure are to control tremors, dystonic movement, and rigidity. Hence the procedure has been applied to reduce involuntary movement and rigidity in cerebral palsy, but with varying responses. They cannot alleviate Spasticity, which is the predominant feature of cerebral palsy. Therefore, the indications for stereotaxic thalamotomy are definitely limited to patients, having involuntary movements and rigidity due to the damaged extra pyramidal tract.

Oral medication has been used for reduction of Spasticity. It is useful not only for relieving Spasticity but also is helpful for relieving pain especially in adult patients. Importance of oral medication should never be ignored. However, it is also true that this is not used without side effect. Disadvantages include decrease in mental vividness, and weakening of respiratory function with decrease in respiratory volume, depending on the dosage of oral medication. Hence, to provide and reserve vividness for CP patients, considerations on how to minimize the use of this oral medication would be needed, substituting oral medication with other methods.

Intrathecal Balcolen therapy is another type of medication therapy. It is reported that this therapy reduces Spasticity in various levels of patients including the totally involved quadriplegic patients, as well as ambulatory diplegic patients. Disadvantage of Intrathecal Baclofen therapy are a possibility of intradural infection and fibrosis, causing some adhesions around the spinal cord and roots, the need for repetitive replacement of the pump and tube, and need to refill the pump much often. Another disadvantage is the possibility of respiratory depression due to inhibition of the nerves to the intercostal muscles. Hence, to preserve a healthy life, breathing difficulty should be avoided, even if it is to a minimal extent.

Use of Botulinum toxin injection is also popular. This injection seems to be very effective in reducing Spasticity. However, the shortcoming of Botulinum injection is that its effect is not long lasting and therefore frequent injections are needed. Another rare possible shortcoming is that breathing difficulty will be inevitably caused, depending on the dosage of injection and it can become fatal and dangerous for patients if it is used in multiple sites in sufficient amounts.

Selective dorsal rhizotomy (SDR) is a neurosurgical approach and is gaining popularity. Many papers of the effect of SDR on reduction of Spasticity are presented. It seems certain that this approach is very effective in reducing Spasticity and for weakening muscle power, while increasing the range of motion in gait analysis. However, one of the major problems of SDR could be loss of antigravity stability, due to loss of activity of the antigravity muscles. There is no way of differentiating the nerve fibers to spastic muscles and the ones to antigravity muscles. In the literature, there are reports of increased range of motion, but reports of improvement in antigravity stability are few. Reports of postoperative deformities such as severe lordosis, gross increase in anterior tilt of the pelvis, severe pes valgus deformity and frequent worsening of dislocation of the hip suggest the loss of antigravity stability around the joints and worsening of motor function. Another serious drawback is that fibers of sensory nerves are sectioned unselectively in this surgery. SDR induce injury of sensory and sympathetic nerves. It is not documented that sensory nerves can be selectively differentiated from the afferent fibers at the rootlet level. This means that sensory nerves get sectioned unintentionally and that the damage depends on the extent of the section. More detailed scientific study would be needed, before they are advocated as an antispasticity therapy in patients with cerebral palsy.

Orthopedic surgery has been considered to have serious limitations in achieving functional improvements. It was used as an adjutant to assist of other approaches and to restore normal alignment, correcting contractures and deformities, and acquiring stability by arthrodesis. It has been considered that orthopaedic surgery cannot control Spasticity, acquire reciprocal movements, to facilitate antigravity muscles, and improve skills and voluntary movement of the hand. Recently, restoration of muscle balance has been tried, with use of muscle releases and tendon transfers. However, loss of antigravity activities after release of antigravity muscles has presented serious problems. The adductor tenotomy with or without anterior obturator neurectomy is one of them. They have been recommended, and have been indispensable procedures for correction of adduction deformity of the hip in some cases. However, careful observations revealed that adductor release including tenotomy of the adductor longus and brevis are likely to destroy antigravity activities of these adductors and induce deteriorating gait without stability. Most physiotherapist and occupational therapist seem to hesitate to recommending this surgery, because postoperatively the stability of the gait of the patient has been somewhat lost.

Iliopsoas recession or tenotomy is effective procedures planned to relieve Spasticity of the hip flexors and to correct flexion deformity of the hip. However, in literature recently, loss of power in hip flexion after total division of iliopsoas has been reported, and hence selective release of the psoas muscle (Concept of OSSCS) has been recommended. Achilles tendon lengthening and heel-cord advancement are popular procedures for correcting equinus deformity in cerebral palsy, and have been the recommended procedures. However, it is a question, if these procedures are evaluated objectively as reliable, by unbiased and introspective orthopedic surgeons. Serious loss in supporting activity of the foot has been reported in cases with spastic diplegia or spastic quadriplegia, after heel cord lengthening and after heel cord advancement. With disillusionment due to poor results after standard orthopedic surgery, many orthopedic surgeons are apt therefore to consider that physical mechanism of the cerebral palsy is completely different from that of normal human body. Many orthopedic surgeons have abandoned avoiding getting involved in treatment of cerebral palsy. Nevertheless, in spite of these desperate situations, many attempts have been pursued in the field of orthopedic surgery all over the world. Various progresses have been made and reported, and various improvements have been presented.

Our approach for control of Spasticity is OSSCS – Orthopedic Selective Spasticity Control Surgery. In the process to overcome these serious problems after the treatment for hip-adduction, hip-flexion deformity, and equinus deformities, it has been confirmed that the multiarticular muscle work differently from the monoarticular muscles in the human body, although they mostly co-exist in the same place. It was also noted the fact that the multiarticular muscles are more hyperactive and are more responsible to hypertonic posture. Contribution of the biarticular muscle to spastic condition in cerebral palsy is already mentioned. It has also been noticed the fact that the monoarticular muscles are closely related to the antigravity activity, which keeps body in an upright position. Thus, the consistency of the muscle activity and the motor functional characteristics of the hypertonicity of cerebral palsy have been clinically analyzed. Here, clinical approvals and applications have been made on the deformities in the cervical spine, thoraco-lumbar spine, shoulder, elbow, hand and fingers, and even for abnormal postural deformities, based on the clinical, anatomical, functional and biological analysis. On the basis of these consistent findings, the idea of orthopedic selective Spasticity-control surgery (OSSCS) was initiated and hereby confirmed that this idea can be applicable not only for control of Spasticity but also to control athetosis movement in any part of the body.

We now reach to the point of fundamental importance that the abnormal postural reflex is only a combination of individual Spasticity and athetosis in the neck, trunk, upper extremities and lower extremities. It becomes obvious that, by relieving Spasticity in these individual parts of the body at each level, these abnormal postural reflexes can be relieved and controlled. Thus, through careful analyses of muscle function and hyper tonicity in each joint, a working concept of orthopedic selective Spasticity-control surgery has been formulated, and confirmed at each clinical case study.

This treatment is also effective for reduction of severe postural abnormality, such as tonic labyrinth reflex and asymmetric tonic neck reflex. With simultaneous release of spastic or athetotic flexors and extensors in each joint, rigidity of the joint can now be lessened and therefore relaxation of the joint can be achieved. With relaxation of the each extremity, the individual movement of each extremity becomes easily feasible and therefore, alternation such as reciprocal movement and cross-patterned movement of the extremities is also facilitated. Here, we can now understand that poor coordination is caused due to difficulty in relaxation of both individual multiarticular flexors and extensors at each joint. Now, we can activate coordinate and alternate movement, while decreasing abnormal movements and postures. We can achieve more stable postures such as sitting and standing, and stable transfers such as crawling and gait by facilitating activity of the antigravity muscles. It has been well documented that orthopedic surgery cannot control Spasticity, but only weakens the muscle. It has been also mentioned that orthopedic surgery can only correct deformities and treat dislocation. However, situation is changing. If we can analyze Spasticity, local reflexes, abnormal reflexes in cerebral palsy in motor-function-wise, and can understand whole movement of cerebral palsy and non-paralyzed body in motor-function-wise, and in motor-developmental point of view and we will be able to control Spasticity effectively with the use of OSSCS. Orthopedic Spasticity control surgery provides us enormous possibilities of controlling Spasticity in the entire human body with cerebral palsy, without losing any useful activities, while facilitating mental and physical activities. By combining the Spasticity control surgery with conventional orthopedic surgery, such as open reduction, VDRO, pelvic osteotomy for dislocation of hip, arthrodhesis of wrist and ankle, spinal fusion, we can deal with wide range of problems in motor activities and activities of daily living with encouraging results while providing a new path for functional improvement and for active life styles in most patients with cerebral palsy. OSSCS can provide us with an opportunity to assist physiotherapist and occupational therapist by controlling hypertonicity in the whole body while making it easy to facilitate basic motor functions such as rolling, crawling, sitting, kneeling, standing and independent gait.

The fundamentals of OSSCS are clear and uncomplicated and are based on the physical and biological findings. OSSCS is based on the concept that muscles are classified into two types – monoarticular and multiarticular. Electromyographic studies proved that multiarticular muscles are spastic or hypertonic and are responsible for various deformities in cerebral palsy and the monoarticular muscles are normal and responsible for joint stability and erect posture in human being. Thus by selectively releasing these multiarticular muscles we can activate the monoarticular muscles to facilitate function and erect posture.
The most important aspect of OSSCS is postoperatively there is no decrease of motor function as monoarticular muscles are preserved. There is no loss of sensations as seen in many Spasticity reducing procedures. The technique is quite reliable and promising procedure for control of Spasticity.

Another important aspect of OSSCS is that its indications are wide and hypertonicity in the entire body can be relieved. All kinds of hypertonicity – Spasticity, rigospasticity and athetosis can de corrected.

The decision making and treatment techniques are demanding. In order to achieve successful results, orthopedic techniques should be skillfully conducted by trained and experienced orthopedic Surgeons trained in Pediatric Orthopaedics, since we are going to correct complex motor disorders which have not responded to other procedures. Which muscles should be released? Which end should be released proximal or distal? What kind of release should be done? Intramuscular lengthening? Sliding lengthening? Z lengthening? Tenotomy? How much and how long these lengthening should be done? What other conventional orthopedic surgeries should be combined? All these questions and problems have to be answered correctly and there is no scope for error.

When the Orthopedic surgeon applies these principles of OSSCS accurately in the management of cerebral palsy, he will be able to promise definite improvements for patients with cerebral palsy. Here, we would like to present our experience with OSSCS for the last 13 years and show how these approaches can be used in the treatment of cerebral palsy.

Peek A Boo and the Object Permanence

2013-09-19T22:26:00.002+05:30

Peekaboo is thought by developmental psychologists to demonstrate an infant's inability to understand object permanence.Object permanence is an important stage of cognitive development for infants. Numerous tests regarding it have been done,usually involving a toy, and a crude barrier which is placed in front of the toy, and then removed, repeatedly. In early sensorimotor stages, the infant is completely unable to comprehend object permanence. Psychologist Jean Piaget conducted experiments with infants which led him to conclude that this awareness was typically achieved at eight to nine months of age. Infants before this age are too young to understand object permanence. A lack of Object Permanence can lead to A-not-B errors, where children reach for a thing at a place where it should not be.

GMFCS

2013-09-16T14:19:00.001+05:30

The Gross Motor Function Classification System or GMFCS is a 5 level clinical classification system that describes the gross motor function of people with cerebral palsy on the basis of self-initiated movement abilities. Particular emphasis in creating and maintaining the GMFCS scale rests on evaluating sitting, walking, and wheeled mobility. Distinctions between levels are based on functional abilities; the need for walkers, crutches, wheelchairs, or canes / walking sticks; and to a much lesser extent, the actual quality of movement.

The original version of the GMFCS was developed in 1997. As of 2007, the expanded and revised version, known as GMFCS - E&R, further includes an age band for youth 12 to 18 years.

The original concept was developed collaboratively by Robert Palisano, Professor of Physiotherapy at Drexel University; Peter Rosenbaum, Professor of Developmental Paediatrics at McMaster's ; Stephen Walter, Professor of Biostatistics at McMaster's; Dianne Russell; Ellen Wood; and Barbara Galuppi.

GMFCS is now the standard in both North America and Western Europe for mobility assessment and ambulatory ability prediction for cerebral palsy. The examination is done using the "Gross Motor Function Measure", (GMFM), a set of 66 sitting (truncal control) as well as walking exercises conducted during the GMFM assessment that help the specialist classify the person into one of the system's five levels or, sometimes, to classify the person as "in between" two different levels.

What is 'SSMLS'

2013-09-16T14:03:00.002+05:30

SSMLS means ‘Single Stage Multiple Level Surgery’ that means we operate at multiple levels in one stage.

What are the advantages of SSMLS?

1. Because we operate in one stage, all the deformities and contractures in that particular limb are corrected at one time; so that execution of physiotherapy and rehabilitation program becomes easy.

2. Surgery on one limb reduces the tone in the other extremities, if involved and also improves the function to some extent.

3. Developing milestones, walking pattern and activities of daily living becomes easy.

4. It is also economic.

OSSCS

2013-09-16T13:57:00.002+05:30

Orthopedic Selective Spasticity Control Surgery for Children with Spastic Cerebral Palsy

Control of spasticity has become an urgent need for orthopedic surgeons in the treatment of cerebral palsy. Many approaches for control of spasticity have been advocated. However, control of spasticity is not so easy and at times seems to cause serious drawbacks such as sensory disturbance, recurrence and loss of stability.

Orthopedic selective spasticity control surgery [OSSCS] is an orthopedic procedure designed to control or reduce hypertonicity in cerebral palsy. Various types and severity of hypertonicity can be appropriately controlled by the use of selective muscle release surgery. The spasticity control surgery not only corrects deformities such as shoulder retraction, elbow deformity, scoliosis, flexion deformity of hip, knee and ankle- foot, but also promises better hand and finger skills and reach movements of the upper extremity, stabilizes the trunk and lower extremities and relives the hypertonicity in the cervical, thoracic and lumbar spine. It also facilitates respiration and speech while lessening drooling remarkably. By combining the spasticity control surgery with conventional orthopedic surgery, such as open reduction, VDRO, pelvic osteotomy for dislocation of hip, arthrodhesis of wrist and ankle, spinal fusion, we can deal with wide range of problems in motor activities and activities of daily living with encouraging results while providing a new path for functional improvement and for active life styles in most patients with cerebral palsy. OSSCS can provide us with an opportunity to assist physiotherapist and occupational therapist by controlling hypertonicity in the whole body while making it easy to facilitate basic motor functions such as rolling, crawling, sitting, kneeling, standing and independent gait.

The most important aspect of OSSCS is postoperatively there is no decrease of motor function as monoarticular muscles are preserved. There is no loss of sensations as seen in many spasticity reducing procedures. The technique is quite reliable and promising procedure for control of spasticity.

Another important aspect of OSSCS is that its indications are wide and hypertonicity in the entire body can be relieved. All kinds of hypertonicity – spasticity, rigospasticity and athetosis can de corrected.

The decision making and treatment techniques are demanding. In order to achieve successful results, orthopedic techniques should be skillfully conducted since we are going to correct complex motor disorders which have not responded to other procedures. Which muscles should be released? Which end should be released proximal or distal? What kind of release should be done? Intramuscular lengthening? Sliding lengthening? Z lengthening? Tenotomy? How much and how long these lengthening should be done? What other conventional orthopedic surgeries should be combined? All these questions and problems have to be answered correctly.

When the Orthopedic surgeon applies these principles of OSSCS accurately in the management of cerebral palsy, he will be able to promise definite improvements for patients with cerebral palsy. Here, we would like to present ideas and techniques of OSSCS and show how these approaches can be used in the treatment of cerebral palsy.

ULNAR CLAW HAND,ULNAR PARADOX,HAND OF BENEDICTION

2013-07-11T09:23:00.002+05:30

Ulnar Claw and Hand of Benediction are characteristic signs of nerve injury. Although they look largely the same, the underlying pathology is very different. In this article, we shall look at the basic anatomy, and apply this to both cases, and thereby understanding the clinical presentation of the two signs.

Ulnar Claw

This is a deformity that is mostly seen in long-term cases of a lesion of the ulnar nerve. To explain it, we need to consider which muscles are paralysed by a lesion at the wrist:

Medial Two Lumbricals: Flexes the MCP (metacarpophalangeal joints) of the little and ring fingers. Extends the IP (interphalangeal joints) of the little and ring fingers

Interossei: Abduct and adduct the fingers

Hypothenar Muscles: Flex, adduct, and oppose the little finger

Adductor Pollicis: Adducts the thumb

The key set of muscles that are paralysed are the lumbricals. There is now a loss of flexion at the MCP joint and a loss of extension at the IP joints.

This results in the ulnar claw; the MCP joints are hyperextended by unopposed extension from the extensor digitorum, and the IP joints are flexed by unopposed flexion from the flexor digitorum profundus. This only occurs in the little and ring fingers as the lateral two lumbricals are innervated by the median nerve.

Ulnar Paradox

Now consider at lesion of the ulnar nerve at the elbow. In addition to the muscles of the hand, these muscles are paralysed:

Medial half of Flexor Digitorum Profundus: Flexes the IP joints of the ring and little fingers

Flexor Carpi Ulnaris: Flexes and adducts the wrist

The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralysed, and there will not be any flexion of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints, giving a less evident claw hand.

This is known as the ‘ulnar paradox’ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.

Hand of Benediction

Hand of benediction occurs as a result of injury to the median nerve. It is only apparent if the patient is asked to make a fist.

Result of median nerve damage

Again, we need to consider the muscles paralysed if a lesion to the median nerve occurs at the wrist:

All the flexors in the anterior compartment of the arm, except the medial half of the flexor digitorum profundus and the flexor carpi ulnaris.

Lateral Two Lumbricals: Flexes the MCP (metacarpophalangeal joints) of the middle and index fingers. Extends the IP (interphalangeal joints) of the middle and index fingers.

If the patient is asked to make a fist, they will be able to flex the little and ring fingers. This action is performed by the medial half of the flexor digitorum profundus and the medial two lumbricals.

The patient will not be able to flex the index and middle fingers. Thus, the patient displays a claw shape, where the little and ring fingers and flexed, the index and middle fingers extended.

Contrasting Ulnar Claw and Hand of Benediction

At a first glance, distinguishing between the two can be difficult, but there are numerous differences between ulnar claw and hand of benediction.

Understanding Disuse Atrophy

2013-07-10T22:58:00.003+05:30

By Whitney Lowe

Observations from clinical practice have indicated that one of the most significant detrimental effects of disuse on the body is muscular atrophy. Disuse atrophy might occur from an injury that forces the individual to keep an area in a cast for a prolonged period.
It also might occur in situations in which bed rest or non-weight-bearing is mandated for rehabilitation from an injury. Regardless of the cause of the disuse, we now have learned a great deal about what occurs in muscle tissue as a result of disuse, and it's clear that it leads to significant muscular dysfunction. Muscles throughout the body are comprised of different types of fibers. Human muscle has two primary fiber types. The first is called type 1, or slow-twitch muscle fiber. These fibers are most prevalent in muscles used for endurance, such as the postural muscles of the body. The second fiber variation is type 2, or fast-twitch fibers. These fibers are more prevalent in muscles that do short, powerful bursts of activity. Note that not everyone has the same percentage of fiber type in each of his or her muscles. That is one reason some individuals excel at distance running, while others excel at sprinting. In animal studies, there is some indication that disuse atrophy affects these two different types of fibers at a different rate.¹ However, in humans there is no conclusive evidence to suggest either type of muscle fiber atrophies faster than the other.
It's surprising how fast disuse atrophy might occur. This has been studied by investigating what happens during limb immobilization after injury. One study found that muscle wasting was detected in as little as three days following immobilization.² The degree of atrophy experienced in a muscle depends on how that muscle is used. For example, it's evident that disuse atrophy occurs much more rapidly in antigravity muscles than in their antagonists.¹ Antigravity muscles are the primary ones used to hold us upright and resist the downward pull of gravity. This is one reason you see atrophy in the quadriceps muscles much more quickly than in the hamstrings.
Another factor related to disuse atrophy that is very evident with the quadriceps, is the position of immobilization. It has been shown that disuse atrophy is exacerbated for a muscle held in a shortened position. Most knee pathologies keep the knee immobilized in extension, rather than in flexion. When the knee is in extension, the quadriceps are passively shortened and the hamstrings are held in a lengthened position. The passive shortening of the quadriceps encourages the loss of integrity of sarcomeres in the muscle.¹ This is one of the primary reasons range of motion is limited following immobilization. Immediately after the immobilization, it's important to encourage adequate stretching of the quadriceps fibers to speed the return to optimal function.
Interesting studies about muscle atrophy have been done with astronauts and cosmonauts aboard the space shuttle and the space station.³ These individuals develop significant amounts of muscle atrophy after spending time in a zero-gravity environment. At first, it was thought the lack of movement was what led to the muscular atrophy, but recent studies have indicated otherwise.⁴ During space shuttle missions, the astronauts often are engaged in vigorous muscular activity while carrying out their work on equipment. What appears to be more significant for all muscles of the body is the absence of load-bearing and muscular effort required to resist gravity.
It appears disuse also might have detrimental effects on neuromuscular function, in addition to the structural changes in muscle tissue. Several researchers examined muscle strength after immobilization and found there was a greater degree of strength loss compared to the amount of muscle atrophy measured by muscle size reduction.⁵ Because the strength loss was greater than the degree of muscle atrophy, there appears to be something else occurring other than muscular atrophy alone. It has been suggested the strength loss is due to an inability to recruit the motor unit properly. In essence, there is a "forgetting" of how to properly coordinate motor function that occurs from disuse.
It has been established that there are significant structural, neuromuscular and biochemical changes in muscles as a result of disuse. We also know from clinical experience that massage appears to have significant beneficial effects in restoring range of motion following immobilization or inactivity. It would be valuable to take these concepts and look at them together, to see if there is some better understanding we might gain of how best to use massage to combat muscular atrophy resulting from disuse.

NeuroDynamic Tests

2013-06-30T08:45:00.002+05:30

Upper limb tension test 1 (median nerve bias)

Shoulder girdle depression
Shoulder joint abduction
Forearm supination
Wrist and finger extension
Shoulder joint laterally rotated
Elbow extension

Upper limb tension test 2a (median nerve bias)

Shoulder girdle depression
Elbow extension
Lateral rotation of the whole arm
Wrist, finger and thumb extension

Upper limb tension test 2b (radial nerve bias)

Shoulder girdle depression
Elbow extension
Medial rotation of the whole arm
Wrist, finger and thumb flexion

Upper limb tension test 3 (ulnar nerve bias)

Wrist and finger extension
Forearm pronation
Elbow flexion
Shoulder girdle depression
Shoulder lateral rotation
Shoulder abduction

Slump test (entire nervous system)

Hands behind back
Thoracic flexion
Cervical flexion
Extend one knee
Dorsiflex foot of extended knee
Cervical extension
Extend other leg with cervical flexion

Prone knee bend (or femoral tension test)

Side lying on unaffected side
Unaffected side: grasping tibia in full hip flexion
Affected side: passive hip extension with full knee flexion
Thoracic and cervical spine flexed
Extension is the desensitizing test

Straight leg raise (sciatic nerve)

Supine
Medial hip rotation, then flexion, with knee extended
Ankle dorsiflexion (tibial nerve)
Ankle plantarflexion and foot inversion (common peroneal nerve)
Hip adduction (sciatic nerve)
Increasing hip medial rotation (sciatic nerve)
Passive neck flexion (SC, meninges and sciatic nerve)

Lumbar Extension Syndrome

2013-06-28T20:48:00.003+05:30

Lumbar Extension Syndrome – 2nd most common diagnosis

Common Medical Diagnoses:

Spinal Stenosis
Degenerative Disk Disease
Spondylolisthesis
Herniated Disk
Osteoarthritis of the Spine

Description:
Low back pain that may or may not radiate into both legs (sometimes only 1 leg). This pain is aggravated when the spine is straighter or bent backwards (increased lordosis).
Diagnostic Tests:

Bending forward may relieve symptoms when standing up from bending forward will increase symptoms.
Lying flat with the legs extended is more painful than lying flat with the knees bent or are pulled to the chest.
Lying flat on your stomach is painful.
Increased lumbar lordosis with bending a knee in prone or lifting the entire leg in prone with pain.
Rocking backward in quadruped improves symptoms while rocking forward increases symptoms.
Arching the back while sitting increases symptoms while slumping the back while sitting decreases symptoms.
Flattening the back against a wall in standing decreases symptoms.

Treatment:

Improve the mobility of the hip flexors and latissimus dorsi while stabilizing with the abdominal muscles.
Improve the activation and strength of the gluteus maximus and abdominals.
Change positions in sitting, standing, and walking to attempt to decrease lumbar extension.

S D Curve Terminologies

2013-06-28T11:12:00.005+05:30

The ease with which a membrane can be stimulated depends on two factors: the strength of a stimulus and the duration for which the stimulus is applied. As the strength of stimulus increases, the time required to excite the membrane decreases and vice versa. Any index of membrane excitability must therefore take into account both the above factors. Three such indices of membrane excitability are rheobase, utilization time and chronaxie.
Rheobase is the theoretical minimum current of electrical stimulus which when applied for an infinite length of time will excite the membrane. Utilization time is the time taken by a stimulus of rheobase strength to excite the membrane. Chronaxie is the time required to stimulate the membrane using double the rheobase strength of stimulus.
Chronaxie is a practical index of membrane excitability. Its value ranges from 0.02 ms in the largest peripheral neurons (Aa) to a maximum of 1.5 ms in the smallest C-fibers. A low chronaxie means greater membrane excitability. Serial measurements of chronaxie provide useful information regarding the progress of nerve healing following injury and surgical repair.

T.E.N.S Modes

2013-06-28T11:01:00.003+05:30

Traditional TENS (Hi TENS, Normal TENS)

Usually uses stimulation at a relatively high frequency (90 - 130Hz) and employ a relatively narrow (short duration) pulses (start at about 100ms) though as mentioned above, there is less support for manipulation of the pulse width in the current research literature. The stimulation is delivered at ‘normal’ intensity - definitely there but not uncomfortable. 30 minutes is probably the minimal effective time, but it can be delivered for as long as needed. The main pain relief is achieved during the stimulation, with a limited ‘carry over’ effect – i.e. pain relief after the machine has been switched off.

Acupuncture TENS (Lo TENS, AcuTENS)

Use a lower frequency stimulation (2-5Hz) with wider (longer) pulses (200-250ms). The intensity employed will usually need to be greater than with the traditional TENS - still not at the patients threshold, but quite a definite, strong sensation. As previously, something like 30 minutes will need to be delivered as a minimally effective dose. It takes some time for the opioid levels to build up with this type of TENS and hence the onset of pain relief may be slower than with the traditional mode. Once sufficient opioid has been released however, it will keep on working after cessation of the stimulation. Many patients find that stimulation at this low frequency at intervals throughout the day is an effective strategy. The ‘carry over’ effect may last for several hours, though the duration of this carry over will vary between patients.

Brief Intense TENS :

This is a TENS mode that can be employed to achieve a rapid pain relief, but some patients may find the strength of the stimulation too intense and will not tolerate it for sufficient duration to make the treatment worthwhile. The pulse frequency applied is high (in the 90-130Hz band) and the pulse duration (width) is also high (200ms plus). The current is delivered at, or close to the tolerance level for the patient - such that they would not want the machine turned up any higher. In this way, the energy delivery to the patients is relatively high when compared with the other approaches. It is suggested that 15 - 30 minutes at this stimulation level is the most that would normally be used.

Burst Mode TENS :

As described above, the machine is set to deliver traditional TENS, but the Burst mode is switched in, therefore interrupting the stimulation outflow at rate of 2 - 3 bursts / second. The stimulation intensity will need to be relatively high, though not as high as the brief intense TENS – more like the Lo TENS. It is proposed that the application of BURST mode TENS can effectively stimulate both the PAIN GATE and the OPIOID mechanisms simultaneously.

Modulation Mode TENS :

In modulation mode, the machine delivers a less regular pattern of TENS stimulation in an attempt to reduce or minimise the accommodation effects of regular, patterned stimulation. Machines offer different methods of varying the stimulation pattern – some vary the frequency, some vary the intensity and some vary the pulse duration, and some machines offer a choice between these methods, though the research evidence to date does not favour one variation method over another. This potentially most useful for patients who use TENS for hours a day, if for no other reason than accommodation occurs at a slower rate and therefore less intensity adjustment may be required.

Mechanism of Action of T.E.N.S

2013-06-28T10:41:00.004+05:30

The type of stimulation delivered by the TENS unit aims to excite (stimulate) the sensory nerves, and by so doing, activate specific natural pain relief mechanisms. For convenience, if one considers that there are two primary pain relief mechanisms which can be activated : the Pain Gate Mechanism and the Endogenous Opioid System, the variation in stimulation parameters used to activate these two systems will be briefly considered.

Pain relief by means of the pain gate mechanism involves activation (excitation) of the A beta (Aβ) sensory fibres, and by doing so, reduces the transmission of the noxious stimulus from the ‘c’ fibres, through the spinal cord and hence on to the higher centres. The Aβ fibres appear to appreciate being stimulated at a relatively high rate (in the order of 90 - 130 Hz or pps). It is difficult to find support for the concept that there is a single frequency that works best for every patient, but this range appears to cover the majority of individuals. Clinically it is important to enable the patient to find their optimal treatment frequency – which will almost certainly vary between individuals. Setting the machine and telling the patient that this is the ‘right’ setting is almost certainly not going to be the maximally effective treatment, though of course, some pain relief may well be achieved.
An alternative approach is to stimulate the A delta (Aδ) fibres which respond preferentially to a much lower rate of stimulation (in the order of 2 - 5 Hz), which will activate the opioid mechanisms, and provide pain relief by causing the release of an endogenous opiate (encephalin) in the spinal cord which will reduce the activation of the noxious sensory pathways. In a similar way to the pain gate physiology, it is unlikely that there is a single (magic) frequency in this range that works best for everybody – patients should be encouraged to explore the options where possible.
A third possibility is to stimulate both nerve types at the same time by employing a burst mode stimulation. In this instance, the higher frequency stimulation output (typically at about 100Hz) is interrupted (or burst) at the rate of about 2 - 3 bursts per second. When the machine is ‘on’, it will deliver pulses at the 100Hz rate, thereby activating the Aβ fibres and the pain gate mechanism, but by virtue of the rate of the burst, each burst will produce excitation in the Aδ fibres, therefore stimulating the opioid mechanisms. For some patients this is by far the most effective approach to pain relief, though as a sensation, numerous patients find it less acceptable than some other forms of TENS as there is more of a ‘grabbing’, ‘clawing’ type sensation and usually more by way of muscle twitching than with the high or low frequency mod

Rancho Los Amigos Cognitive Functioning Scale

2013-06-13T19:13:00.003+05:30

Level 1- No response
Level 2-Generlaised response
Level 3-Localised response
Level 4-Confused Agitated
Level 5-Confused inappropriate
Level 6-Confused appropriate
Level 7-Automatic appropriate
Level 8-Purposeful and appropriate

Root and Peripheral Nerve Innervation of the Lumbosacral Plexus

2013-06-12T20:16:00.002+05:30

Root and Peripheral Nerve Innervation of the Lumbosacral Plexus

Muscle	Nerve	Root
Iliopsoas	Femoral	L2, 3, 4
Adductor longus	Obturator	L2, 3, 4
Gracilis	Obturator	L2, 3, 4
Quadriceps femoris	Femoral	L2, 3, 4
Anterior tibial	Deep peroneal	L4, 5
Extensor hallucis longus	Deep peroneal	L4, 5
Extensor digitorum longus	Deep peroneal	L4,5
Extensor digitorum brevis	Deep peroneal	L4, 5, S1
Peroneus longus	Superficial peroneal	L5, S1
Internal hamstrings	Sciatic	L4, 5, S1
External hamstrings	Sciatic	L5, S1
Gluteus medius	Superior gluteal	L4, 5, S1
Gluteus maximus	Inferior gluteal	L5, S1, 2
Posterior tibial	Tibial	L5, S1

Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes

2013-06-12T20:14:00.002+05:30

Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes

	Conus Medullaris Syndrome	Cauda Equina Syndrome
Presentation	Sudden and bilateral	Gradual and unilateral
Reflexes	Knee jerks preserved but ankle jerks affected	Both ankle and knee jerks affected
Radicular pain	Less severe	More severe
Low back pain	More	Less
Sensory symptoms and signs	Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs	Numbness tends to be more localized to saddle area; asymmetrical, may be unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris
Motor strength	Typically symmetric, hyperreflexic distal paresis of lower limbs that is less marked; fasciculations may be present	Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common
Impotence	Frequent	Less frequent; erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate
Sphincter dysfunction	Urinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence; tend to present early in course of disease	Urinary retention; tends to present late in course of diseas