LASER therapy in physiotherapy

Synonyms: 
•    Therapeutic Laser
•    Low Level Laser Therapy
•    Low Power Laser Therapy
•    Low Level Laser
•    Low Power Laser
•    Low-energy Laser
•    Soft Laser
•    Low-reactive-level Laser
•    Low-intensity-level Laser
•    Photobiostimulation Laser
•    Photobiomodulation Laser
•    Mid-Laser
•    Medical Laser
•    Biostimulating Laser
•    Bioregulating Laser

4 categories of lasers
–    Crystal & Glass (solid - rod)
•    Synthetic ruby & others (synthetic ensures purity)

–    Gas (chamber) – 1961
•    HeNe, argon, CO2, & others

–    Semiconductor (diode - channel) - 1962
•    Gallium Arsenide (GaAs under investigation)

–    Liquid (Dye) - Organic dyes as lasing medium

–    Chemical – extremely high powered, frequently used for military purposes

Types of laser:

Lasers are of 3 different type soft laser, mid laser, power laser. Soft lasers are used for dermatological purposes where depth of penetration is only superficial, Physiotherapy lasers are mid lasers where depth of penetration is from .5-2cm for class III lasers up to 10 cm in type IV lasers. Power lasers are destructive lasers used in different medical & dental surgery.
There are 4 different classes of laser i.e. Class I-IV. All 4 class are used in physiotherapy. However class I-III lasers are commonly used. Class IV physiotherapy & surgical lasers are not to be confused with each other.

Class of lasers:

Class I: Low power lasers
Class II: Power out put up to 1mW (400-700 nm wavelength).
Class IIIa: Power out put up to 5mW.
Class IIIb: Power out put up to 5-500mW.
Class IV: Power out put up to 500-7500mW.

* All lasers can cause eye damage except Class I laser. As the power increases the potential of causing eye damage is more.

* Class III lasers are also known as LLLT i.e. low level laser therapy.

* Class IV lasers are also known as high power laser therapy.

* High-power lasers (class IV) have power output of up to 7,500 mW; and supposedly offer more power, deeper penetration (can penetrate up to 10 cm instead of 0.5 to 2.0 cm for class III lasers) and a larger surface treatment area (cover up to 77 cm2 instead of 0.3 to 5.0 cm2 for class III lasers) 

Modes of Laser:

Either it is continuous or Pulsed. In pulsed laser frequency is a key area for therapeutic efficiency.

Why red or IR lasers are used?
•    Red light affects all cell types
–    Absorbed by the mitochondrial present in all cells
–    Cytochromes (respiratory chain enzymes) within the mitochondria have been identified as the primary biostimulation chromophores (primary light-absorbing molecules).
–    Since enzymes are catalysts with the capability of processing thousands of substrate molecules, they provide amplification of initiation of a biological response with light.

•    Infrared light is more selective absorbed by specific proteins in the cell membrane & affects permeability directly

Tissue response:

•    Magnitude of tissue’s reaction are based on physical characteristics of:
–    Output wavelength/frequency
–    Density of power
–    Duration of treatment
–    Vascularity of target tissues

•    Direct effect - occurs from absorption of photons
•    Indirect effect – produced by chemical events caused by interaction of photons emitted from laser & the tissues

Patient & Laser parameters:

•    Patient parameters
–    Need medical history & proper diagnosis
•    Diabetes – may alter clinical efficacy
–    Medications
•    Photosensitivity (antibiotics)
–    Pigmentation
•    Dark skin absorbs light energy better

 Laser Parameters

–    Wavelength
–    Output power
–    Average power
–    Intensity
–    Dosage

Laser Wavelength: This is measured in Nanometers (nm). Longer wavelength (lower frequency) imparts greater penetration. Wavelength is affected by power.

Laser output: It is measured in Watts or milliwatts (W or mW). It is important in categorizing laser for safety. It is not adjustable.

Power Density or Laser intensity: Beam diameter determines power density. Units of measurement is W or mW/cm2.It takes into consideration actual beam diameter. If light spread over lager area then there is there is lower power density.

Average Power: It is dependant on the mode of laser beam delivery i.e. Continuous or pulse-train (burst) frequency mode. Knowing average power is important in determining dosage with pulsed laser. If laser is continuous laser then avg. power = peak output power. If laser is pulsed (burst) then avg. power is = to peak output power multiplied by duty cycle (frequency).

DOSAGE: Laser dosage is amount of energy applied per unit area. It is measured in Joules/square cm (J/cm2). Joule is unit of energy &1 Joule = 1 W/sec. Dosage is dependent on:
–    Output of laser in mW
–    Time of exposure in seconds
–    Beam surface area of laser in cm2
Various dosage ranges per site (1-9 J/cm2).

Recommended Dosage Range
–    Therapeutic response = 0.001-10 J/cm2
–    Minimal window threshold to elicit response
–    Too much – suppressive effect
–    Open wounds – 0.5-1.0 J/cm2
–    Intact skin – 2.0-4.0 J/cm2
–    Average treatment – 6 J /cm2

Different common lasers in physiotherapy:

1. Helium-Neon Lasers

•    Uses a gas mixture in a pressurized tube
•    Now available in semiconductor laser
•    Emits red light
•    Wavelength:  632.8 nm
•    Power output: 1.0-25.0 mW
•    Energy depth: 6-10 mm
•    The higher the output of the lasers (even though they are still low power) lower the delivery time

2. Indium-Gallium-Aluminum-Phosphide Lasers

•    InGaAip
•    Replacing HeNe lasers
•    Semiconductor
•    Wavelength:    630-700 nm
•    Power output:  same as HeNe
•    Energy depth: superficial wound care

3. Gallium ArsenideLasers

•    Semiconductor - produces an infrared (invisible) laser
•    Wavelength:  904–910 nm
•    Power output: may produce up to 100 mW
•    Energy depth: 30-50 mm
•    Short pulse-train (burst) duration (100-200 ns)

4. Gallium Aluminum ArsenideLasers

•    GaAIAs
•    Semiconductor
•    Wavelength: 780-890 nm
•    Power Output: 30-100 mW (up to 1000 mW)
•    Energy Depth: Very high more than the above said laser

Laser Application techniques:

•    Gridding Technique
•    Divide treatment areas into grids of square centimeters
•    Scanning Technique
•    No contact between laser tip in skin; tip is held 5-10 mm from wound
•    Wanding Technique
•    A grid area is bathed with the laser in an oscillating fashion; distance should be no farther than 1 cm from skin
•    Point Application (On acupuncture point)

Treatment techniques for contact treatment:

Dosage is the most important variable in laser therapy & may be difficult to determine. However it may be simplified i.e. for general application, only treatment time & pulse rate vary. Usually there is a handheld applicator & tip should be in light contact with skin while laser is engaged for pre-calculated time. Maintain laser perpendicular to treatment surface. Put firm contact unless open wound. Clean area prior to treatment.

Always begin with minimal treatment and gradually increase (Better to underexpose than to overexpose). Check for pre/post-treatment changes. Ask the patient how they are doing prior to next treatment because you may have to adjust dosage.

Avoid direct exposure into eyes (If lasing for extended periods of time, safety glasses are recommended). May experience a syncope episode during treatment during chronic pain, but it is very rarely reported.

Application of heat & cold with LASER: If icing – use BEFORE phototherapy because it enhances light penetration. If using heat therapy – use AFTER phototherapy because it decreases light penetration.



Use of Laser therapy in different field of medicine

1. Vascular condition: Venous ulcer (Ref: M.E. Sugrue et al; Annals of Vascular Surgery, Volume 4, Issue 2 , Pages 179-181, March 1990). Results of this pilot study are encouraging. Raynaud's phenomenon is also treated by Laser therapy (Hirschl et al, 2004). Popularly pressure ulcers are treated by laser therapy in neurorehab words.

2. Neurological condition: Stroke (Ref: Int J Stroke. 2012 Feb 2. doi: 10.1111/j.1747-4949.2011.00754.x.). This study named transcranial laser therapy for acute ischemic stroke: a pooled analysis of NEST-1 and NEST-2, support the likelihood that transcranial laser therapy is effective for the treatment of acute ischemic stroke when initiated within 24 h of stroke onset. If ultimately confirmed, transcranial laser therapy will change management and improve outcomes of far more patients with acute ischemic stroke.

Similarly laser therapy is also reported to be beneficial in number of other neurological conditions both in animal & human subjects. Examples are closed-head traumatic brain injury (mice)( In mice it is reported that there is less neurological deficits in post-traumatic brain injury treated with laser for traumatic brain injury.), neurodegenerative diseases (humans) example Alzheimer’s disease. 

3. ENT conditions: Tonsillitis (Vestn Otorinolaringol. 2006;(3):19-22. Russian.), Tinnitus (FrankW et al; GMS Health Technol Assess. 2006 Aug 30;2:Doc17).

4. Surgical conditions: Chronic wound healing, Kaviani and colleagues (2006) examined the effects of low level laser therapy (LLLT) in the treatment of post-mastectomy lymphedema & concluded that LLLT has encouraging results on this condition. LLLT can be used as a conservative therapy for arm lymphoedema secondary to breast cancer treatment (BC Cancer Agency; 2007). Mastodynia is also treated successfully. Lymphangitis is also reported to be treated successfully

5. Dental conditions: post-operative pain after endodontic surgery (Kreisler et al; 2004). Markovic and Todorovic (2007) found after lower third molar surgery laser therapy can be recommended to minimize swelling & oedema. TMJ conditions also show encouraging results.

6. Musculoskeletal conditions: Bursitis, Tendinitis, Ligament injuries, CTS, Neck pain, LBA, myofascial pain syndrome (MPS), Post exercise pain (to treat plyometric induced pain), planter heel pain(Crawford and Thomson, 2003; Landorf and Menz, 2007).

7. Rheumatological conditions: RA (most studied) other rheumatologic pain

8. Other conditions: After effects of tuberculosis, Smoking cessation, Dysmenorrhea etc. 








   

Classification of spondyloarthritides (SpA) & USpA

Classification of spondyloarthritides (SpA) & USpA
Definition: The spondyloarthritides (SpA) are an interrelated group of rheumatic diseases that are characterized by common clinical symptoms and genetic similarities.

For clinical purposes, 5 subgroups are differentiated:
1.    AS (ankylosing spondylitis)
2.    Psoriatic SpA (PsSpA)
3.    Reactive SpA (ReSpA)
4.    SpA associated with inflammatory bowel disease (SpAIBD) and
5.    Undifferentiated SpA (uSpA)

Features of SpA:

Important clinical features of the SpA are
1.    inflammatory back pain (IBP)
2.    asymmetric peripheral oligoarthritis predominantly of the lower limbs
3.    enthesitis
4.    specific organ involvement such as anterior uveitis (eye) , psoriasis (skin) and chronic inflammatory bowel disease

The most important subtype of SpA is ankylosing spondylitis (AS), which is now considered part of axial spondyloarthritis.
ASAS Classification: ASAS stands for Assessment of SpondyloArthritis International Society. 
ASAS group has recently developed criteria to classify patients with axial SpA with or without radiographic sacroiliitis, and criteria to classify patients with peripheral SpA.

Axial SpA:
1. LBA (>3 months almost every day)
2. Radiographs and magnetic resonance imaging (MRI can detect active inflammation and structural damage associated with SpA.)
3. HLA-B27 (Leucocyte antigen): SpA are genetically linked (90% of cases), the strongest contributing factor being HLA B27.
According to the ASAS axial SpA criteria, patients with chronic back pain aged less than 45 years at onset can be classified as having axial SpA if sacroiliitis on imaging (radiographs or MRI) plus 1 further SpA feature are present, or if HLA-B27 plus 2 further SpA features are present.

Peripheral SpA:
1. Patients with peripheral arthritis (usually asymmetric arthritis predominantly involving the lower limbs) enthesitis, or dactylitis.
2. Patients can be classified as having peripheral SpA if 1 of the following features is present: uveitis, HLA-B27, preceding genitourinary or gastrointestinal infection, psoriasis, inflammatory bowel disease, sacroiliitis on imaging (radiographs or MRI) in addition to point no 1.
3. Or if 2 of the following features besides the entry feature are present: arthritis, enthesitis, dactylitis, inflammatory back pain, or a positive family history of SpA.

USpA

Clinical features of USpA:
Vast majority of USpA have IBP (Inflammatory back pain) & asymmetrical peripheral arthritis predominately of lower limbs.

HLA B27 is more helpful uSpA diagnosis: Liao et al analysed the clinical features of Chinese undifferentiated spondyloarthritis (USpA) patients with predominantly axial involvement. They found in Chinese population Both HLA-B27 status and SIJ MRI findings influence the classification of Chinese axial USpA patients, but HLA-B27 seems of more value.

References:
1. Braun J & Sieper J; Z Rheumatol. 2010 Jul;69(5):425-32; quiz 433-4. Spondyloarthritides.
2. van den Berg R & van der Heijde DM; Pol Arch Med Wewn. 2010 Nov;120(11):452-7. How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians.
3. Liao Z et al; Scand J Rheumatol. 2011 Nov;40(6):439-43. Epub 2011 Jul 4. Clinical features of axial undifferentiated spondyloarthritis (USpA) in China: HLA-B27 is more useful for classification than MRI of the sacroiliac joint.

4. http://www.medscape.org/viewarticle/545412_2

Eosinophilic Fascitis: 300 cases in 35 years

All people dealing with soft tissue pain & dysfunction "Eosinophilic Fascitis" is rearrest of the rare condition to encounter.

Take a note of it. It is a matter of debate for all fascia researchers & people involved in "Fascia research congress"

Pubmed link to "Eosinophilic Fascitis":  

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001483/

Lumbar Retrolisthesis: Introduction, types, physiotherapy treatment

A retrolisthesis is a posterior displacement of one vertebral body with respect to the adjacent vertebrae to a degree less than a luxation (dislocation). Retrolisthesis is relatively rare but when present has been associated with increased back pain and impaired back function. Clinically speaking, retrolisthesis is the opposite of spondylolisthesis (anterior displacement of one vertebral body on the subjacent vertebral body). Retrolistheses are most easily diagnosed on lateral x-ray views of the spine. Views, where care has been taken to expose for a true lateral view without any rotation, offer the best diagnostic quality.

Retrolisthesis may occur more commonly than initially believed. However retrolisthesis (backwards slippage of one vertebral body on another) has historically been regarded as an incidental finding, one which doesn’t cause any symptoms, and is considered to be of little or no clinical significance. But there is a possible association between retrolisthesis and increased back pain and impaired back function.

Retrolisthesis may be present in up to 30% of extension radiographs of patients complaining of chronic low back pain. Retrolisthesis has been found to be associated with disc degeneration, decrease in lumbar lordosis, and decrease in vertebral endplate angle.

According to Shen et al (Shen M et al; Spine J. 2007; 7(4): 406–413) it is possible that the contribution of pain or dysfunction related to retrolisthesis was far overshadowed by the presence of symptoms due to the concomitant disc herniation.

Crucial questions in musculoskeletal medicine in retrolysthesis:

1. Do individuals with lumbar disc herniations have increased levels of back pain, back dysfunction, and decreased quality of life pre-operatively if they have concomitant retrolisthesis at the involved herniated disc level?

2. Does the presence of degenerative changes (disc degeneration, degenerative endplate changes, posterior element degenerative changes) along with retrolisthesis worsen the symptoms and / or possibly the prognosis in these operative cases?

Grading & Classification:

Classification system:
Complete Retrolisthesis - The body of one vertebra is posterior to both the vertebral body of the segment of the spine above as well as below.
Stairstepped Retrolisthesis - The body of one vertebra is posterior to the body of the spinal segment above, but is anterior to the one below.
Partial Retrolisthesis - The body of one vertebra is posterior to the body of the spinal segment either above or below.

Since the vertebral body in a retrolisthesis moves in a posterior direction, the grading used for spondylolistheses is of little use. Clinicians & researchers use the following grading systems after following X ray reading:

There are always 2 vertebrae involved in measuring the magnitude of a retrolisthesis for translation (slippage). The lower segment is considered the position of stability. The upper segment rests on it. The upper segment is considered the segment of mobility and is the one being determined for retrolisthesis.

1) A line is drawn along the top of the vertebral body of the lower spinal segment.
2) Then at the top-back most portion of the lower vertebral body, draw line at 90 degrees to line, till it projects well into the body of the vertebra above.
3) Then draw another line parallel to the line just drawn this time at the posterior most lower portion of the upper vertebral body.
4) The distance between the upright lines and is measured. Any distance of 3mm or greater is a retrolisthesis. This measurement represents the degree of translation (slippage) of the upper of the two segments.

1. Few clinicians follow the following criteria:

Percent subluxation can be calculated for any individual with greater than or equal to 3 mm of posterior displacement. A cut-off point of 3 mm has been used previously both in orthopaedic research and clinical practice. This 3mm cut-off corresponds to a slip of 8% which is used as the lower limit to define retrolisthesis.

2. Other few follow the following criteria:

In this grading system anterior to posterior dimension of the intervertebral foramina (IVF) is divided into four equal units. A posterior displacement of up to ¼ of the IVF is graded as Grade 1, ¼ to ½ as Grade 2, ½ to ¾ as Grade 3, ¾ to total occlusion of the IVF as Grade 4.

Joint stability & retrolisthesis: 

Joint stability is easily evaluated by the use of flexion and extension lateral x-ray views of the spine. If vertebral translation present on standing (stressed by gravity) lateral view x-rays then it indicates that the spinal joints at those levels are already in a "significantly stressed" state. It further means that if this is the condition then there may be degree of soft tissue looseness at best and soft tissue tearing at worst otherwise a positional translation of this magnitude could not be present.

Implications of joint instability are derived from DRE (Diagnosis related estimates) tables. If translation of 4.5mm & angular change of 15 degree or more at L1, L2 or L 3, 20 degree or more at L4 and 25 degree or more at L5 is found then Category IV instability is present. This would mean that 20% to 23% “whole person impairment” is present at each level where this if found.
Pathology & structures involved:

Retrolysthesis is caused in lumbar by flexion injury or by prolonged & continual use of lumber spine flexion over a period of time.

Spine instability causes damage to of the connecting soft tissues especially juxtaposed ligaments, discs, muscles, tendons and fascia. Muscle spasm may also be present. Nerve compression may be present at intervertebral foramen (IVF). The compression of the IVF’s contents include spinal (sensory and motor) nerves, arteries, veins and lymphatic vessels which cater to the nutritional and waste removal needs of the spinal cord.

Degenerative spinal changes are often seen at the levels where a retrolisthesis is found. These changes are more pronounced as time progresses evidenced by end plate osteophytosis, disc damage, disc narrowing, tearing failure and eventually results in disc bulging.
“A retrolisthesis hyper loads at least one disc and puts shearing forces on the anterior longitudinal ligament, the annular rings, nucleus pulposis, cartilage end plates and capsular ligaments. The bulging, twisting and straining tissues attached to the endplates pull, push and stretch it. It is worsened with time, gradually
becoming irreversible. This is the aetiology of degenerative joint disease in retrolysthesis.

X-ray & radiological findings:

•    Vacuum phenomenon (in the nucleus pulposis of the intervertebral disc below the retrolisthesis),
•    Reduction of disc height with corresponding loss of the disc space,
•    Marginal sclerosis (more dense due to stress) of the adjacent vertebral bodies,
•    Osteophyte (spur) formation and
•    Apophyseal (guiding) joint instability.
•    With a retrolisthesis there is always a less than ideal positioning of spinal segments. (subluxation)
•    There is also always a reduced anterior to posterior dimension of the spinal canal compared to the way it is supposed to be. This leads to nerve signal alteration.
•    The greater the posterior displacement, the more significant it is for producing nerve root impingement and irritation, a dysfunctional spinal cord even to the point of a cauda equina compression syndrome if present in the lower lumbar spine.

Patient clinical presentation:

Patients present with varied S/S with retrolysthesis from little pain to severe disabling pain. Patient may also present with sciatica with or without neurological deficits. In patients with neural claudication lumbar canal stenosis due to lysthesis is also seen.

Physiotherapy:

Both IV joints & facet joints may produce pain & radiation.

Maitland transverse glides/ lateral PA glides on to the side of pain can be administered in cases associated mostly with facet restrictions. Central PA is also administered in appropriate cases with mutifidus & other spinal exercises. LS belt in majority cases may aid relief from pain.

McKenzie’s exercises to stretch the anterior spinal structures both with mobilization & manipulation in McKenzie style along with home exercises in McKenzie is highly advisable.

Spine muscle atrophy is seen in many cases of long standing retrolythesis. Spine stabilization exercises are sought in most cases and appropriate home exercises must be advised with follow ups with the physiotherapist.

Electrotherapy is directed to reduce pain. Few clinicians also believe that modalities like SWD or MWD can reduce the rate of degeneration hence also used in degenerative retrolysthesis.

Sitting ergonomics: Different sitting postures & analysis of chair sitting muscle work

Different varieties sitting postures:

A. Common sitting postures:

1.    Chair sitting
2.    Crossed sitting
3.    Crossed sitting with arms wrapped around both knees & locked in front
4.    Half crossed sitting
5.    Crook sitting
6.    Inclined sitting (to back)
7.    Inclined sitting (to sides)
8.    Inclined long sitting
9.    Side sitting
10.    Stoop sitting
11.    Fall out sitting
12.    Ride sitting
13.    Kneel sitting
14.    Crouch sitting

B. Activities in sitting:

1.    Twisting in sitting
2.    Bending & reaching in sitting (sidewise- office works & in front- driving)
3.    Hitching & Hiking (to relieve pressure on buttocks in prolonged sitting)

C. Co-existing unavoidable stress factors in sitting:

1.    Whole body vibration (driving)
2.    Noise stress
3.    Visual stress
4.    Psychological stress

Analysis of muscle work in sitting posture:

Ideal sitting posture: The following discussion is in the context of a quiet ideal chair sitting posture without any upper limb activity. The position is taken on a flat base chair or stool, the height & width of the sitting area allow the thighs to supported & hips and knees is flexed to 900 . In ideal sitting femora are parallel to each other & feet rest on the floor with ankle at 900 where as hells are vertically below the knees.

Muscle work in ideal sitting posture:

a.    Joints of lower extremity have no muscle work except at hip. Flexors of hip work in reverse origin insertion fashion to prevent slumping of the lumbar spine.

b.    Joints of spine:
i. Global extensor muscles of the spine (Ex-Multifidus): these postural muscles keep the trunk upright. Action of these muscles may be counterproductive at lumbar & cervical spine where it’s action produces a bow string effect & increases the lordotic curvature leading to reduction in the over all height of the spine at these places. Therefore at the lumbar & cervical spine this action must be counteracted by the local flexors (lumbar & cervical spine flexors) to ensure local spine lengthening and maintain the correct & ideal local spine posture.  
ii. Flexors of the lumbar spine (Abdominals): In sitting they must work to prevent the bow string effect produced by the global extensor muscle. Scientific literature indicates they contract in an in to out fashion. Hence transverse abdominis is of prime importance in maintaining the core stability & correct spinal alignment. Where as the straight abdominals (rectus abdominis) maintain the correct pelvic tilt matching the spine alignment so that correct contact points are maintained at the chair base- body interface.
iii. Flexors of the cervical spine (pre-vertebral neck muscles) act to prevent the bow string effect produced by the global extensor muscle.
iv. Posture of the head on the cervical spine is finely controlled at the CVJ & at atlanto-axial joint by own set of flexors-extensors to maintain this sagittal posture.
   
c.    Other joints in sitting:
i. TMJ: elevators of the mandible close the mouth against the pull of the gravity.
ii. Thoraco-scapular junction: Thoraco scapular muscle (rhomboids) retracts the scapula so that the glenoid cavity faces laterally. Cervico scapular muscles (levator scapulae) work to elevate a depress scapula due to the pull of the gravity.

d.    Joints of upper extremity: No muscle work is required for quite sitting but sitting with occupational arm demands may leads to more activation of the external rotators of the arm, abductors, elbow flexors, forearm pronators, wrist extensors & finger flexors. 

Baastrup disease: Lumbar interspinous bursitis

This disease is named after Danish radiologist (1855 - 1950) Christian Ingerslev Baastrup.

Introduction & Epidemiology:
It is claimed that Baastrup disease is responsible for intractable LBA (1). Though it is reported in mostly lumbar spine it’s cervical spine variant is also reported (2). Gardella called Baastrup disease as spinous process syndrome (3). It is reported in many occupational areas such as miners (4) & heavy vehicle drivers (8). Among of much debate now it is considered mostly a case of aging related problem. Let us discuss in little more detail:

The Baastrup disease is characterized by the development of abnormal contact between adjacent spinous processes of the lumbar spine that results in rubbing against each other producing a bursitis which further result in focal midline pain and tenderness relieved by flexion and aggravated by extension.

Epidemiology:
It tends to be more common in the elderly. According to Maes et al (5) the prevalence of Baastrup disease is 8.2% (44 of 539) of the study population. In this study the lumbar spine was studied. This study also revealed that Baastrup disease is associated with age (P = 0.001), central canal stenosis (P = 0.0013), disc bulging (P = 0.0341), and anterolisthesis (P = 0.0429). There were no associations between Baastrup disease and disc degeneration, disc herniation, endplate findings, retrolisthesis, scoliosis, lordosis, or gender.
According to Kwong et al (6); Baastrup disease occurs with high frequency among the elderly. This study suggests that Baastrup disease develops with increasing age and is part of the expected degenerative changes in the aging spine. According to these researchers (6) in their CT scan based study of 1008 patients evidence of Baastrup disease was found in 413 patients (41.0%). A decade-on-decade increase in frequency was found with a peak of 81.3% among patients older than 80 years. As many as five spinal levels were found to be affected in some patients (4.1% of 413), but in most patients (35.4%), one level was affected. Baastrup disease was most common at L4-L5. Associated degenerative changes were found at almost all affected levels (899/901). Hence Kwong et al urged the clinicians that because of the nearly universal association with other degenerative changes, caution must be taken before diagnosing Baastrup disease as the cause of back pain.
According to Hanger (8) prevalence rate of this disease in a group of heavy automotive vehicles drivers is 13% of the test population.

Pathology
Patients with Baastrup disease may experience pain owing to irritation of the periosteum or adventitial bursae between abutting spinous processes. This process can result in a degenerative hypertrophy, inflammatory change and even a pseudarthrosis with bursa formation. This interspinous bursa may extend between the ligamentum flavae in the midline forming an epidural cyst and further contributing to the already existing canal stenosis.
This condition is usually seen patients with excessive lordosis of the lumbar spine. Often Baastrup lesions of the lumbar spine are located at L3-L4 and L4-L5 segments (8).

Palpation
I myself employ the following technique to find a Interspinous bursa is swollen or not.
First the spinous processes are palpated. The gap between the spinous process (Interspinous area) is located and palpating finger (usually the thumb) is slided on the slope following a parallel path way to that of laminas. Reaching on to the area between the spinous process from the side is easy & if Baastrup disease is present then obviously high degree of tenderness is elicited.This palpation also gives us the idea if the crowding of (kissing of ) spinous process as compared with other interspinous spaces & further it may reveal the tissue texture of the local tissue. Inflammed bursa with cyst may impart a "bouggy" feeling to the palpating hand. 

Radiographic features (9)
Plain film and CT
 •    often shows close approximation and contact of adjacent spinous processes (kissing spines)
•    there is resultant enlargement, flattening and reactive sclerosis of apposing interspinous surfaces.

MRI
May demonstrate interspinous bursal fluid and a postero-central epidural cyst(s). MRI can be very helpful in determining whether there is resulting posterior compression of the thecal sac.

Baastrup's sign: Also known as kissing spine, is an radiographic sign. It is characterized by posterior spinous processes 'kissing' and touching one another on sagittal plane.

Treatment (9)
Both conservative and surgical options are available for treatment. Local steroid injection into the interspinous processes will often ease the back pain. Surgical options include interspinous process decompression devices (e.g, Wallis system, X STOP), and steroid / local anaesthetic injection into the bursa.

Physiotherapy:

No references are there about physiotherapy. However electro-analgesia & thermo-analgesia are quite effective. SWD, PSWD, MWD & FIR exert powerful anti-inflammatory effect with thermo-analgesia. IFT gives anti-inflammatory effect with electro-analgesia. UST in pulsed mode directed appropriately to the focal tissue is both anti-inflammatory & analgesic.
Manual mobilization techniques are tried once the local tenderness is less. Contrast heat in acute inflammation & Hot fomentation thrice a day is also very effective in long standing cases which should be used as a home remedy. Egronomic corrective methods & postural awareness are of utmost importance as they may be primary factor that produced such a disorder. Manual therapists well versed with soft tissue & fascial techniques should try out techniques that may lengthen the thoracolumbar fascia.
The outcome of physiotherapy is so satisfactory that author opine on his clinical experience, steroid infiltration & surgery are rarest of rare probabilities to be employed. 

References:
1. FERNANDEZ DE LA MELA I; Medicamenta (Madr). 1951 Dec 10;9(210):404-5.[Lumbar interspinal nearthrosis (Baastrup disease) as responsible for some intractable backaches].

2. VIALLET P J Radiol Electrol Arch Electr Medicale. 1950;31(3-4):206-7. [Two cases of cervical localization of Baastrup disease].

3. GARDELLA G; Ann Radiol Diagn (Bologna). 1952;24(4):260-74.[Spinous process syndrome (Baastrup disease)].

4. Gajdek D; Chir Narzadow Ruchu Ortop Pol. 1976;41(2):171-4. Polish. No abstract available. [Baastrup syndrome of the lumbar spine in miners].

5. Maes R et al; Spine (Phila Pa 1976). 2008 Apr 1;33(7):E211-5. [Lumbar interspinous bursitis (Baastrup disease) in a symptomatic population: prevalence on magnetic resonance imaging.]

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9. http://radiopaedia.org/articles/baastrup_syndrome

Classification of spinal cord injury: ASIA classification Vs Frankel classification

Clinicians have long used a clinical scale to grade severity of neurological loss in SCI. First devised at Stokes Manville before World War II and popularized by Frankel in the 1970's, the original scoring approach segregated patients into five categories.

Frankel classification:Grade A:  no function
Grade B: sensory only
Grade C: some sensory and motor preservation
Grade D: useful motor function
Grade E: normal function

ASIA classification:Grade A:  Complete. No motor or sensory function preserved in the sacral segments (S4-S5)
Grade B: Incomplete. Sensory function is preserved but motor function is affected below the neurological level & includes the sacral segments (S4-S5)
Grade C: Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3.
Grade D: Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle more than 3.
Grade E: Normal. Motor & sensory functions are normal.

5-Clinical syndromes in incomplete SCI by ASIA classification:1. Central cord syndrome 2. Brown-Sequard syndrome 3. Anterior cord syndrome 4. Conus medullaris syndrome 5. Cauda equina syndrome
The ASIA committee also classified incomplete spinal cord injuries into five types. A central cord syndrome is associated with greater loss of upper limb function compared to the lower limbs. The Brown-Sequard syndrome results from a hemisection lesion of the spinal cord. Anterior cord syndrome occurs when the injury affects the anterior spinal tracts, including the vestibulospnal tract. Conus medullaris and cauda equina syndromes occur with damage to the conus or spinal roots of the cord.

Advantages of ASIA impairment scale:
1. First, instead of no function below the injury level, ASIA A is defined as a person with no motor or sensory function preserved in the sacral segments S4-S5. This definition is clear and unambiguous.
The new ASIA A categorization turns out to be more predictive of prognosis than the previous definition where the presence of function several segments below the injury site but the absence of function below a given level could be interpreted as an "incomplete" spinal cord injury.
2. ASIA B is essentially identical to Frankel B but adds the requirement of preserved sacral S4-S5 function. It should be noted that ASIA A and B classification depend entirely on a single observation, i.e. the preservation of motor and sensory function of S4-5.
3. The ASIA scale also added quantitative criteria for C and D. The original Frankel scale asked clinicians to evaluate the usefulness of lower limb function. This not only introduced a subjective element to the scale but ignored arm and hand function in patients with cervical spinal cord injury. To get around this problem, ASIA stipulated that a patient would be an ASIA C if more than half of the muscles evaluated had a grade of less than 3/5. If not, the person was assigned to ASIA D.
4. ASIA E is of interest because it implies that somebody can have spinal cord injury without having any neurological deficits at least detectable on a neurological examination of this type. Also, the ASIA motor and sensory scoring may not be sensitive to subtle weakness, presence of spasticity, pain, and certain forms of dyesthesia that could be a result of spinal cord injury. Note that such a person would be categorized as an ASIA E.

These changes in the ASIA scale significantly improved the reliability and consistency of the classification. Although it was more logical, the new definition of "complete" injury does not necessarily mean that it better reflects injury severity.