Saturday, May 31, 2008

Effects of interferential current in psoriatic arthritis:

Interferential current (IFC) was suggested to improve the skin manifestations of psoriasis vulgaris, possibly by enhancing the intracellular concentration of cyclic AMP.
Walker UA et al assessed the efficacy of IFC on psoriatic arthritis. Nine consecutive patients were analyzed at baseline and after 16 weeks of IFC therapy. Bipolar IFC was applied twice daily to hands, feet plus all affected joints.
They found:
1. IFC improved SF-36 assessed body pain, but not other SF-36 subscales.
2. Morning stiffness, tender joint counts, and physician assessed disease activity improved.
3. In contrast, visual analogue scale assessed pain, CRP and ESR measurements were unchanged. MRI of the most affected hand or foot documented a tendency towards worsened tendinitis, soft tissue swelling, and new joint space narrowing and erosions. Bone scintigraphy showed a trend towards deterioration. New joints became inflamed within treated sites.
They concluded because of above features that; IFC has analgesic effects in psoriatic arthritis, but does not have a satisfactory disease modifying effect.

BRAVO PHYSIOS- but when is our term in INDIA?

In one of the reputed journals of surgery in UK back in 1995 published an article authored by Weale AE et al titled “who should see orthopaedic outpatients--physiotherapists or surgeons?”.
Following are points directly from his paper Weale AE et al:
1. Orthopaedic outpatient waiting lists are long and the majority of referrals are for conditions that do not respond to surgical intervention.
2. Many of these patients are best managed by physiotherapy, orthotics or steroid injections, which can be administered by an appropriately trained physiotherapist.
3. The effectiveness of a physiotherapist with extended training in orthotics and steroid injection was compared with staff grade orthopaedic surgeons in the management of orthopaedic outpatients judged unlikely to require surgery from the general practitioner's referral letter.
4. Some 221 patients with mechanical low back pain and foot and shoulder disorders were seen by a physiotherapist and 97 by staff grade surgeons over a 10-month period. Outcome was assessed by postal questionnaire or telephone contact 6-12 months following discharge. Outcome was satisfactory in 80 per cent of patients overall, 65 per cent of low back and 69 per cent of neck pain, 80 per cent of foot and 83 per cent of shoulder disorders.
5. An appropriately trained physiotherapist is as effective as staff grade surgeons in managing orthopaedic outpatients unlikely to benefit from surgical intervention. This has implications both in reduction of outpatient waiting lists and hospital doctor hours of work.

No treatment evidence in Post-op. metacarpophalangeal arthroplasty in 2008!

Rheumatoid arthritis is encountered here in India with consistent regularity. MCP joints are the commonest joint to be affected. In a chronic RA patient MCP joint is flexed & deviated to the ulnar side. This deformity produces a great functional disability. One of the surgical options is MCP joint arthroplasty. It has been performed for people with rheumatoid arthritis (RA) since the 1960s.
For eight to 12 weeks following surgery, patients wear hand splints and perform exercises to maintain and increase motion in the healing hand. Post-operative therapy regimes share common aims of encouraging MCP flexion and extension without the recurrence of flexion or ulnar deviation deformity.
In a study by Massy-Westropp N et al (2008) published in Cochrane database reviews compared the effectiveness of post-operative therapy regimes for increasing hand function after MCP arthroplasty in adults with rheumatoid arthritis.

The search included:
The Cochrane Musculoskeletal Group Register,
MEDLINE (January 1950 to August 2006),
EMBASE (January 1993 to August 2006),
CINAHL (January 1982 to August 2006),
Digital Dissertations (January 1960 to August 2006),
DARE (The Cochrane Library 2006, Issue 3),
Current Contents Connect (January 1998 to August 2006),
and AMED (January 1985 to August 2006)
These data bases were searched for randomised controlled trials and controlled clinical trials using rheumatoid arthritis and hand as the search terms and they evaluated the efficacy of a post-operative therapy regime for MCP arthroplasty.

Their search only identified one controlled clinical trial involving 22 participants.
The majority of the evidence for various splinting and exercise regimes consisted of case series and case studies.
Results from the one (poor quality) trial suggest that the use of continuous passive motion is not effective in increasing motion or strength after MCP arthroplasty.

They concluded:
Well-designed randomised controlled trials which compare the efficacy of different therapeutic splinting programmes following MCP arthroplasty are required.
As mentioned above just results of one study (silver level evidence) suggest that continuous passive motion alone is not recommended for increasing motion or strength after MCP arthroplasty.

Foot note: A strong & prudent post operative physiotherapy protocol designing is required. Difficult to execute the plan in India as it is rarely done in India.

A Chinese epidemiological study on cervical spondylosis

A Chinese epidemiological study on cervical spondylosis Wang B et al (2004) investigated 1009 Chinese people. They study consisted of Questionnaires and X-rays of people with different occupations, ages, and sexes.
High and middle pillow-lovers occupied 80.03%.
Imaging features: most of the degenerative changes of cervical spine were located between C5-6 (40.79%), C4-5 (26.29%), and C6-7 (18.20%).
Patients with vertebral osteophyte were 65.75%, intervertebral space narrow 36.87%, intervertebral foramen narrow 29.19%, and physiological curve change 31.03%.

Use or not to use pillow in neck pain:

Erfanian P et al (2004) a group of private physio-practitioners found a experimental semi-customized cervical pillow was effective in reducing low-level neck pain intensity, especially in the morning following its use in a 4 week long study.

Thursday, May 29, 2008

what indian epidemiological studies say on obesity?

An epidemiological study of obesity in Shimla town was conducted by Sood RK et al in 1996 published in Indian journal of medial science. The study explored prevalence of obesity, its relation to age and physical activity in Indian context. The authors concluded Primary prevention is required to tackle this disease risk factor through health education focussing on promotion of moderate regular physical activity.

capsular patterns

Capsular patterns at different joints:

A) Joints spanned by muscles:
1. TM joint: increasing limitation of opening the mouth.
2. Shoulder joint: limitation in the following order from maximum to minimum, lateral rotation (most limited)- abduction- medial rotation (least limited).
3. Elbow joint: flexion more limited than extension. Rotations free and painless. For each 90-degree limitation of flexion there is 10-degree limitation of extension.
4. DRU joint: full range of motion with pain only at the limits of motion.
5. Wrist joint: equal degree of limitation of flexion and extension.
6. Trapezium-first-metacarpal joint (1st CM joint): more limitation of abduction than extension, flexion is full.
7. 2nd to 5th CM joint: limited motion in all directions.
8. IP joints of all the fingers: more limitation of flexion than extension.
9. Hip joint: limitation in the following order from maximum to minimum,
Medial rotation and flexion (most)- abduction- adduction and lateral rotation (little or no)- by Dr. cyriax
Medial rotation-extension-abduction-lateral rotation- by Kaltenborn.
10. Knee joint: extension is more limited than flexion. For each 3-degree limitation of flexion there is 50-degree limitation of extension.
11. Tibiofibular joint: a) Upper- pain on contraction of biceps femoris.
b) Lower- pain when the mortice is sprung.
12. Ankle joint: more limitation of plantiflexion than dorsiflexion.
13. Talocalcanial/Subtalar joint: limitation of varus (supination) till the joint fixes in valgus (pronation).
14. Mid-tarsal joint: limitation in the following order from maximum to minimum,
Dorsiflexion- plantiflexion-adduction-medial rotation (inversion). Abduction and lateral rotation (eversion) are full.
15. 1st MTP joint: more limitation of extension than flexion. For 10 to 20-degree limitation of flexion there are 60 to 80-degree limitation of extension.
16. 2nd to 5th MTP joint: tend to fix in extension, its obvious that there is more limitation of flexion.
17. IP joints of all the toes: tends to fix in flexion, its obvious that there is more limitation of extension.

B) Joints not spanned by muscles:
1. SC/AC joints: pain at the extreme range.
2. Sacroiliac, symphysis pubis & sacrococcygeal joint: pain when stress falls on the joint.

C) Joints of the spinal column:
1. Cervical joints: side flexion and rotation are equally limited towards both the sides. Extension is limited but flexion is full.
2. Thoracic joints: limitation in the following order from maximum to minimum,
Extension- side flexions & rotations (equal to both sides)- flexion.
3. Lumbar joints: limitation in the following order from maximum to minimum, equal limitation of side flexions-flexion-extension.

My approch to SI joint dysfunction

step-1: SLR test on involved must be more than60-70 degrees
step-2: compression & distraction test, Wilson-Barstow maneuver
step-3: long sitting test (leg length from short to long or from long to short?), sitting flexion test
step-4: by the step 3; i am almost sure whether the pain is because of innominate dysfunction or due to sacral dysfunction
step-5: trial treatment & mobility and pain assessment

Wednesday, May 28, 2008

current sports medicine review

According to Brukner PD et al (2006, medical journal of Australia) advancement of imaging and other diagnostic techniques such as magnetic resonance imaging and arthroscopy; have shown the commonest causes of the hip pain & dysfunction are due to labral injuries, chondral injuries, rim lesions, synovitis and tears of the ligament teres in sports arena.

Hydrotherapy combined with multi-sensory therapy in Israel- A emerging new horizon of treatment.

Snoezelen therapy is controlled multisensory stimulation. The combination of the two therapeutic approaches i.e. hydrotherapy and Snoezelen therapy enhances the treatment effect by utilizing the unique characteristics of each approach and thus creates a new intervention approach.
Beit Issie Shapiro is a non-profit community organization of Israel is providing a range of services for children with developmental disabilities and their families with this combined approch. The organization provides direct services for nearly 6,000 children and adults each year.

Electrical stimulation therapies enhance spinal fusions to postoperative cases

Spinal instability caused by disease or trauma is treated by spinal fusion. Following the operative procedure electrical stimulation therapies are given to enhance spinal fusion. Three types of technologies are available clinically: direct current, capacitive coupling, and inductive coupling to enhance spinal fusions. The mechanisms of action of each of the three electrical stimulation therapies are different. The latter is the basis of pulsed electromagnetic fields and combined magnetic fields. Scientific studies support the validity of electrical stimulation treatments.

New data demonstrates that the up-regulation of several growth factors may be responsible for the clinical success seen with the use of such technologies.

Changes in Bobath techniques & comparison of Bobath and Motor relearning program

Bobath concept :
The Bobath concept, based on the work of Berta and Karel Bobath, offers therapists working in the field of neurological rehabilitation a framework for their clinical interventions. It is the most commonly used approach in the UK. According to Lennon S et al (2000) Bobath concept and its main theoretical assumptions had changed since 1990. Although they recognize that over the last half-century the concept has undergone considerable developments, proponents of the Bobath concept have been criticized for not publishing these changes.
The Bobath concept, usually known as neuro-developmental treatment (NDT) in America, is one of the major approaches used to rehabilitate patients following stroke; however since the last publication of Bobath (1990), the concept has been taught via an oral tradition on postgraduate courses.
Bobath method is to improve quality of the affected body side's movements in order to keep both sides working as harmoniously as possible. While applying this method at work, physical therapist guides patient's body on key-points, stimulating normal postural reactions, and training normal movement pattern. Core themes defining Bobath program is analysis of normal movement, control of tone and facilitation of movement. Neuroplasticity was described as the primary rationale for treatment with therapists using afferent information to target the damaged central nervous system. Tone remained a major problem in the rehabilitation management of the hemiplegic patient; however much attention was also directed towards the musculoskeletal system. Both facilitation of normal movement components and task specific practice using specific manual guidance were considered critical elements of the Bobath concept. For Bobath therapists, physiotherapy has an important impact on both the performance components of movement and functional outcomes.
Motor relearning program (MRP):
Motor relearning program (MRP) is based on movement science, biomechanics and training of functional movement. Program is based on idea that movement pattern shouldn't be trained; it must be relearned.

Research input says Motor relearning program (MRP) is better than Bobath program:

Langhammer B et al (2000) examined whether two different physiotherapy regimes caused any differences in outcome in rehabilitation after acute stroke. They found physiotherapy treatment using the motor relearning program is preferable to that using the Bobath program in the acute rehabilitation of stroke patients.
Krutulyte G et al (2003) indicates that physiotherapy with task-oriented strategies represented by MRP, is preferable to physiotherapy with facilitation/inhibition strategies in comparison to Bobath program, in the rehabilitation of stroke patients.

Higher research technique i.e. Delphi technique proving the effectiveness of Bobath programs:
Raine S (2006) used the Delphi technique to enable experts in the field to define the current Bobath concept. The Delphi study was an effective research tool, maintaining anonymity of responses and exploring expert opinions on the Bobath concept. The experts stated that Bobath's work has been misunderstood if it is considered as the inhibition of spasticity and the facilitation of normal movement, as described in some literature. They agreed that the Bobath concept was developed by the Bobaths as a living concept, understanding that as therapists' knowledge base grows their view of treatment broadens.

Tuesday, May 27, 2008

Do 'sliders' slide and 'tensioners' tension?

An analysis of neurodynamic techniques and considerations regarding their application is done by Coppieters MW in journal of manual therapy, Australia (2008).
This study was a cadaveric biomechanical study. It measured longitudinal excursion and strain in the median and ulnar nerve at the wrist and proximal to the elbow during different types of nerve gliding exercises.
The results confirmed the clinical assumption that 'sliding techniques' result in a substantially larger excursion of the nerve than 'tensioning techniques' (e.g., median nerve at the wrist: 12.6 versus 6.1mm, ulnar nerve at the elbow: 8.3 versus 3.8mm), and that this larger excursion is associated with a much smaller change in strain (e.g., median nerve at the wrist: 0.8% (sliding) versus 6.8% (tensioning)).

The findings demonstrate that different types of nerve gliding exercises have largely different mechanical effects on the peripheral nervous system. Hence different types of techniques should not be regarded as part of a homogenous group of exercises as they may influence neuropathological processes differently.

Degenerative lumbosacral spondylolisthesis: possible factors which predispose the fifth lumbar vertebra to slip.

Hosoe H et al (2008) analysed a number of radiological measurements in an attempt to clarify the predisposing factors for degenerative spondylolisthesis of the lumbosacral junction.
They identified 57 patients with a slip and a control group of 293 patients without any radiological abnormality apart from age-related changes.
The relative thickness of the L5 transverse process, the sacral table angle and the height of the iliac crest were measured and evaluated.
They found that:
1. The transverse process of L5 was extremely slender +
2. the sacral table more inclined +
3. And the L5 vertebra was less deeply placed in the pelvis in patients with a slip compared with the control group.
They concluded that the L5 vertebra is predisposed to slip when these above mentioned factors act together on a rigidly-stabilised sacrum. This occurs more commonly in women, probably as a result of constitutional differences in the development of the male and female spine.

Cranial electrotherapy stimulation- treatment implications in fibromyalgia

In past cranial electrotherapy stimulation (CES) has been reported to be effective in tinnitus, anxiety etc. In another study by Lichtbroun AS et al (2001) cranial electrotherapy stimulation (CES), micro-current levels of electrical stimulation are passed across the head via electrodes clipped to the ear lobes with an aim to gauge the effect of this treatment on fibromyalgia.

In a double-blind, placebo-controlled study in which 60 randomly assigned patients were given 3 weeks of 1-hour-daily CES treatments, sham CES treatments, or were held as wait-in-line controls for any placebo effect in the sham-treated patients.

Treated patients showed improvement in tender point scores, and self-rated scores of general pain level. In addition, there were significant improvement in quality of sleep, self-rated feelings of well-being and quality of life, plus gains in six stress-related psychological test measures. No placebo effect was found among the sham-treated controls.

A role of CES in affecting the brain's pain message mechanisms and/or neurohormonal control systems may be the probable mechanism. It is concluded that CES is as effective as the drug therapies in several trials, with no negative side effects, and deserves further consideration as an additional agent for the treatment of fibromyalgia.

Monday, May 26, 2008

Physiotherapy in seronegative spondylarthropathies.

Physiotherapy-induced prevention of ankylosis in terms of radiographic signs still remains uncertain. Physiotherapy is regarded as a major form of treatment for patients suffering from seronegative spondylarthropathies.
Proper systematic review on the efficacy of physiotherapy in this group (seronegative spondylarthropathies) is not available. Pain reduction by treatment with either heat or cold in peripheral and spinal joints is one of the major areas of clinical attention in physiotherapy. Decreased inflammation in controlled studies using thermotherapy, electrotherapy, magnetic fields, or laser-light has been reported. Exercise therapy has additive beneficial outcome. The efficacy of physiotherapy may be underestimated because of the lack of the means for comprehensive assessment of seronegative spondylarthropathies.

The efficacy of traction for back pain: a systematic review of randomized controlled trials.

Harte AA (2003) reviewed the efficacy of traction for patients with low back pain (LBP) with or without radiating pain from data sources of MEDLINE, CINAHL, AMED, and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) 1966 to December 2001.
They concluded evidence for the use of traction in LBP remains inconclusive because of the continued lack of methodologic rigor and the limited application of clinical parameters as used in clinical practice.

Sunday, May 25, 2008

Effects of electric stimulation to chronic stroke patient.

During my graduation days in 1993, prescribing splints to the hemiplegic foot and hand was a crime because it would provide stimulus to ball of Gt. toe and similar anatomic area of hand that ware thought to increase spasticity in the respective region. Similarly giving ES (electric stimulation) to spastic muscles for example extensors of wrist and finders or DF of ankle was a crime. After graduation I followed the same path it I my self decided to go against it and see if it helps I found marked changes in function of extensors of wrist and finders or DF of ankle with ES.

"crack" after lumbar manipulation

Side posture lumbar manipulation if successful is followed by a audible click. Form where that originates is a question? After one successful side posture lumbar manipulation, if another side posture lumbar manipulation is tried immediately then one may not hear another click. There is a refractory period between another click is heard with a successful side posture lumbar manipulation. What is the duration of that refractory period?
The answers are the audible "crack" heard during side posture lumbar manipulation is believed to originate from the zygapophyseal joints. And according to a recent study by Bereznick DE et al the average refractory period is 68.33 minutes.

Lumbosacral manipulation reduces dysmenorrheal symptoms!

Holtzman DA et al (2008) reported dysmenorrhea may be alleviated with treatment of motion segment restrictions of the lumbosacral spine with drop table technique (a specific chiropractic technique)
Their study spanned over a 4-week period. 16 females were screened for symptoms of primary dysmenorrhea and motion restrictions of the lumbosacral spine. Thirteen subjects were enrolled into the study. Bilateral and unilateral lumbosacral flexion and extension restrictions were treated using drop table manipulations 3 times during each of the 2 consecutive menstrual cycles.

Saturday, May 24, 2008

Physiotherapy in temporomandibular disorders.

There is a consensus on treatment strategies for temporomandibular disorders (TMDs) being reversible. Among therapies, physiotherapy is often chosen for the treatment of TMD pain and dysfunction because it is simple and non-invasive, it has a low cost as compared with other treatments, it allows an easy self-management approach. Recent reports and clinical experience, however, suggest that this approach can be promising, particularly if it is tailored towards the individual patient. The favourable cost benefit ratio over other treatment modalities seems to indicate that physiotherapy can be regarded as a first choice approach in selected TMD patients.

Rucksack type orthosis

A special orthosis named 'rucksack type orthosis' has been devised and is used for patients who have back pain due to anterior bending posture of the trunk. So-called rucksack type orthosis (RO), has been used to relieve low back pain and fatigue during prolonged standing and walking for the elderly with spinal deformities. However, little is known about the RO's kinematical effects.
Studies have found that Lumbar curvature and the trunk angle of inclination during standing improved significantly when the RO was used. Back extensor muscle activities (T9, L3, and L5) during standing and walking decreased significantly when the RO was used. There were no significant differences in the activities of the upper trapezius and vastus lateralis during standing and walking. Elderly with lumbar deformities might be able to stand and walk more efficiently with the RO. The RO could prove to be valuable in preservation therapy for the elderly with decreased lumbar lordosis or lumbar kyphosis.
Explore more on it.

SLAP lesion & associated other lesions with it

Superior labral anterior posterior (SLAP) tears are an abnormality of the superior labrum usually centered on the attachment of the long head of the biceps tendon. Tears are commonly caused by repetitive overhead motion or fall on an outstretched arm. SLAP lesions can lead to shoulder pain and instability. Clinical diagnosis is difficult thus imaging plays a key diagnostic role. The normal anatomic variability of the capsulolabral complex can make SLAP lesions a diagnostic challenge. Concurrent shoulder injuries are often present including rotator cuff tears, cystic changes or marrow edema in the humeral head, capsular laxity, Hill-Sachs or Bankart lesion.

Friday, May 23, 2008

When a wheeze is not asthma?

Vocal cord dysfunction (VCD) is an uncommon condition which often mimics asthma in presentation and severity. Vocal cord dysfunction, which is a dysfunction of larynx involves unintentional paradoxical adduction of the vocal cords during inspiration.
It can be evaluated by exercise testing in conjunction with pulmonary function testing in suspected vocal cord dysfunction. In these cases although normal pulmonology function tests are elicited with the patient at rest, exercise testing reveals blunting of the expiratory loop with attenuation of the inspiratory loop unique to VCD. The video laryngoscopy technique confirms the diagnosis.
Exercise testing is a rapid and noninvasive means of diagnosing vocal cord dysfunction in a small subset of patients, but video laryngoscopy, remains the gold standard of diagnosis of VCD.

Change in pain biomarkers after OMT

Underlying mechanisms explaining the effects of osteopathic manipulative treatment (OMT) are poorly defined. Change in various nociceptive (pain) biomarkers that have been suggested as important mediators in this process. A pilot study by Degenhardt BF et al on 20 subjects (10 with chronic low back pain, 10 controls without chronic LBP) if OMT influences levels of circulatory pain biomarkers reveals that, concentrations of several circulatory pain biomarkers were altered after OMT. The degree and duration of these changes were greater in subjects with chronic LBP than in control subjects without the disorder.

Pain biomarkers used by Degenhardt BF et al are:
1. beta-endorphin (betaE),
2. serotonin (5-hydroxytryptamine [5-HT]),
3. 5-hydroxyindoleacetic acid (5-HIAA),
4. anandamide (arachidonoylethanolamide [AEA]),
5. and N-palmitoylethanolamide (PEA).

Groin pain- It may not always be a insertional inflammation tears are also possible in Hip adductors.

Chronic groin pain in athletes frequently results from adductor insertional tendinopathy. Lohrer H et al reported acute tears of the proximal adductor tendons as a rare cause of groin pain that requires early repair. Diagnosis can been made clinically and was confirmed by ultrasound and MRI. Following early repair using suture anchors and functional postoperative rehabilitation, full sports ability was re-established five, six and seven months, respectively.


A short scale for the assessment of motor impairments and disabilities in Parkinson’s disease:

Clinical examination
1. Rest tremor
Assess each arm separately during 20 seconds; hands rest on thighs; if tremor is not evident at rest, try to keep the patient attentive—for example, by having them count backwards with eyes closed

1=small amplitude (1 cm) occurring spontaneously, or obtained only while keeping patient attentive (any amplitude)
2=moderate amplitude (1–4 cm), occurring spontaneously
3=large amplitude (>4 cm), occurring spontaneously.
2. Postural tremor
Check with arms outstretched, pronated and semipronated, and with index fingers of both hands almost touching each other (elbows flexed); assess each position during 20 seconds.

1=small amplitude (1 cm)
2=moderate amplitude (1–4 cm)
3=large amplitude (>4 cm).
3. Rapid alternating movements of hands
Rapid alternating pronation/supination movements of upper hand, each time slapping the palm of the horizontally held lower hand during 20 seconds; each hand separately

1=slow execution, or mild slowing and/or reduction in amplitude; may have occasional arrests
2=moderate slowing and/or reduction in amplitude or hesitations in initiating movements or frequent arrests in ongoing movements
3=can barely perform task.
4. Rigidity
Assess passive movements of elbow and wrist over full range, with the patient relaxed in sitting position; ignore cogwheeling; check each arm separately

1=mild rigidity over full range, no difficulty reaching end positions
2=moderate rigidity, some difficulties reaching end positions
3=severe rigidity, considerable difficulties reaching end positions.

5. Rise from chair
Patient is instructed to fold arms across chest; use straight back chair

1=slowly; does not need arms to get up
2=needs arms to get up (can get up without help)
3=unable to rise (without help).
6. Postural stability
Stand behind the patient and pull patient backwards, while patient is standing erect with eyes open and feet spaced slightly apart; patient is not prepared

0=normal, may take up to two steps to recover
1=takes three or more steps; recovers unaided
2=would fall if not caught
3=spontaneous tendency to fall or unable to stand unaided.
7. Gait
Assess gait pattern; use walking aid or offer assistance, if necessary

1=mild slowing and/or reduction of step height or length; does not shuffle
2=severe slowing, or shuffles, or has festination
3=unable to walk.
8. Speech

1=slight loss of expression, diction, and/or volume
2=slurred; not always intelligible
3=unintelligible always or most of the time.
9. Freezing during ‘‘on’’
Freezing is characterised by hesitation when trying to start walking or being ‘‘glued’’ to the ground while walking

1=start hesitation only, occasionally present
2=frequently present, may have freezing when walking
3=severe freezing when walking.
10. Swallowing

1=some difficulty or slow; does not choke; normal diet
2=sometimes chokes; may require soft food
3=chokes frequently; may require soft food or alternative method of food intake.

11. Speech

1=some difficulty; may sometimes be asked to repeat sentences
2=considerable difficulty; frequently asked to repeat sentences
3=unintelligible most of the time.
12. Feeding (cutting, filling cup, etc.)

1=some difficulty or slow; does not need assistance
2=considerable difficulty; may need some assistance
3=needs almost complete or complete assistance.

13. Dressing

1=some difficulty or slow; does not need assistance
2=considerable difficulty; may need some assistance—for instance, buttoning, getting arms into sleeves
3=needs almost complete or complete assistance.
14. Hygiene (washing, combing hair, shaving, brushing teeth, using toilet)

1=some difficulty or slow; does not need assistance
2=considerable difficulty; may need some assistance
3=needs almost complete or complete assistance.
15. Changing position (turning over in bed, getting up out of bed, getting up out of a chair, turning around when standing)

1=some difficulty or slow; does not need assistance with any change of position
2=considerable difficulty; may need assistance with one or more changes of position
3=needs almost complete or complete assistance with one or more changes of position.
16. Walking

1=some difficulty or slow; does not need assistance or walking aid
2=considerable difficulty; may need assistance or walking aid
3=unable to walk, or walks only with assistance and great effort.
17. Handwriting

1=some difficulty—for instance, slow, small letters; all words legible
2=considerable difficulty; not all words legible; may need to use block letters
3=majority of words are illegible.

18. Dyskinesias (presence)

1=present some of the time
2=present a considerable part of the time
3=present most or all of the time.
19. Dyskinesias (severity)

1=small amplitude
2=moderate amplitude
3=large amplitude.
20. Motor fluctuations (presence of ‘‘off’’ periods)
What proportion of the waking day is patient ‘‘off’’ on average?

1=some of the time
2=a considerable part of the time
3=most or all of the time.
21. Motor fluctuations (severity of ‘‘off’’ periods)

1=mild end-of-dose fluctuations
2=moderate end-of-dose fluctuations; unpredictable fluctuations may occur occasionally
3=severe end-of-dose fluctuations; unpredictable on–off oscillations occur frequently.

Wednesday, May 21, 2008

Hurray Gynecological physiotherapists- Treating fallopian tube occlusion with a manual pelvic physical therapy!

Wurn BF et al (2008) did a study to determine the efficacy of a non-invasive, manual soft-tissue physical therapy in opening completely blocked fallopian tubes in infertile women with confirmed bilateral occlusion and a history indicative of abdominopelvic adhesions.
There are a total of 28 infertile women (mean age = 35.2) with diagnosed complete tubal occlusion (proximal, midtubal, distal, or combination). The patients were being treated for various types of abdominopelvic pain and dysfunction (eg, intercourse and/or pelvic pain, menstrual cramps, endometriosis pain).
As physiotherapeutic intervention a 20-hour series of manual physical therapy treatments (mean duration = 1 week) designed to address pain and restricted soft tissue mobility due to adhesions and micro-adhesions was aministered. The therapists accessed some of the deeper structures (such as the fallopian tubes) indirectly by manipulating the peritoneum, uterine and ovarian ligaments, and neighboring structures.
Of the 28 patients, 17 demonstrated post-treatment unilateral or bilateral patency, as measured by hysterosalpingography or natural intrauterine pregnancy. The median interval between the last treatment date and patency confirmation was 1 month. Nine of the 17 (53%) patent patients reported a subsequent natural intrauterine pregnancy.

They concluded since truly occluded tubes are not known to reopen spontaneously, the results suggest this non-invasive therapy might be considered as an adjuvant to standard gynecological procedures in treating tubal occlusion.

Core stability exercises

Core strengthening, often called lumbar stabilization, also has been used as a therapeutic exercise treatment regimen for low back pain conditions. Sports medicine practitioners use core strengthening techniques to improve performance and prevent injury.
The so-called core is the group of trunk muscles that surround the spine and abdominal viscera. Abdominal, gluteal, hip girdle, paraspinal, and other muscles work in concert to provide spinal stability. Core stability is essential for proper load balance within the spine, pelvis, and kinetic chain. Core stability and its motor control have been shown to be imperative for initiation of functional limb movements, as needed in athletics.
Anatomy of the core, the progression of core strengthening, the available evidence for its theoretical construct, and its efficacy in musculoskeletal conditions must be explored before advocating treatment through this immensely popular technique.

Physiotherapists & prescription of NSAIDs

In 2008 IAP conf. Dr. B.S. Desikamani told the outlines of an extended scope practice. If you are an IAP member, then you might be remembering the demands of Bihar chapter of IAP on use of PAINKILLERS by a physiotherapists. There was a lot of hue and cry about the issue. The case was even in court whether physiotherapists should prescribe NDAIDS or not. There is no opinion or research available that leads us to conclude the demands of other physiotherapists of India. We present the following, a review of Australian physiotherapist’s use of NSAIDs. This article is composed from articles of Kumar S & Grimmer K.
In Australia, physiotherapy is a primary contact profession when practiced in private ambulatory settings. Primary contact means that physiotherapists take responsibility for diagnosis, decisions on interventions, appropriate ongoing management, and costs related to benefits. For most physiotherapists, the most common clinical presentations relate to symptoms from musculoskeletal conditions. There is considerable research evidence for many "physiotherapy" techniques in the management of musculoskeletal symptoms.
Physiotherapists do not have the training or the legislative powers to prescribe NSAIDs. As part of these management strategies, some physiotherapists may use nonsteroidal antiinflammatory drugs (NSAIDs) as an adjunct to treatment on non-prescription dispensing mode. A written survey instrument was developed and administered to 750 physiotherapists in South Australia, Tasmania and the Australian Capital Territory (50% of the registered physiotherapists). Responses were received from 285 physiotherapists. The survey identified opportunities for patient misuse and misadventures with NSAIDs in conjunction with physiotherapy management. Differences in physiotherapist understanding of the dosage and actions of oral and topic administrations of NSAIDs were highlighted, as were the moral and ethical responsibilities of physiotherapists to patients considering taking NSAIDs. The study identified the need for regular professional updates on quality use of NSAIDs.
However, physioterapists can recommend that patients seek advice about appropriate adjunct NSAIDs from pharmacists and/or medical practitioners. The roles and responsibilities of key health providers in this area appear to be well defined in terms of minimizing medication misadventure and optimizing patient health outcomes. This survey of physiotherapist behaviors and practices, however, identified a number of "gray" areas that could confront unwary physiotherapists, or pose dilemmas for those without the support of medical/pharmacist colleagues. These gray areas relate to the adjunct use of topical NSAIDs in physiotherapy management and making recommendations for the use of oral NSAIDs.
This paper reports on qualitative data that highlights the dilemmas confronting physiotherapists.
Now folks:
1. Does a physiotherapist in a graduation syllabus cover enough pharmacology to co-prescribe some medications like NSAIDS in musculoskeletal practice or inhaler administration during chest physiotherapy of asthma?
2. Do you know how Dentists ware resisted 30-40 years back when they started prescribing medications or even writing doctor in front of their mane? Now compare today’s scenario.
3. Have you ever compared how Podiatry an allied health science is growing in this aspect?
The need is immense of co-prescription of adjuvant medications in physiotherapy practice. To make an essential first hand practice it is at most necessary. For that I think a modification is required in syllabuses we cover. If that is not possible ESP modules must be available to fulfill the lacuna that a first hand physiotherapist feels while practicing the profession. In my opinion a physiotherapist bias exists around the world; we should resolve it come what may.

Tuesday, May 20, 2008

Dynamic MRI evaluation of lumbar spine- Manual therapy implications

Flexion and extension movements or positions have been advocated in the treatment of various forms of low back dysfunction due to the potential pain relieving effects attributed to displacements of the intervertebral disc (IVD). Kinetic MRI is a novel dynamic magnetic resonance imaging (MRI) system used to study lumbar disc herniations. Many times a static MRI may not reveal disc disorder yet functional MRI may reveal pathology.
Edmondston SJ (manual therapy, 2000) did MRI to evaluate the influence of sagittal plane positions on lumbar IVD height and nucleus displacement in a small asymptomatic population.T2-weighted sagittal plane images from L1 to S1 were obtained from 10 subjects (mean age: 30+/-5 years) positioned supine in lumbar flexion, followed by extension. Changes in disc height and localization of nucleus position (determined by peak MRI signal intensity) between the two positions were calculated. He found:
1. Despite the anterior displacement of the nucleus in extension observed in the pooled analysis, 30% of discs did not follow this trend. Nucleus degeneration was observed in at least one disc in nine subjects and in 26% of all discs examined.
2. Lumbar spine position was found to be associated with small measured changes in anterior disc height and nucleus position, however, this response was variable within and between individuals. The theoretical concept of a stereotypical effect of spinal position on the lumbar IVD is challenged by these initial data.
In another study Zou J et al’s (spine, 2008) tried to determine if adding flexion and extension MRI studies to the traditional neutral views would be beneficial in the diagnosis of lumbar disc herniations. They found a significant increase in the degree of lumbar disc herniation was found by examining flexion and extension views when compared with neutral views alone. Dynamic MRI views provide valuable added information, especially in situations where symptomatic radiculopathy is present without any abnormalities demonstrated on conventional MRI.
In the lieu of above said finding Edmondston’s recommendation sounds apt. His recommendation for the manual therapists is as follows: since the health of the disc is often unknown in clinical practice, manual therapy treatment for lumbar spine pain should be based on the symptomatic response to movement and position rather than biomechanical theory.

The effect of disc degeneration and facet joint osteoarthritis on the segmental flexibility of the lumbar spine.

A biomechanical and imaging study by Fujiwara A et al (spine, 2005) of human cadaveric spinal motion segments reveal that:
1. Axial rotational motion was most affected by disc degeneration, and the effects of disc degeneration on the motion were similar between genders.
2. Facet joint osteoarthritis also affected segmental motion, and the influence differed for male and female spines. With cartilage degeneration of the facet joints, the axial rotational motion increased, whereas the lateral bending and flexion motion decreased in female segments.

Monday, May 19, 2008

Spinal mobilization & manipulation- which is the Order of the day?

Bronfort G et al studied the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. Bronfort G et al suggested that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. Assendelft WJ et al studied the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. Assendelft WJ et al found there is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Does Cryotherapy Improve Outcomes With Soft Tissue Injury?

In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully explained. Additionally, the low methodologic quality of the available evidence is of concern.
Then the question arises what is the clinical evidence base for cryotherapy use? To this question Hubbard TJ et al in 2004 found cryotherapy is effective in decreasing pain. But they suggested many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.

Does McKenzie therapy improve outcomes for back pain?

Busanich BM et al searched databases like DARE, CINAHL, CENTRAL, EMBASE, MEDLINE and PEDro for efficiency of McKenzie therapy for spinal pain. They collected data from five lumbar trials. The pooled studies ware short term (less than three months) and from three at intermediate (3-12 months) follow-up.
McKenzie therapy results in a decrease in short-term (<3>12 months) outcomes or outcomes other than pain and disability (eg, quality of life).
They found at short term follow-up the McKenzie therapy provided a mean 8.6 point greater pain reduction on a 0 to 100 point scale and a 5.4 point greater reduction in disability on a 0 to 100 point scale than comparison. At intermediate follow-up, relative risk of work absence was 0.81 favoring McKenzie, however the comparison treatments provided a 1.2 point greater disability reduction. In the one cervical trial, McKenzie therapy provided similar benefits to an exercise program. The results of this review show that for low back pain patients McKenzie therapy does result in a greater decrease in pain and disability in the short term than other standard therapies.
Making a firm conclusion on low back pain treatment effectiveness is difficult because there are insufficient data on long term effects on outcomes other than pain and disability, and no trial has yet compared McKenzie to placebo or no treatment. To date, no authors have compared McKenzie therapy with placebo or no treatment.
There are also insufficient data available on neck pain patients.

Sunday, May 18, 2008

Recommendation of arrangement for management of sudden cardiac arrest in athletes:

You might have remembered a couple of year back in a foot ball match a DEMPO (GOA football club) striker lost his life because of sudden cardiac arrest. It followed up with death of another brazilian dying from the same issue this time perhaps from Mohan Bagan. Hence for sports therapists I am urging to go through the Inter-Association Task Force (sponsored by the National Athletic Trainers' Association) consensus recommendations on emergency preparedness and management of sudden cardiac arrest in athletes. Following are the points:
1. Comprehensive emergency planning is needed for high school and college athletic programs to ensure an efficient and structured response to sudden cardiac arrest.
2. Essential elements of an emergency action plan include establishment of an effective communication system, training of anticipated responders in cardiopulmonary resuscitation and automated external defibrillators use, access to an automated external defibrillators for early defibrillation, acquisition of necessary emergency equipment, coordination and integration of on-site responder and automated external defibrillators programs with the local emergency medical services system, and practice and review of the response plan.
3. Prompt recognition of sudden cardiac arrest, early activation of the emergency medical services system, the presence of a trained rescuer to initiate cardiopulmonary resuscitation, and access to early defibrillation are critical in the management of sudden cardiac arrest.
4. In any collapsed and unresponsive athlete, sudden cardiac arrest should be suspected and automated external defibrillators applied as soon as possible for rhythm analysis and defibrillation if indicated.

Fascia able to contract in a smooth muscle-like manner! (Medical hypothesis)

Dense connective tissue sheets, commonly known as fascia, play an important role as force transmitters in human posture and movement regulation. Fascia is usually seen as having a passive role, transmitting mechanical tension which is generated by muscle activity or external forces.
Contractile cells in fascia has been discovered which suggest that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics. In vitro studies with fascia which have reported biomechanical demonstration of an autonomous contraction of the human lumbar fascia.
Active fascial contractility could have interesting implications for the understanding of musculoskeletal pathologies with an increased or decreased myofascial tonus. It may also offer new insights and a deeper understanding of treatments directed at fascia, such as manual myofascial release therapies or acupuncture.

Fascia able to contract in a smooth muscle-like manner! (Medical hypothesis)

Dense connective tissue sheets, commonly known as fascia, play an important role as force transmitters in human posture and movement regulation. Fascia is usually seen as having a passive role, transmitting mechanical tension which is generated by muscle activity or external forces.
Contractile cells in fascia has been discovered which suggest that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics. In vitro studies with fascia which have reported biomechanical demonstration of an autonomous contraction of the human lumbar fascia.
Active fascial contractility could have interesting implications for the understanding of musculoskeletal pathologies with an increased or decreased myofascial tonus. It may also offer new insights and a deeper understanding of treatments directed at fascia, such as manual myofascial release therapies or acupuncture.

Modalities acting on myofascial pain and trigger-point sensitivity.

Ischemic compression leads tissue ischemia under treatment during the period of application of force. Following the release of compressive force there is gush of local circulation. Ischemic compression therapy provides alternative treatments using either low pressure (pain threshold) and a long duration (90s) or high pressure (the average of pain threshold and pain tolerance) and short duration (30s) for immediate pain relief and myofascial trigger point sensitivity suppression.

According to Hou CR et al (2002) combinations such as hot pack plus active ROM and stretch with spray, hot pack plus active ROM and stretch with spray as well as TENS, and hot pack plus active ROM and interferential current as well as myofascial release technique, are most effective for easing myofascial trigger point pain and increasing ROM.

spinal cord injuries & nerve regeneration

The proliferation and differentiation of neural progenitors continue throughout the lifetime, instead of cell division stopping at the postnatal period. In the spinal cord, these cells differentiate into different kinds of glial cells. Based on his current research in spinal cord injury (SCI), the author Qun L reported that the implantation of functional electrical stimulation (FES) in the motor cortex or the peripheral nerve increases cell birth and differentiation of endogenous neural stem cells in the spinal cord. FES promotes remyelination and neural repair.

Saturday, May 17, 2008

PAL- physical activity level

Physical activity level is the ratio between total energy expenditure (TEE) divided by basal metabolic rate or resting metabolic rate (RMR) of the individual (PAL=TEE/RMR). In the general population, physical activity level ranges between 1.2 and 2.2-2.5. There is no sex difference in the level of physical activity. Higher PAL values can be maintained by training and supplementation of the diet with energy-dense, carbohydrate-rich formulas.

Exercise is medicine.

250,000 deaths each year attributed to a sedentary lifestyle, it is incumbent upon physicians to include a discussion of regular physical activity with their patients, at every visit. But physicians are still reluctant, however, to prescribe exercise for their patients. Although many cite lack of time or poor reimbursement for counseling services, the majority of primary care physicians are simply unsure of how to effectively begin discussing exercise with their patients.

American college of sports medicine have long been campaigning “exercise is medicine” author Pearce PZ (2008) in a journal of sports medicine wrote about the medical benefits of regular physical activity, including weight loss and reduction in the risk of heart disease and certain cancers, are well known. He reviewed the medical benefits of exercise, basic principles of physiology, and then the components of an exercise prescription.
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Friday, May 16, 2008

importance of lumbar coupling biomechanics in physiotherapy practice.

Knowledge of lumbar coupling biomechanics is foundational in many manual therapy disciplines. 3-D studies of lumbar coupling indicate that coupling direction may not be predictable. The majority of physiotherapists indicated that lumbar coupling biomechanics were important or very important, frequently used during treatment, and necessary for validation of manual therapy. Cook C et al investigated physiotherapists' perception of importance of lumbar coupling for validation of manual therapy, necessity in treatment, and perceived direction of lumbar coupling biomechanics.
They found strong pre-conceptual perceptions of coupling necessity, and the importance placed upon lumbar coupling for treatment could lead to disparities among physiotherapists in lumbar manual therapy assessment and treatment.

use passive intervertebral motion (PIVM) assessment

Manual therapists commonly use passive intervertebral motion (PIVM) assessment within physical examination. In a survey consisting of Dutch manual therapists revel that; Dutch manual therapists most frequently apply passive segmental motion assessment to the cervical region and they prefer three-dimensionally coupled motions.
1. They consider end-feel or, to a lesser extent, provocation of patient's pain as decisive for diagnostic conclusions.
2. They believe that these spinal motion tests are important for treatment decisions and are confident in their conclusions drawn from it. These perceptions were largely stable across subgroups of therapists with different gender, age, experience, and educational background.

Thursday, May 15, 2008

Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care!

Oldmeadow LB et al (2007) investigated the impact, quality and acceptability of a musculoskeletal screening clinic provided by physiotherapists for patients referred to the outpatient orthopaedic department at a major metropolitan hospital. 52 patients with non-urgent musculoskeletal conditions at the Northern Hospital (a tertiary teaching hospital in outer Melbourne) were assessed by one of two physiotherapists with postgraduate qualifications and subsequently by an orthopaedic surgeon between 29 November 2005 and 6 June 2006.

They concluded nearly two-thirds of patients with non-urgent musculoskeletal conditions referred by their GPs to one public outpatient orthopaedic department did not need to see a surgeon at the time of referral, and were appropriately assessed and managed by experienced, qualified physiotherapists.

A biomechanical study of artificial cervical discs using computer simulation.

Disc arthroplasty is an alternative approach to cervical fusion surgery for restoring and maintaining motion at a diseased spinal segment. Different types of cervical disc arthroplasty devices exist and vary based on their placement and degrees of motion offered. Ahn HS et al, 2008 (journal: spine) studied the biomechanics of different design features of cervical disc arthroplasty devices. They concluded simulation model showed the impact simple design changes may have on cervical disc dynamics. The predicted facet loads calculated from computer model have to be validated in the experimental study.

The quadratus lumborum- it’s effiency

The fascicular anatomy of quadratus lumborum vary considerably, between sides and between subjects, with respect to the number of fascicles, their prevalence, and their sizes. Approximately half of the fascicles act on the twelfth rib, and the rest act on the lumbar spine.
According to a study by Phillips S et al in 2008 magnitudes of the compression forces exerted by quadratus lumborum on the lumbar spine, the extensor moment, and the lateral bending moment, were each no greater than 10 % of those exerted by erector spinae and multifidus. Their data indicated that quadratus lumborum has no more than a modest action on the lumbar spine, in quantitative terms. Its actual role in spinal biomechanics has still to be determined.

Wednesday, May 14, 2008

Orthopedic screening service in primary care by Physiotherapists in UK.

This following article is an review of Hattam P et al (1999).Historically, provision of orthopaedic services has been hospital based with GPs referring patients for specialist opinion. Growing demands on the service have led to new initiatives to reduce waiting times. One such initiative has been the introduction of usually physiotherapists, working with an extended scope of practice who see patients after referral to secondary care and determine the patients' ongoing management. Studies to date have examined the effect of an orthopaedic assistant working alongside a consultant in the hospital environment. This study describes the impact on the management of the orthopaedic caseload in one general practice resulting from "screening" prior to referral to secondary care by a physiotherapist with an extended scope of practice. It demonstrates the successful management of the majority of patients within primary care.

Accident and emergency department: the effect of the introducing a ESP physiotherapy practitioner.

Jibuike OO et al (2003) assessed the effect of the introduction of a physiotherapist with an extended scope of practice in the management of acute soft tissue knee injuries in an accident and emergency (A&E) department.
An experienced physiotherapist was appointed to run the Acute Knee Screening Service after additional training. Local guidelines and protocols were developed in conjunction with trauma knee surgeons, radiologists, physiotherapists, and A&E doctors.
The initial diagnosis of patients with acute knee injuries referred to the service showed meniscal injuries (38%), cruciate ligament injuries (18%), fractures (2%), patellofemoral joint injuries (10%), and others (32%).
95% of patients referred to Acute Knee Screening Service were seen within one week. Medical time was saved in both A&E and trauma clinic. 59% of patients were treated and discharged from the service without further medical review. 39% were referred to trauma clinic and of these 44% had MRI scans performed as requested by the physiotherapist. 88% of these scans showed significant abnormality: (nine, anterior cruciate ligament tears, one, posterior cruciate ligament tears, and nine meniscal tears).
They concluded a physiotherapy practitioner working with an extended role is a valuable addition to an A&E department. The AKSS improves the quality of care of acute knee injuries, saves medical time, and fosters cooperation across services within the NHS.
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Management of pediatric neuromuscular scoliosis

There are two varieties of neuromuscular scoliosis one spastic the other flaccid.prior to surgical management, conservative management is proposed for patients with neuromuscular scoliosis in many clinical situations. Functional benefits of conservative management of neuromuscular scoliosis comprise stable sitting, easier use of upper limbs, discharge of the abdomen from the collapsing trunk, increased diaphragm excursion, and, not always, prevention of curve progression.
The main aim of in spastic disorders is to maintain the symmetry around the hip joints. Bracing is technically difficult and often is not tolerated well by cerebral palsy children. In patients with flaccid paresis, the fitting and the use of brace is easier than in spastic patients. The flexibility of the spinal curvature is more important.
Continuously improving techniques of conservative management, comprising bracing and physiotherapy, together with correctly timed surgery incorporated in the process of rehabilitation, provide the optimal care for patients.

Tuesday, May 13, 2008

Experimental Physiotherapy- passive physiological movements producing analgesia

The analgesic effects of passive movements on deep-tissue pain have not been sufficiently explored in human studies.
Nielsen MM et al (2008) examined the effect of passive physiological movements (PPMs) on deep-tissue pain sensitivity.

Seventeen healthy subjects were included in this randomised crossover study. In one session an electrically driven bicycle performed 30min PPM of the knee joint. Another session without PPM served as control. The effect of PPM on experimental muscle pain was assessed. Muscle pain was induced by i.m. injection of hypertonic saline into the tibialis anterior muscle and the pain intensity was scored on an electronic visual analogue scale (VAS). The pressure pain sensitivity was assessed by recording of pressure pain thresholds (PPTs). McGill Pain Questionnaire (MPQ) was used to describe the quality of the induced pain. Compared with the control session PPM demonstrated: (1) a reduction of the experimental muscle pain intensity (VAS area and peak) and duration (17-31%, P<0.03), (2) lower MPQ score and a change in quality profile of experimental muscle pain (25%, P<0.01) and (3) an increased PPT (17%, P<0.0005).

The present study demonstrated that PPM produced an immediate analgesic effect on deep-tissue pain indicating a possible involvement of neural inhibitory mechanisms.

Complete Decongestive Therapy

A protocol of complete decongestive therapy (CDT) involves manual lymphatic drainage (MLD), compression garments, skin care, and remedial exercises. Karadibak D et (2008) evaluated the effects of kinesiophobia, quality of life, and home exercise programs on women with upper extremity lymphedema (published in journal of surgical Onchology, 2008).
The women were taken to a 12-week therapy program once per day, 3 days per week. A home program, consisting of compression bandage exercises, skin care and walking was recommended. Absolute volume and percentage of volume of the lymphedema were compared before and after treatment. The kinesiophobia, quality of life, and home-based program were assessed before and after physiotherapy.
In upper extremity lymphedema, the use of complex physiotherapy programs (CDP) can decrease edema and fear of activity, and increase the quality of life.

Physiotherapy does not helps much in distal radial fractures in adults

Hey friends following is a excerpt of a review of physiotherapy treatment of fracture around wrist joint. the review claims that physiotherapy is not very successful in rehabilitating such cases. Read it & give opinion.
Rehabilitation as part of treatment for adults with a broken wrist. Particularly in older women, a broken wrist (comprising a fracture at the lower end of one of the two forearm bones) can result from a fall onto an outstretched hand. Treatment usually includes putting the bone fragments back in place, if badly displaced, and immobilising the wrist in a plaster cast. Exercises and other physical interventions are used to help restore function and speed up recovery. HHG Handoll et al (2006) reviewed 15 randomised controlled trials including 13 comparisons in a total of 746 mainly female and older people. Initial treatment was plaster cast immobilisation in all but 27 participants who had surgery. Some trials were well conducted but others were methodologically compromised and none provided conclusive evidence. There was weak evidence that rehabilitation (hand therapy or task-orientated therapy) started during immobilisation improved hand function after plaster cast removal but not in the longer term (two trials). There was weak evidence that outcome after supervised exercises started during immobilisation did not differ from outcome after unsupervised exercises (one trial). The rest of the interventions under test were started post-immobilisation, mainly after removal of the plaster cast. There was weak evidence indicating that formal rehabilitation therapy (four trials), passive mobilisation of the wrist joint complex by the therapist while the patient remained inactive (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion of the injured forearm (one trial) did not improve outcome. There was weak evidence of a short-term benefit of using a continuous passive motion device (after external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial). They concluded that there was not enough evidence available to determine the best form of rehabilitation for people with wrist fractures.

Monday, May 12, 2008

static stretching related force output decrements!

When I did my PG thesis on “acute effect of static stretching on total CPK & margarita Kalamen test in female athletes” my primary aim was to decide whether static stretching related to reduction of force out put was due to physiological inhibition of muscle or due to reduced biochemical support (licking CPK enzyme) to working muscle that affects the immediate energy release. Holt BW et al (2008) compared the impact of different types of warm-up on countermovement vertical jump (VJ) performance. Sixty-four male Division I collegiate football players completed a pretest for VJ height. The participants were then randomly assigned to a warm-up only condition, a warm-up plus static stretching condition, a warm-up plus dynamic stretching condition, or a warm-up plus dynamic flexibility condition. VJ performance was tested immediately after the completion of the warm-up. The results showed that there was a significant difference (P < .05) in VJ performance between the warm-up groups. Posttest jump performance improved in all groups; however, the mean for the static stretching group was significantly lower than the means for the other 3 groups. The static stretching negated the benefits gained from a general warm-up when performed immediately before a VJ test.
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Robot-aided neurorehabilitation

Colombo R et al (2005) reported robot-aided neurorehabilitation may improve the motor outcome and disability of chronic post-stroke patients. In 1991, a novel robot, MIT-MANUS, was introduced to study the potential that robots might assist in and quantify the neuro-rehabilitation of motor function. MIT-MANUS proved an excellent tool for shoulder and elbow rehabilitation in stroke patients, showing in clinical trials a reduction of impairment in movements confined to the exercised joints. This successful proof of principle as to additional targeted and intensive movement treatment prompted a test of robot training examining other limb segments. Relationship between robot measured parameters and the clinical assessment scales show a moderate and significant correlation. So robot measured parameters may provide useful information about the course of treatment and its effectiveness at discharge.
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Osteopathic manipulative medicine

According to Gunnar Brolinson P et al (2008) Osteopathic medicine is among the fastest-growing sectors of health care. By the year 2020, it is projected that approximately 100,000 doctors of osteopathic medicine will be practicing in the United States. In USA More than 50% of new osteopathic physicians receive their residency training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) rather than in programs approved by the American Osteopathic Association (AOA).
Manipulation, a component of osteopathic medicine, is often a subject of debate, especially in today's age of evidence-based medicine. Questions are raised: What is the purpose of osteopathic manipulation? Who would benefit from it? What harm can come from the practice?

Allee BA et al, 2006 examined the implications of this training pattern for trends in the practice of osteopathic manipulative treatment (OMT), the authors’ surveyed attitudes toward OMT with questionnaires targeted to osteopathic and allopathic residents in family medicine residency programs. Following is the result:
Fewer osteopathic residents in ACGME-accredited family medicine programs (39.5%) reported frequent use of OMT than did osteopathic residents in AOA-approved family medicine programs (67.9%). This difference appears to result more from experiences during residency training than from expectations formed before residency training. Ninety percent of the allopathic residents who responded to the survey said they believed that OMT is effective for treating somatic dysfunction. Moreover, 70.9% of allopathic physicians indicated they had at least some interest in learning OMT. To the authors' knowledge, this study was the first to quantify a change in attitude of allopathic residents toward a more positive view of osteopathic medicine.
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Sunday, May 11, 2008

Internal Derangement of Shoulder!

Labral tears do occur more in atheletic population & to a lesser degree in normal population.
how to diagnose it?
any quick test for it?
option is only surgery or is/are there any tested rehabilitation protocol (s)?

Patency VS. Perfusion in vertebral artery examination before CMT

The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the maneuver has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by manual practitioners to rule out the risk of possible injury to the vertebral artery. To date, these testing procedures are taught to students and carried out in daily clinical practice, despite the considerable controversy that exists about their validity.
Miley ML et al in 2008 tried to find out does cervical manipulative therapy (CMT) cause vertebral arterial dissection (VAD) and subsequent ischemic stroke? What is the best estimate of the incidence of CMT associated with VAD and ischemic stroke? They concluded there is weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy.
Mann T et al (2001) reviewed the mechanisms by which complications occur, particularly when the applied force is trivial or there is no injury to the vertebral arteries, and the factors that increase risk of complications. In addition, implications are drawn for use of the recently revised Australian Physiotherapy Association (APA) guidelines. In the absence of vertebral artery rupture, complications are proposed to arise from vasospasm, haemostasis, endothelial injury or turbulent flow. These mechanisms have a sound scientific basis but have yet to be demonstrated as specifically causing vertebrobasilar complications. The most important risk factors for vertebrobasilar complications appear to be prior trauma to the vertebral arteries and symptoms of vertebrobasilar ischaemia from previous manipulation. There is weak evidence that hypoplasia of the vertebral arteries also increases the risk of complications. Neither general vascular factors nor pre-existing degenerative conditions of the cervical spine increase risk of vertebrobasilar complications. The procedures described in the APA guidelines test adequacy of total cerebral perfusion during cervical movements rather than patency of the vertebral arteries or their susceptibility to injury. The guidelines may therefore indicate potential for surviving a complication from manipulation. They may also identify patients at risk of complications from minor trauma. It is recommended that the procedures described in the APA guidelines be applied prior to every manipulation, and that manipulation be avoided in the presence of any signs of vertebrobasilar insufficiency. However a manual therapist must look in to the following recommendations by Thiel H et al.
In a review Thiel H et al did following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.

Neuroliguisticprogramming (NLP)

short form of neuroliguistic programming is NLP. some may call it hypnosis but that is not exactly correct. Accepted as a alternative therapy NLP & mental imegery are slowly getting acceptance of mainstream clinicians. for example many dental surgeons are employing this technique for minor surgical procedures rather than giving anesthesia. physios we can induct this in to our pain management program. you can get information form folloing links:

Saturday, May 10, 2008

Cyriax's lumbar assessment

Cyriax, the genius who gave birth to many innovation in understanding Orthopaedic diagnosis does only 4 movement testings in lumbar spine & do no separately assess active and passive movements.
check out folks....

Endurance exercises does not modify body composition!

In a discussion in New York Magazine had me reeling my head. The author, Gary Taubes, claims that exercise doesn’t work. Fat people stay fat, and lean people stay lean. All exercise does is burn a few calories, then boost your appetite and make you want to eat more. He cited a number of studies showing that regular exercise does yield some benefit, but doesn’t really help you to lose weight in the long term. Taubes focused on endurance exercise like durational running, biking, and jogging. Despite doing these aerobic exercises rates of obesity and diabetes have skyrocketed, and people still can’t keep the weight off. According to him this type of exercise also puts your body in distress mode. It releases the stress hormone cortisol, which actually boosts triglyceride blood levels and cholesterol oxidation – both things that can clog your arteries and cause heart attacks. Cortisol also lowers serum testosterone and growth hormone levels, which can lead to depression, decreased muscle mass, and clouded thinking. Is there’s a big problem with his analysis?
Have your opinion folks…..

Physical activity for cancer!

According to Thune et al people who are expending 4.5 MET and above daily have less chances of all varieties of cancer. physios who prescribe exercise & recommend activity or at least have the chance of motivating people at community settings must do a little bit of search & formulate daily physical activity protocols for individual & the community.

Friday, May 9, 2008

Technique administration in manual therapy

GD Maitland said do not become preoccupied with technique of manual therapy administration. Friends, diagnose the mechanical dysfunction. find out the positional diagnosis & have a static mental image of the fault & try to have a dynamic mental image (when moving how the dysfunctional part is moving). try to recognise the altered forces. introduce the treatment forces accordingly. you will see as you are gaining experience you your self is able to develop techniques which are different from peers and are as effective as the peers.

when to start neural glides?

friends to my experience if neural glides are started at in appropriate stage of treatment protocol may worsen the symptoms.
according to me it must always start at a point PAIVM with strongest grade becomes negative.

Have you tried transverse glides?

friends i have applied B/L transverse glide on senile kyphosis related back ache with great result. try it on patients complaining of non radiating back ache (severe to mild, any type) with senile kyphosis. ask me how to apply in detail at:

Have you tried vacuum cupping ?

vacuum cupping is one very effective method for releasing adhesion. if used properly then it can release adhesion between:
skin & bone
bone & muscle
muscle & skin
muscle & fascia
so try it physios!!!

Thursday, May 8, 2008

Change a term in anaerobic training!

Lactate threshhold is better known as Lactate inflation point. It is the rate of exercise beyond which there is build up of blood lactate.

Training in Sports Consists Of....

sports training consists of:
1. supplemental Exercises for supplemental training
2. Compensation exercises for muscle dysbalance
3. Regeneration exercises for speeding up recovery from exercises sessions
4. activating exercises for increasing body activation
5. exercises for body deactivation
6. exercises for worm up & increasing
7. exercises for worm down

obesity news

this news is for those physios wishing to work in obesity industry
* Ghrelin a intestinal hormone, makes food more appealing. folks; this hormone can make any body fat by increasing the carving & food intake.
** A recent report says 10% of all adipocytes die.

Wednesday, May 7, 2008

will anything change for indian physios after council formation?

can a council in physiotherapy bring on the following:
professional autonomy?
change in professional status?
accessibility to ESP (extended scope practices)?

no research!

hey guys,
there is very scanty or no research on "impact of breathing exercises on lymphatic circulation". direct evidence based (lymphoscintigraphy) researches are not done yet! physio researchers try to explore different types of PRANAYAMA'S effects on lymphatic circulation.

burn out in physios!

before developing a aptitude or a liking for a branch it is difficult to work in it. PT in neurological conditions may be boring to some. but those who have developed a aptitude for it; it is easy. before you start to show symptoms of burn out start liking the subject you work or at least you choose a subject that you like.

shfting sciatica

have you ever heard or clinically checked a patient with shifting of a sciatica pain from one limb to other. do you know what it means?

Tuesday, May 6, 2008

walk to health with pedometers

pedometers are unique gadgets for health maintenance & augmentation. the microprocessor based sensor senses each step a walker takes. so they tell you about:
1. how many steps you have taken?
2. how many calories you have burned?
3. how many kilometers you have covered? and many more...

doe to reproducibility of it's results they are used in research.
to purchase it in India call 0674-2436217 (9 am-12 pm)

physiotherapy in disc disorders

many medical practitioners do not have the idea that spinal exercise can changes disc dynamics. what radiological evidences are there? ask for a case study at:

physiotherapy jobs in pujab

there are openings of physiotherapy jobs in LOVELY PROFESSIONAL UNIVERSITY
visit following site:
apply on line:

physios do you know? there are 2 vareities if DPT (Doctor of physical therapy)

there are two varieties of DPT(Doctor of physical therapy) programs.
the first is a entry level DPT: by entering in to the program you graduate into a Doctor of physical therapy rather a bachelor of physical therapy. this initiate is taken by APTA (USA). DPT course found in all most all universities imparting physical therapy programs in USA. Transitional DPT programs are conducted by various universities for those who are holding bachelors degree in physical therapy. by a survey by 2011 all most all the physios of USA will have a DPT degree.
try following links:

second is a post graduate entry level DPT: this program is an alternative & comparable program to PHD. PHD is completely a research oriented program but post graduate DPT consists of approximately 75% research & 25% course work. this program can be compared to super specialization of physiotherapy. many Australian universities are providing the program
try following links:

Sunday, May 4, 2008

physio wanting to specialise in MBA, try MBA (DA)

physiotherapists wanting to specialize in MBA may try it in DA- disability administration i.e. MBA (DA). the course is only one of it's kind, presently imparted only at NIMH, Secunderabad
for more information visit:
www.nimhindia. org

manual therapy leaders of india

prof. P P Mohanty (HOD Physiotherapy, SV NIRTAR). Prof. Mohanty mostly delivers his CMEs on manual therapy in NIRTAR. To know his CME programs visit the SV NIRTAR site:
E mail:
Prof U S Mohanty, organization: Manual Therapy Federation of India (MTFI)
To know his CME programs visit:
E mail:
Dr. Deepak Kumar, organisation: Capri Institute of manual therapy
To know his CME programs visit:

carriers in clinical research for physiotherapists

medvarsity (APOLLO HOSPITAL) have launched a clinical research course.
find more on it in the following address:
e mail:

list of sites of best PG education in physiotherapy in india

SV NIRTAR is one of the most esteemed organisations in INDIA to provide PG education in the field of physiotherapy in India. the state of art organization provides all that you dream of while doing PG. there are 2 areas of specialization provided by the institute. students have great chance of employment in Private as well as government sector. for further information click here: or E

Saturday, May 3, 2008

is physiotherapy community neglected in policy formulations and community activity prescriptions for obesity? what else is required to convince the concerned authorities that the physiotherapists are therapeutic exercise specialists?

obesity & role of physiotherapist

should there be a role of physiotherapist in non-pharmacological obesity rehabilitation. is todays physiothrapist is equipped enough for safe physical activity evaluation & pescription in obesity?

what is the simplest test to differentiate anterior innominate & posterir innominate?

can lengthening to shortening or shorting to lengthenig be used as a quick test for anterior or posterior innominates? how much reliable it would be?

is spinal traction is losing conscent of physiotherapists?

many physiotherapists are now arguing that spinal traction is a redundant modality specially after bio mechanical understanding of spinal mechanisms. they are preferring manual therapy as a major modality in spinal mechanical abnormalities.