Monday, June 30, 2008

Cervical SNAGs: a biomechanical analysis.

Hearn A et al (2002) reported clinical efficacy of cervical SNAGs (applied ipsilateral to the side of pain when treating painfully restricted cervical rotation) cannot be explained purely on the basis of the resultant biomechanical effects in the cervical spine.

Thursday, June 26, 2008

Movement testings are more reliable than other diagnostic methods in cervicogenic headache (CGH) but validity remains a question.

According to Haldeman S et al (2001) the notion that headaches may originate from disorders of the cervical spine and can be relieved by treatments directed at the neck is gaining recognition among headache clinicians.. There remains considerable controversy and confusion on all matters pertaining to the topic of CGH. However, the amount of interest in the topic is growing, and it is anticipated that further research will help to clarify the theory, diagnosis, and treatment options for patients with CGH. According to Frese A et al (2008) Upper cervical pain is frequent in different primary headaches and not sufficient evidence for cervicogenic headache (CGH). Biological markers should help to differentiate CGH from other headache disorders.
In most cases, imaging techniques of the cervical spine are not helpful for the diagnosis of CGH.
Symptoms and signs of neck involvement, such as a mechanical precipitation of attacks, a restriction in range of motion of the cervical spine, and the existence of ipsilateral neck, shoulder, or arm pain, seem to be reasonably valid for the diagnosis of CGH, but its reliability and validity should be confirmed in larger studies.
Positive diagnostic blockades of cervical structures or its nerve supply are not specific for CGH. Neurophysiological investigations give some insight into the pathophysiological mechanisms of CGH but are not diagnostic. In CGH, calcitonin gene-related peptide levels do not differ between the symptomatic and the asymptomatic side, between the jugular and the cubital blood, and between days with and without headache. There is no evidence for an activation of the trigeminovascular system in CGH. It can be concluded that CGH is not just a migraine variant triggered by neck dysfunction but a functional entity.
Until then, it is essential that clinicians maintain an open, cautious, and critical approach to the literature on cervicogenic headaches.

Wednesday, June 25, 2008

do you know what % of diabetes is preventable?

Runge CF of department of applied economics and law and the center for international food and agricultural policy, University of Minnesota (USA) estimated : Among the incidence of diabetes, 60% can be directly attributed to weight gain.
By controling weight this diabetes can be prevented by rational food intake & daily exercise regimen.

Why is the developed world Obese?

Obesity has risen dramatically in the past few decades. However, the relative contribution of energy intake and energy expenditure to rising obesity is not known. Moreover, the extent to which social and economic factors tip the energy balance is not well understood. According to a review article by Bleich S et al (2008), exploratory study estimates the relative contribution of increased caloric intake and reduced physical activity to obesity in developed countries using two methods of energy accounting. Results in many studies in western countries show that rising obesity is primarily the result of consuming more calories. Bleich S et al estimated by multivariate regression models and use simulation analysis to explore technological and sociodemographic determinants of this dietary excess. Their results indicate that the increase in caloric intake is associated with technological innovations as well as changing sociodemographic factors.
Many studies have attributed rapid urbanization in all most all parts of the world with associated with change in multiple factors favorable of obesity development. One of the foremost factors that come to mind is enhanced mechanization & gadget usage has lead to over all reduction in day to day caloric expenditure in physical activity. Migration to such an environment leads to obesity.

Friday, June 20, 2008

Rotator interval & pathologies caused by it:

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint located between the distal edges of the supraspinatus and subscapularis tendons and contains the insertions of the coracohumeral and superior glenohumeral ligaments. These structures form a complex pulley system that stabilizes the long head of the biceps tendon as it enters the bicipital groove of the humeral head.
Lesions of the rotator interval may result in
1. Glenohumeral joint contractures- adhesive capsulitis
2. Shoulder instability
3. Anterosuperior internal impingement.
4. Lesions to the long head of the biceps tendon.

Common impingements

From the anatomical and clinical viewpoints, impingements are classified as
1. Bone impingement,
2. Soft tissue impingement and
3. Entrapment neuropathy, depending on what impinges on the others.

Examples: The most important impingement syndromes of the upper and the lower limbs from the clinical viewpoint are as follows.
In the upper limb:
1. Supraspinatus impingement is a frequent cause of shoulder pain in both athletes and the normal population; the painful subacromial arch is a typical sign of the rotator cuff impingement syndrome and of outlet and non-outlet impingement as well.
2. As for the elbow, both medial and lateral impingement.
3. The carpal tunnel syndrome is the most common peripheral entrapment neuropathy of the upper limb; it is caused by compression of the median nerve at the wrist.
In the lower limb:
1. Iliotibial band friction syndrome, which is the most common overuse syndrome of the knee and the ankle impingement syndrome.
2. The latter includes anterolateral impingement (with chronic anterolateral and lateral pain and ankle instability), sinus tarsi impingement, anterior impingement (with pain during foot dorsiflection and posterior impingement.
3. The tarsal tunnel syndrome is the most important ankle entrapment neuropathy causing burn pain and paresthesias in the toes and sole of the foot.

Plantar fascitis update

Considered to be most often the result of a degenerative process at the origin of the plantar fascia at the calcaneus, Plantar fasciitis is a common cause of heel pain, which frustrates patients and practitioners alike because of its resistance to treatment. However, neurogenic and other causes of subcalcaneal pain are frequently cited. A combination of causative factors may be present, or the true cause may remain obscure. Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. Plantar fasciitis has been associated with obesity, middle age, and biomechanical abnormalities in the foot, such as tight Achilles tendon, pes cavus, and pes planus.
Management strategies are:
Nonsurgical treatment is ultimately effective in approximately 90% of patients. Nonsteroidal anti-inflammatory drugs, rest, pads, cups, splints, orthotics, corticosteroid injections, casts, physical therapy, ice, and heat.
Targeting tissue specific stretching: A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. A recent study concluded, program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fascitis.

Thursday, June 19, 2008

Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion.

The hypothesis that the Ely's test for evaluating rectus femoris flexibility and joint range of motion (ROM) is a reliable clinical tool is challenged by Peeler J et al (2008) the results of their study call into question the statistical reliability of the Ely's test. However according to these researchers more research is required to determine the variables that may confound statistical reliability of Ely's test that is commonly used in a clinical setting to assess function about the thigh region.

Result of whole body vibration on Kinesthsia (sum of all kinesthetic input)

Go through the following article by Dolny DG et al (2008):
WBV platforms produce frequencies ranging from 15-60 Hz and vertical displacements from ~1-11 mm, resulting in accelerations of ~2.2-5.1 g.
1. With WBV training, younger fit subjects may not experience gains unless some type of external load is added to WBV exercise.
2. However, sedentary and elderly individuals have demonstrated significant gains in most measures of muscle performance, similar with comparable traditional resistance exercise training programs.
3. WBV training also has demonstrated gains in flexibility in younger athletic populations and gains or maintenance in bone mineral density in postmenopausal women.
4. Acute exposure to WBV in sports persons has produced mixed results in terms of improving jump, sprint, and measures of muscle performance.

We thought aerobic exercises only helps in Fibromyalgia, look what is coming up!!

According to recent studies Busch AJ et al (2008) Aerobic-only training has beneficial effects on physical function and some Fibromyalgia symptoms. Strength-only training may also improve Fibromyalgia symptoms, but requires further study.

I always had thought stretching prior to explosive work out put is not prudent. Studies are confirming my way of thinking:

LaRoche DP et al (2008) of Department of Kinesiology, University of New Hampshire, Durham, New Hampshire, USA. did a study was to determine whether muscle force, power, and optimal length were affected by 4 weeks of static or ballistic stretching.
The study suggested:
1. Individuals can routinely stretch following exercise to maintain flexibility but should avoid stretching prior to exercise requiring high levels of muscle force.
2. Before exercise that requires high muscular forces, individuals may perform dynamic, sport-specific exercises to increase blood flow, metabolic activity, temperature, and compliance of the muscle.

Wednesday, June 18, 2008

Where we (physios) are heading.

A review of Hambrecht R throws a light on how sports physical therapy has been accepted as a treatment.
Over the last 2 decades the clinical application of physical exercise as a therapeutic strategy has developed from rehabilitation to prevention and treatment of cardiovascular diseases. This shift in clinical application was accompanied by a more systematic research approach of the involved mechanisms and the objective clinical assessment of sport interventions using prospective randomized clinical trials. This ongoing process established physical exercise as an evidence-based and guideline-oriented treatment option.
1. In stable coronary artery disease (CAD), exercise therapy has long been used for rehabilitation purposes following an acute myocardial infarction. A recent meta-analysis revealed a significant 27% reduction of total mortality among training patients. Four mechanisms are considered important mediators of the reduced cardiac event rate: improvement of endothelial function, reduced progression of coronary lesions, reduced thrombogenic risk, and improved collateralization.
2. In stable chronic heart failure (CHF), physical activity was traditionally discouraged-with negative consequences for the patients: exercise intolerance worsened, the progression of disease-related muscular atrophy accelerated. A carefully designed exercise program at 50-70% of the maximal oxygen uptake was effective in improving exercise capacity by 12-32%. In a recent meta-analysis, exercise therapy reduced the relative risk of CHF mortality by 35% and CHF-related hospitalizations by 28%.
Considering the growing body of evidence in favor of sport as a therapy, training interventions should be considered additional/alternative therapeutic strategies as compared with established pharmacological/interventional options.

Physical therapy in HIV patients!!!

HIV-infected persons often experience a loss of lean tissue mass, which includes decreases in skeletal muscle mass. This HIV-associated wasting is significant because it has been associated with accelerated disease progression and increased morbidity.

In an attempt to counter muscle wasting in HIV-infected persons, treatments have been suggested that target these mechanisms. Nutritional supplementation, cytokine reduction, hormone therapy and resistance exercise training are potential treatments for this condition.

Resistance exercise training, which is more easily accessible to this population than other treatments, holds promise in counteracting the process of HIV wasting, as it has been successfully used to increase lean tissue mass in healthy and clinical populations.

Vertebral fracture cascade and it’s impact

Once an initial vertebral fracture is sustained, the risk of subsequent vertebral fracture increases significantly. This phenomenon has been termed the "vertebral fracture cascade". Mechanisms underlying this fracture cascade are inadequately understood. Evidence suggests that non-bone parameters differ between individuals with and those without osteoporotic vertebral fractures. Neurophysiologic properties, particularly trunk control and balance, are affected by the presence of a vertebral fracture.

The truth about Cervical radiculopathy:

According to Rhee JM et al (2007):
1. Cervical radiculopathy is a disorder involving dysfunction of cervical nerve roots that commonly manifests as pain radiating from the neck into the distribution of the affected root.
2. Acute cervical radiculopathy generally has a self-limited clinical course, with up to a 75% rate of spontaneous improvement. Thus, nonsurgical treatment is the appropriate initial approach for most patients.
3. When nonsurgical treatment fails to relieve symptoms or if a significant neurologic deficit exists, surgical decompression may be necessary.
4. Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches.

Tuesday, June 17, 2008

Try focus to out side than inside!

Non-articular conditions (NAC) cause the majority of painful conditions rather than articular ones in mid age and elderly. NACs appear to be common in older adults with knee pain. They make a significant contribution to knee pain severity and functional limitation and are likely to represent additional, rather than alternative, causes of knee pain/functional limitation to osteoarthritis (OA).

One more contraindication for TENS!

Today patients often need devices for more than one condition, and consideration must be given to the interaction between them. The use of transcutaneous electrical nerve stimulation (TENS) for pain relief is increasing. At the same time the implantable cardioverter defibrillator (ICD) is a routine treatment for malignant tachyarrhythmias.
Researchers have reported undersensing of ICD device while co-working with TENS. This might prevent the ICD from delivering shock when it should. Because of the potentially serious consequences of interference do not recommend the use of TENS in patients with ICD.

Pyriformis morphometry, it’s test position and impact of test position

The piriformis syndrome is one of the non-discogenics causes of sciatica. It results from the compression of the sciatic nerve (SN) by the piriformis muscle (PM) in the neutral and piriformis stretch test position. Following are important things to know about it.
1. The location of the sciatic nerve with respect to consistent bony landmarks: mid way between the greater & the ischial tuberosity.
2. The test position is: 30 degrees adduction 60 degrees flexion and approximately 10 degrees medial rotation position of the hip joint.
3. Morphometric data suggest that after stretch test position, the infrapiriforme foramen becomes narrower; the SN becomes closer to the ischial spine of the hip bone, and the angle between the SN and the transverse plane increases.

Differential diagnosis of painful hip in children & clinical decision making

A case I saw toay (18.6.2008): Today a 14 year old girl came to me with complain of stiff hip. All the movements ware severely limited. Her parents told that in 2006 dec she suddenly suddenly complained of hip pain. They could not tell any thing on fever. Radiographs showed reduced joint space, irregular joint margin, decreased neck length, osteoporosis in the head and neck of femur. She has been diagnosed with 4 different diseases by 4 different doctors:
1. LP disease
2. tubercular arthritis
3. septic arthritis
4. transient synovitis
Following is a topic for 1st hand physiotherapists for quick referrals. Children with a painful hip present a diagnostic challenge since clinical differentiation between septic arthritis, transient synovitis and Perthes disease may be difficult. Septic arthritis, a potentially life-threatening and debilitating medical emergency, requires early recognition for successful treatment, while transient synovitis and Perthes disease may be managed conservatively. An "ideal" single test for discrimination between these conditions is currently not available.
Because of the very severe nature of the of septic arthritis we are focusing on diagnosis of septic arthritis only.
Kocher et al. septic arthritis diagnosis is based on four clinical variables:
1. History of fever,
2. Non-weight-bearing,
3. An erythrocyte sedimentation rate of >or=40 mm/hr,
4. And a serum white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L).
Many other researchers found these criteria may not good enough for diagnosis. Few other researchers found following criteria helpful for diagnosis of septic arthritis.
All children with septic arthritis had hip effusion shown by ultrasound and at least two of the following criteria: fever, elevation of erythrocyte sedimentation rate (ESR) and of C-reactive protein (CRP). None of the children without effusion on ultrasound or who lacked two or all criteria had septic arthritis. Radiographs had no significant impact on the decision-making in primary evaluation of acute hip pain.
Once the acuteness subsides physios should mobilize the joint. The presentation as late as the above mentioned case require more aggressive approach. An experienced clinician will decide which approach and which techniques are good for individual patients. I found Mulligan’s techniques very very helpful.

Monday, June 16, 2008

Drug versus physiotherapy in neuropahic pain

Neuropathic pain is a chronic pain syndrome caused by drug-, disease-, or injury-induced damage or destruction of sensory neurons within the dorsal root ganglia of the peripheral nervous system. Characteristic clinical symptoms include the feeling of pins and needles; burning, shooting, and/or stabbing pain with or without throbbing; and numbness. Hyperalgesia and allodynia are special kind of neuropathic pain that is provoked by mechanic or thermal stimuli. Periphery mechanisms of neuropathic pain include hyperexcitability of cell membrane and periphery sensibilization. Central mechanism includes central sensibilization, central reorganization of alphabeta fibers and loss of inhibition mechanisms.
Mononeuropathy, plexopathy, radiculopathy, and myelopathy, lesions of thymus, cortex or brain stem are real cause of neuropathic pain. There is no adequate adaptation and produce suffering without biological helpfulness. The aim of treatment of patient with neuropathic pain is soothing of pain and suffering and prevention of further development of pathological process.
Although the primary goal is to alleviate pain, clinicians recognize that even the most appropriate treatment strategy may be, at best, only able to reduce pain to a more tolerable level.
1. 1st line drug treatment: tricyclic antidepressants, antiepileptic drugs, topical antineuralgics, analgesics. If a patient does not respond to treatment with at least 3 different agents within a drug class, agents from a second drug class may be tried.
2. 2nd line of treatment: narcotic analgesics or refractory treatment options may provide some benefit.
3. 3rd line of drug treatment: Patients who do not respond to monotherapy with any of the first- or second-line agents may respond to combination therapy. But Carbamazepin was the drug of choice till ten years ago. Since then the leader position in treatment has belong to gabapentin in dose from 900-2400 mg daily. Currently the new drug is tested, antiepileptic pregabaline. The first experiences are promising.
4. If all of the above steps fail then candidate is a fitting case to be referred to a pain clinic. Because the techniques used at pain clinics tend to be invasive, referrals to these clinics should be reserved for patients who are truly refractory to all forms of pharmacotherapy.
Neuropathic pain continues to be one of the most difficult pain conditions to treat. A pain treatment protocol appropriate for each patient should be designed. The algorithm will also help streamline referrals to specialized pain clinics, thereby reducing waiting list times for patients who are truly refractory to traditional pharmacotherapy.
A comparison of pharmacotherapy with physiotherapy!
Physical therapy especially in the form of electromodulation of pain is the alternative or adjunct of pharmacotherapy. For example TENS can modulate primary order neuron relay of pain. And again it also can help produce beta endorphin to modulate secondary order neuronal relay of pain. Prudent applications of tens duration, frequency are sought so that both the effects could be gained in one sitting of physiotherapy. In my opinion TENS parallels the first three steps of pharmacotherapy.

Central poststroke pain!

The following is a review of Henry JL et al (2008) on Central poststroke pain:
Thalamic pain was first described 100 years ago by Déjerine and Roussy and has been described as "among the most spectacular, distressing, and intractable of pain syndromes".
Central poststroke pain (CPSP), formerly known as thalamic pain syndrome of Déjerine and Roussy, is a central neuropathic pain occurring in patients affected by stroke.
It is one manifestation of central pain, which is broadly defined as central neuropathic pain caused by lesions or dysfunction in the central nervous system.
CPSP is characterized by:
1. Constant or intermittent pain and is associated with sensory abnormalities, particularly of thermal sensation.
2. The pain is frequently described as burning, scalding, or burning and freezing, other symptoms are usually vague and hard to characterize, making an early diagnosis particularly difficult.
3. Those who develop CPSP may no longer be under the care of health care professionals when their symptoms begin to manifest, resulting in misdiagnosis or a significant delay before treatment begins.
4. Patients may also exhibit spontaneous dysesthesia and the stimulus-evoked sensory disturbances of dysesthesia, allodynia and hyperalgesia.

Diagnosis is complicated by cognitive and speech limitations that may occur following stroke, as well as by depression, anxiety and sleep disturbances.

Diet tips for you

The fat contains more than twice the calories compared to macroutrients and it is 7 times more easily converted to body fat than carbohydrates.

physios in weight loss industry do not advise fad diet to your client

The diet that promotes a restricted eating-plan or certain liquid foods lacking sufficient food value is termed as Fad Diet. The fad diets are very low in calories so they cause very fast weight loss. However, quick weight loss may not be healthy and - in most cases - is not fat loss. It is actually water-loss which is quickly regained when the dieter resumes normal eating. The fad diets can cause weight cycling, which means a continuing pattern of gaining and losing weight. The fad diets are considered unhealthy. The common examples of Fad diets include the Cabbage Soup Diet and the Grapefruit Diet etc.
baba RAMDEV have been prescribing "LAUKI KI RUS" which is also a fad diat.
be careful guys!!!

Sunday, June 15, 2008

Lower limb neurodyamical changes in inversion sprains of ankle!

Pahor S et al did slump test to investigate the effect of ankle inversion sprain on neurodynamic function in 18 subjects. The sensory response and restriction in range of knee extension in the slump test were assessed. Three different foot and ankle positions were used-neutral, dorsiflexion (DF) and plantarflexion with inversion (PFI).
Results indicated that:
1. although there was a significantly greater lack of knee extension on the injured side compared to the non-injured side in all three foot and ankle positions, knee extension was most restricted in the PFI position, which is considered to bias the common peroneal tract.
2. The slump test in PFI produced symptoms in the lateral aspect of the lower leg and ankle extending slightly anteriorly and posteriorly and into the dorsum of the foot. This distribution corresponds to that of the superficial peroneal nerve.
3. The slump test in neutral and DF produced areas of response similar to each other, which included the posterior aspect of the knee, thigh and calf. The release of cervical flexion resulted in a significant reduction in symptoms in each test.
These results may indicate altered neurodynamic function following ankle inversion sprain, and have implications for assessment and treatment of subjects with ankle sprain.
Published in journal of manual therapy(1996)

Mew medical hypothesis- Spinal manipulation and spinal mobilization influence different axial sensory beds.

The following is an account of Bolton PS et al (2006) in the journal of medical hypothesis.
Manipulation and mobilization are two forms of manual therapy commonly employed in the management of musculoskeletal disorders. Spinal manipulation and mobilization are often distinguished from one another by reference to certain biomechanical parameters such as peak force, duration and magnitude of translation. However, as of yet, there is relatively little research which distinguishes between them in terms of neurological mechanisms or clinical effectiveness. Theories concerning the mechanisms underlying the therapeutic effects of manipulation and mobilization commonly make reference to mechanical events such as the release of entrapped tissue or the disruption of intra-articular adhesions. Relatively less attention is given to neural effects.
This article hypothesizes that:
1. At least in part, spinal manipulation preferentially influences a sensory bed which, in terms of anatomical location and function, is different from the sensory bed influenced by spinal mobilization techniques.
2. More specifically, it also hypothesize that manipulation may particularly stimulate receptors within deep intervertebral muscles, while mobilization techniques most likely affect more superficial axial muscles.
3. In part, rationale for this hypothesis is based on differences in mechanical advantage of the respective manual procedures on multi-segmental versus short intervertebral muscles.

Friday, June 13, 2008

negitive pillow bias!

In a survey we also found a negative bias for pillow exists among doctors reflected in their advice to a patient suffering from acute cervical pain with or with out radiation. Many (23 out of 31 referring doctors to our center) of them during an acute cervical pain episode either advised their patients not to use a pillow or use a thin pillow. There was no specification of how thin the pillow should be for such conditions.

Monday, June 9, 2008

dizziness due to cervical origin- treatment

Many cases of dizziness are due to cervical origin. Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. Many of referring doctors feared that I might not help them which in term will produce a bad name for them. The skills ware there with me. One day a monk reported (1st hand) to me that he is having dizziness while prostrating in the temple, while sitting in meditations etc. I used Central PA to C6, C5. Currently I am exploring SNAGs of B.Mulligan. and combinimg both Maitlands & Mulligans. Following is an account of SNAGs helping patents with dizziness of cervicogenic origin: Reid SA et al (2007) found, SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction.

mobilization of thoracic spine to treat neck pain!

I have a personal experience of mobilization of thoracic spine reducing neck and back pain & dysfunctions. Being the intermediate area of the spine, thoracic spine influences the kinesis & postural attitude of the cervico-capital & lumbo-sacral area. I found a support to my line of thinking from a study by Cleland JA et al (2007). They studied “Short-term effects of thrust versus non-thrust mobilization/manipulation directed at the thoracic spine in patients with neck pain” through a RCT. The results suggested that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.

High-velocity low-amplitude manipulation (HVLA) VS. Mobilization exercises in subjects presenting with mechanical neck pain.

Martinez-sequra R et al (2006) did a RCT to analyze the immediate effects on neck pain and active cervical range of motion after a single cervical high-velocity low-amplitude (HVLA) manipulation or a control mobilization procedure in mechanical neck pain subjects. The result suggested, a single cervical HVLA manipulation was more effective in reducing neck pain at rest and in increasing active cervical range of motion than a control mobilization procedure in subjects suffering from mechanical neck pain.

new gaget in physiotherapy

few of the machines that produce EM waves we use i.e. SWD, MWD that produce waves of wavelength of few meters to decimeters. But there are machines which produce electromagnectic milimeter waves. explores the use and effects.

Saturday, June 7, 2008

trigger points in head & neck: it's implication

Commonly designated idiopathic neck pain and some primary headaches (ie, tension-type headache or migraine) fit the descriptions of referred pain originating in muscle trigger points (TrPs).
Some authors found that both muscle TrPs in neck-shoulder muscles and cervical joint dysfunctions contribute at the same time to neck pain perception.
Several recent studies reported that both tension-type headache and migraine are associated with referred pain from TrPs in the suboccipital, upper trapezius, sternocleidomastoid, temporalis, or superior oblique muscles.
Referred pain elicited by active TrPs mimics the pain areas observed during head pain attacks in these primary headaches.
Farnandez-De-Las- Penas C et al (2007) concluded in their of article that the pain profile of neck and head syndromes may be provoked referred pain from TrPs in the posterior cervical, head, and shoulder muscles.

Shoulder impingement symptoms of over head athlete & rehab.line

Shoulder impingement symptoms of over head athlete:
(1) Acquired glenohumeral anterior instability,
(2) Loss of GH internal rotation range of motion, and
(3) lack of retraction strength. Based on recent literature,
The following guidelines should be used with impingement symptoms (as described above):
(1) Shoulder rehabilitation should be integrated into kinetic chain training, not only in the advanced phases of the athlete's rehabilitation, but from the initial phases;
(2) Both angular and translational mobilisations can be used in the treatment of acquired loss of glenohumeral internal rotation range of motion to stretch the posterior structures of the glenohumeral joint; and
(3) In the rehabilitation of scapular dyskinesis, the therapist should focus on restoration of trapezius muscle balance in the scapular exercises, with special attention to strength training of the retractors.

Pathophysiology of disk-related sciatica: what the current evidences point to.

Sciatica in patients with disk disease was long ascribed to pressure put on the sciatic nerve root by a herniated disk. Following is a review of Mulleman D et al (2006) on role for chemical factors acting in conjunction with this mechanical insult.
Suggestion of chemical factor involvement comes from a number of clinical observations:
1. Disk surgery does not consistently provide pain relief,
2. Large disk herniations are not always symptomatic,
3. Severe pain may be present in patients without imaging evidence of nerve root compression,
4. The severity of symptoms and neurological signs is not well correlated with the size of the disk herniation, and conservative therapy is often effective.
Experimental studies have provided further evidence for a chemical component:
1. Disk herniations can undergo spontaneous resorption,
2. The intervertebral disk is immunogenic,
3. And mediators for inflammation have been identified within intervertebral disk tissue
The current pathophysiological theory incriminates proinflammatory substances secreted by the nucleus pulposus (NP). When preexisting or concomitant mechanical injury to a nerve root occurs, these substances can cause nerve root pain.
Available information points to tumor necrosis factor-alpha (TNF-alpha) as the main candidate among substances potentially responsible for nerve root pain. Therefore, trials of TNF-alpha antagonists in patients with disk-related sciatica are warranted.

What Will Happen Through Careless Dieting?

People just use their concept of decreasing the calories but they do not realize that they can harm themselves through their own way of fixing their calories. We must take the calories required by us to do the work throughout the day and in order to do that we must eat a balanced diet, but when people start eating less this will cause them to feel fatigued and weak and they tire pretty easily and thus are unable to perform the tasks at hand. Not eating properly also predisposes a person to suffer through infections and results in a weak immune system.

Friday, June 6, 2008

endurance exercise induced LDL changes may not be there but what it revels?

Many exercise training studies have not reported significant changes in plasma LDL-C levels following training, a variable frequently used to estimate CVD risk. However, a lack of change in the concentration of LDL-C following endurance exercise training may mask potentially favorable changes in LDL composition and in the concentrations of LDL sub-fractions.
Indeed, Williams and his group have shown overweight men who exercised for one year (with or without diet), 25-50 min per session, 3-5 times per week reported:
1. increased LDL peak flotation rate,
2. as well as LDL peak particle diameter, and
3. decreased small LDL mass concentrations in plasma despite no change in mean plasma LDL-C concentration.
Hence lack of change in plasma LDL-C levels may not always adequately reflect changes in LDL concentration and distribution as exercise training may induce simultaneous changes in small LDL, large LDL and IDL-cholesterol levels.

why previous studies did not report exercise induced weight loss:

However, as previously discussed, many exercise training studies did not report any significant reduction in body weight.
1. Most training studies have not been designed to investigate the effect of exercise on body fatness, but rather to investigate the potential metabolic effects of exercise training and its relation to cardiovascular disease risk.
2. And in many of these exercise training protocols, there was no control of subjects' caloric intake.
These two factors have obviously a considerable impact on the potential reduction of body weight following endurance exercise training and may therefore be partly responsible for the equivocal results reported.

do not expect to loose weight with cardio protocol- you need to be aggrasive yet safe with the protocol formulation

To achieve weight loss through exercise, a minimal prescription of exercise becomes very important as the energy expenditure induced by typical training protocols used to improve cardiorespiratory fitness (3 sessions of 30 minute walk at 75% of Vo2max) will not lead to substantial energy deficit and the magnitude of body weight loss will be generally quite small.

do you know obesity is one of the fastest growing epidemics?

The prevalence of obesity is increasing rapidly in all age groups and is one of the fastest growing epidemics, now affecting 10-40% of the adult population.
Obesity increases the risk of serious co-morbidities such as type 2 diabetes, cardiovascular disease, certain cancers and reduced life expectancy, and these complications may account for 5-10% of all health .
The risk of diabetes is particularly increased by obesity, and 80-95% of the increase in diabetes can be attributed to obesity and overweight with abdominal fat distribution.

Thursday, June 5, 2008

power walking

Experts recommend aerobic exercise, strength, flexibility, and balance exercises. Aerobic or endurance activities are good for heart, lungs, circulation, and muscles. Activities to choose from include walking, hiking, dancing, swimming, skating, cycling, and cross-country skiing. Simple walking is one of the best activities to stimulate circulation, improve the pumping of heart, and general better feeling. A more intense workout while walking is swing arms back and forth, lengthening the stride etc are called “pace walking”, or “power walking” by experts.

dose-response relationship of adiponectin & exercise!

One study reported a dose-response effect of resistance training intensity and the augmentation of adiponectin. Anti-inflammatory cytokine adiponectin may assume critical importance in exercise induced weight loss.

High protein diet on weight loss:

Amid speculations of enhanced solute load associated with high protein diet that may further compromise nephrological status of the obese; still high quality RCTs compel us to look into such diet protocols comprising of high-protein diet. Meckling KA et al (2007) examined the effects of 3:1 and 1:1 carbohydrate to protein ratios, hypocaloric diets with and without exercise, and risk factors associated with the Metabolic Syndrome in overweight and obese Canadian women. Habitual diets of the subjects were energy restricted and were to contain either a 1:1 or 3:1 ratio of carbohydrate to protein energy. Subjects either exercised 3 times/week or maintained their normal level of activity for 12 weeks. The main outcome measures were weight loss, blood lipids, blood pressure, insulin, body composition, nitrogen balance, fitness, and resting energy expenditure. They concluded high-protein diet was superior to a low-fat, high-carbohydrate diet either alone or when combined with an aerobic/resistance-training program in promoting weight loss and nitrogen balance, while similarly improving body composition and risk factors for the Metabolic Syndrome in overweight and obese Canadian women.

relationship between aerobic fitness & fat oxidation under sedantary condition

Kriketos AD et al (2000) investigated the contributions of physical fitness and body composition to 24-hour fat oxidation in adults under sedentary conditions in a whole-room calorimeter.

The results show that
In male subjects under sedentary conditions, 24-hour fat oxidation is positively related to body fat mass and negatively related to VO2max (the marker used here for level of physical fitness). This supports our hypothesis that regularly active males maintain lower body fat stores as the low contribution to daily fat oxidation from a lower body fat mass is counterbalanced by the high contribution to fat oxidation from daily physical activity.
The lack of a relationship between VO2max and 24-hour energy expenditure under the sedentary conditions of this study suggests that the major effects of physical activity on total daily energy expenditure and fat oxidation may occur during and relatively quickly after an exercise bout. Further, cessation of regular exercise will likely be associated with a high risk of positive fat balance and weight gain.

prudent weight loss recommedation

According to Tremblay A (1999) for the obese individual complying with an activity programme and healthy food habits, a body weight loss of 10% is a realistic goal before the occurrence of resistance to further loss of body fat.

Wednesday, June 4, 2008

which fat reduction by exercise improve diabetes

Visceral fat loss after aerobic exercise training improves glucose metabolism and is associated with the reversal of insulin resistance in older obese men and women (O'Leary VB, 2006).

correlation between aeroic fitness, IMCL, insulin sensitivity in trained & untrained subjects

Thamer C et al (2003) reported obesity and aerobic fitness are important determinants of intramyocellular lipids (IMCL). Intramyocellular lipids and insulin sensitivity are negatively correlated in untrained subjects. The correlation between the two parameters is modified by the extent of aerobic fitness and cannot be found in endurance trained subjects. Thus, measurements of aerobic fitness and body fat are indispensable for the interpretation of intramyocellular lipids and its relationship with insulin sensitivity.

post exercise fat store replenishment in muscles

Décombaz J et al (2001) reported that post-exercise fat intake strongly promotes intramyocellular lipids repletion independently of training status i.e. the replenishment is similar in trained and sedentary subjects. Furthermore, replenishment of intramyocellular lipids can be completed within a day when fat intake is sufficient.

how myocellular lipid changes in exercising & non exercising muscles

Intramyocellular lipid content is increased after exercise in non-exercising human skeletal muscles but decreased after exercise in exercising muscles.

over night fast pushes predominately lipid as the substrate for modarate prolonged exercise

Van Loon LJ et reported that intramuscular triglyceride stores form an important substrate source during moderate intensity exercise (60% of the VO2max) in endurance-trained male athletes following an overnight fast, with the oxidation rate of muscle- plus lipoprotein-derived TG being decreased with the duration of exercise.

no gender difference in substrate utilization duging submaximal exercise

Roepstorff C et al working on “gender differences in substrate utilization during submaximal exercise in endurance-trained subjects” reported no gender difference existed in the relative contribution from carbohydrate and lipids to the oxidative metabolism across the leg during submaximal exercise at the same relative workload.

impact of exercise on fat & glycogen store

Schrauwen P et al showed that lean subjects are capable of rapidly adjusting fat oxidation to fat intake on a high-fat diet when glycogen stores are lowered by exhaustive exercise. However, it has been proposed that obese subjects have impaired fat oxidation. Schrauwen P et al studied the effect of low glycogen stores on fat oxidation after a switch from a reduced-fat diet to an high-fat diet in obese subjects. They found, obese subjects are capable of rapidly adjusting fat oxidation to fat intake when glycogen stores are lowered by exhaustive exercise.

impact of exercise on fat and carbohydrate store

Schrauwen P et al showed that lean subjects are capable of rapidly adjusting fat oxidation to fat intake on a high-fat diet when glycogen stores are lowered by exhaustive exercise. However, it has been proposed that obese subjects have impaired fat oxidation. Schrauwen P et al studied the effect of low glycogen stores on fat oxidation after a switch from a reduced-fat diet to an high-fat diet in obese subjects. They found, obese subjects are capable of rapidly adjusting fat oxidation to fat intake when glycogen stores are lowered by exhaustive exercise.

obesity 4/ FQ-RQ affects body weight

The effects of physical activity on the 24-hour RQ (respiratory quotient) that allows the organism to operate with an average RQ as low as the diet's FQ (fat quotient) in the presence of less body fat. Hence diet's carbohydrate-to-fat ratio can be an important parameter in shaping the interactions between physical activity and body weight maintenance.

obesity -3 / “Exercise leading to fitness and weight management” is a reflection of body’s metabolic statement to exercises:

There is direct influence of physical activity on the underlying metabolic determinants of energy balance. Physical activity facilitates weight maintenance through direct energy expenditure and improved physical fitness. The latter facilitates the amount and intensity of daily activities. Both components are of importance in relation to energy and substrate balance. Exercise may act as a substitute for an enlarged fat mass, in bringing about rates of fat oxidation commensurate with fat intake. Metabolic effects on lipid mobilization and oxidation and morphological/biochemical changes in the muscle fiber, contribute to this successful regulation of body weight. A limited number of studies indicate that, the minimal level of additional energy expenditure by physical exercise required for protection against gain in excessive body fatness, is around 12 kcal/kg body weight/d.

obesity 2/ what we mst focus in obesity has changed it is change in energy balance over time

1. According to Goran MI, resting metabolic rate is the largest component of daily energy expenditure, and physical activity-related energy expenditure is the most variable.
2. There is convincing evidence of susceptible individuals fail to compensate for periodic fluctuations in energy expenditure and become obese.
3. The major dependent variable that needs to be examined in relation to the cause of obesity is not energy expenditure but change in energy balance over time and the ability to regulate body energy stores.

obesity topics 1-treatment of obesity are discouraging for doctors, other health professionals and patients

According to the journal of public health and nutrition (2007) the promotion of physical activity is difficult and so the results of treatment of obesity are discouraging for doctors, other health professionals and patients. Proactive efforts from patients and health providers with an intensive feedback between them may be extremely helpful. However, they only lead to modest enduring weight loss, and their limited impact on prevention of complications means they should not be pushed too insistently on patients. When patients want assistance with weight loss, their individual body weight history should be carefully analysed before embarking on a weight loss programme.

Tuesday, June 3, 2008

How much rational the doctors treatment are for mechanical neck disorders- review of evidence.

To address the persisting controversy regarding medicinal therapies and injections use on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash; Peloso P et al did a review of current articles on the subject which was published in 2007.
The treatments subjected to analysis are: oral NSAIDs, psychotropic agents, steroid injections, and anaesthetic agents.
1. For acute whiplash, administering intravenous methylprednisolone within eight hours of injury reduced pain at one week, and sick leave but not pain at six months compared to placebo in one trial.
2. For chronic neck disorders at short-term follow-up, intramuscular injection of lidocaine was superior to placebo, treatment advantage 45% and dry needling, but similar to ultrasound in one trial each.
3. In chronic neck disorders with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain and improved function more than when given by intramuscular route at one-year follow-up, in one trial.
4. In subacute and chronic neck disorders, muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.
5. In participants with chronic neck disorders with or without radicular findings or headache, there was moderate evidence from five high quality trials that Botulinum toxin A intramuscular injections had similar effects to saline in improving pain, disability or global perceived effect.

The conclusions are as follows:
1. Moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial.
2. Lidocaine injection into myofascial trigger points appears effective in two trials.
3. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND.
4. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.

Exercises for mechamical neck disorders

Kay TM et al (2005) reviewed assess the effectiveness of exercise therapy to relieve pain, or improve function, disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).
They found:
1. Specific exercises may be effective for the treatment of acute and chronic MND, with or without headache.
2. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both.
3. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term.
4. The relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored.

The evidences they found are:
1. There is limited evidence of benefit that acute range of motion (AROM) may reduce pain in acute MND (whiplash associated disorder (WAD)) in the short term.
2. There is moderate evidence of benefit that neck strengthening exercises reduce pain, improve function and global perceived effect for chronic neck disorder with headache in the short and long term.
3. There is unclear evidence regarding the impact of a stretching and strengthening program on pain, function and global perceived effect for MND.
4. However, when this stretching and strengthening program focuses on the cervical or cervical and shoulder/thoracic region, there is moderate evidence of benefit on pain in chronic MND and neck disorder plus headache, in the short and long term.
5. There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisation or manipulation for subacute and chronic MND with or without headache, in the short and long term.
6. A program of eye fixation or proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain, function, and global perceived for chronic MND in the short term, and on pain and function for acute and subacute MND with headache or WAD in the long term.
7. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute MND or WAD.
8. There was evidence of no difference between the different exercise approaches.

Effects & claims of High-velocity low-amplitude- theory & research

When the clinical efficacy of spinal manipulative treatment for spinal pain has been assessed, high-velocity low-amplitude thrust (HVLAT) manipulation and mobilization have been regarded as clinical interventions giving identical and equivalent biologic effects. Hypotheses for lesions that respond to HVLAT manipulation were:
(1) Release of entrapped synovial folds or plica,
(2) Relaxation of hypertonic muscle by sudden stretching,
(3) Disruption of articular or periarticular adhesions, and
(4) Unbuckling of motion segments that have undergone disproportionate displacements.

Evans W (2002) reviewed is to critically discuss previous theories and research of spinal HVLAT manipulation, highlighting reported neurophysiologic effects that seem to be uniquely associated with cavitation of synovial fluid.

Evans W’s comments on 2 separate modes of action from zygapophyseal HVLAT manipulation:

1. Intra-articular "mechanical" effects of zygapophyseal HVLAT manipulation seem to be absolutely separate from and irrelevant to the occurrence of reported "neurophysiologic" effects.
2. Cavitation should not be an absolute requirement for the mechanical effects to occur but may be a reliable indicator for successful joint gapping.

So he concluded that, identification of these claimed unique neurophysiologic effects will provide enough theoretical reason for HVLAT manipulation. Thus manipulation & mobilization are to be assessed independently as individual clinical interventions.

Monday, June 2, 2008

GO- YO YO with exercises buddy

Urban Life Versus Rural Life:

There is a huge difference between the Urban life and the rural life. In order to maintain our lifestyle and manage our expenses, we forget the most important thing, and that is us. We eat unhealthy and we do not exercise and this leads us to have excessive weight and it grows to such a level where it is difficult for us to manage it. On the other hand, if we analyze lifestyle in the rural areas, it is seen that people spend most of their time work on cultivation, so that they could eat and this is something that requires strenuous routines and keeps them fit and healthy throughout their lives and they encounter less medical problems than the people living in the urban areas.
The American College of Sports Medicine recommends that adults get 30-45 minutes of exercise three to five days each week, maintaining the intensity for the duration of the exercise. Each session should contains a 5-10 minute warm up and cool down period. If weight loss is a major goal, aerobic activity should at least 30 minutes a day for five days each week.

Exercise: facts
The National Association for Sport and Physical Education (NASPE) recommends at least 60 minutes, and up to several hours of physical activity per day for children and adolescents
Children should participate in several bouts of physical activity lasting 15 minutes or more each day
It is important to choose an activity that is fun so that motivation to continue the activity will remain high
Experts say people gain a lot of weight is not that they eat a lot; it is that they do not exercise. Simple things that are needed to ensure good quality exercise every single day are listed below:
1. Ensure high Quality Sleep: absence of sleep or sleeping less leads to lethargy & sluggishness the next day, we do no feel inclined to do exercises. So to ensure to have good exercise every day, it is really important that one gets a good sleep every night. So getting adequate sleep will be a major factor in achieving good quality exercise.
2. Walking Regimen: Brisk walk is a very healthy exercise regimen and can be done very easily. For this regimen, we advise that the people must use a jogging track to walk; as hard surfaces like concrete can affect weight bearing joints adversely, which in turn would result in cessation of your exercise plan. In order to start this program, it is healthy to start with a 30 minute program for five times a week. A brisk walk is recommended to lose weight is advised by a lot of health experts.
3. Treadmill Regimen: Machines like stationary bikes, treadmills etc helps us to carry out exercise routines and lose weight. Treadmill machines have a lot of features in which one can adjust the speed of the machine according to the exercise plan for that day. The other big benefit that one can get from the treadmill machine is that there are days when we do not have time to go out and exercise and we can utilize those machines and workout on that day so that the schedule is not broken. We can listen to some light music or watch television while executing our exercise plan during that.
4. Taking out Time for Our Own Health: people usually don’t have time for exercise, forgetting that they are doing everything on the basis of their good health that is keeping them going, and it is really odd that they do not have time for their own health. One must exercise every day and not stress self to a point where he have a “turn off feeling” from exercise. One must remember that good health is a blessing not only for him and but also for his family.

Upper limb fascia & how it is influenced by muscles:

Fascia is a membrane that extends throughout the whole body and numerous muscular expansions maintain it in a basal tension. During a muscular contraction these expansions could also transmit the effect of the stretch to a specific area of the fascia, stimulating the proprioceptors in that area.
Histological characteristics of the deep fascia of the upper limb:
Specimens taken from the antebrachial and brachial fasciae demonstrated that fasciae are formed of numerous layers of undulating collagen fibre bundles. In each layer, the bundles are parallel to each other, whereas adjacent layers show different orientations.
Each layer is separated from the adjacent one by a thin layer of adipose tissue, like plywood. Many elastic fibres and a variety of both free and encapsulated nerve endings, especially Ruffini and Pacini corpuscles, are also present, suggesting a proprioceptive capacity of the deep fascia.
Specimens taken from different areas of upper limb [taken at the level of: (a) the expansion of pectoralis major onto the bicipital fascia, (b) the middle third of the brachial fascia, (c) the lacertus fibrosus, (d) the middle third of the antebrachial fascia, (e) the flexor retinaculum.] revel abundant innervation of the fascia consisting in both free nerve endings and encapsulated receptors, in particular, Ruffini and Pacini corpuscles.
However, differences in innervation were seen between retinaculum the more innervated element whilst the muscle (pectoralis major) expansions the less innervated. This suggests that the retinaculum has more a perceptive function whereas the tendinous expansions onto the fascia have mostly a mechanical role in the transmission of tension that confirms that the fascia plays an important role in proprioception, especially dynamic proprioception.
MRI study shows:
1. The clavicular part of the pectoralis major muscle sent a fibrous expansion onto the anterior portion of the brachial fascia, its costal part onto the medial portion and medial intermuscular septum. Thus the pectoralis major fascia always continues with the brachial fascia in two distinct ways: the fascia overlying the clavicular part of pectoralis major had an expansion towards the anterior brachial fascia, whereas the fascia covering its costal part extended into the medial brachial fascia and the medial intermuscular septum.
2. The latissimus dorsi muscle showed a triangular fibrous expansion onto the posterior portion of the brachial fascia. In the posterior region of the arm, the fascia of the latissimus dorsi sent a fibrous lamina to the triceps brachial fascia.
3. The posterior part of the deltoid muscle inserted muscular fibres directly onto the posterior portion of the brachial fascia, its lateral part onto the lateral portion and the lateral intermuscular septum.
4. The lacertus fibrosus was also composed by two groups of fibres: the main group was oriented downwards and medially, the second group longitudinally.
5. The triceps tendon inserted partially into the antebrachial fascia, while the extensor carpi ulnaris sent a tendinous expansion to the fascia of the hypothenar eminence.
6. The palmaris longus opened out into a fan-shape in the palm of the hand and sent some tendinous expansions to the flexor retinaculum and fascia overlying the thenar eminence muscles.
Function of Pectoral girdle muscles i.e. pectoralis major, latissimus dorsi and deltoid are connected not only through it’s muscular attachment to the humerus but also through the deep fascia i.e. the brachial fascia of arm. Hence during the various movements of the arm, these expansions stretch selective portions of the brachial fascia, with possible activation of specific patterns of fascial proprioceptors. It is hypothesized that the tendinous muscular insertions maintain the fascia at a basal tension and create myofascial continuity between the different muscles actuating flexion and extension of the upper limb, stretching the fascia in different ways according to the different motor directions.
Pathogenesis of pain from fascia:
1. The undulating collagen fibre bundles and elastic fibres, the fasciae can adapt to stretching, but this is only possible within certain limits, beyond which nerve terminations are activated by stretching. This mechanism allows a sort of "gate control" on the normal activation of intrafascial receptors.
2. The capacity of the various collagen layers to slide over each other may be altered in cases of over-use syndrome, trauma or surgery. In such cases, the mechanism of the fascia on the nervous terminations is lost, causing incorrect paradoxical activation of nerve receptors within the fascia, resulting in the propagation of a nociceptive signal even in situations of normal physiological stretch. At the same time, the layered collagen fibres allow transmission of tension according to the various lines of force. This structure of the muscular fascia guarantees perceptive and directional continuity along a particular myokinetic chain, acting like a transmission belt between two adjacent joints and also between synergic muscle groups.

Sunday, June 1, 2008

Pathologies of TLF (Thoracolumbar Fascia) and mechanisms of it’s pain genesis:

Many investigators have defined the presence of innervation in control (no back pain) tissue specimens.
In a study to define the innervation of the thoracolumbar fascia (in problem back pain patients who have articular abnormality defined through pain-provocation discography or facet blocks) found that the thoracolumbar fascia may be deficiently innervated in problem back pain patients. In this study sample collected from operating room (form lumbar spinal surgery patients) and later processed and studied under light and electron microscopy failed to identify specific neural end-organs in any of the specimens. Rather these samples show microscopic changes suggestive of ischemia or inflammation in this tissue were found.
But recent finding suggest otherwise. In addition to free nerve endings, two types of encapsulated mechanoreceptors (Ruffini's and Vater-Pacini corpuscles) were identified. These findings support the hypothesis that the thoracolumbar fascia may play a neurosensory role in the lumbar spine mechanism.

Joints affected in Hurler syndrome.

Hurler syndrome is an autosomal recessive metabolic storage disease. (physios explore more on the disease). Characteristic musculoskeletal findings associated are acetabular dysplasia and failure of ossification of the superolateral femoral head. Genu valgum of variable severity due to failure of ossification of the lateral aspect of the proximal tibial metaphysis are also observed
1. All patients were independently mobile, with restriction of internal hip rotation being the most significant clinical finding.
2. Valgus knees and pronated feet were typical associated findings.

at last happy to see a formal PG in manual therapy course

manual therapy is being popular & practised by many physios in our country. it is taught by many competent authorities but there was no formal PG in manual therapy. PG in orthopaedic physiotherapy was there which was thought to cover manual therapy. but manual therapy it self is very huge subject. PG manual therapy is available at
check in