Sunday, August 31, 2008

os peroneum syndrome: a cause of plantar lateral foot pain.

Os peroneum syndrome; a term coined by Sobel M et al is a cause of plantar lateral foot pain. Painful Os peroneum syndrome results from a spectrum of conditions that includes one or more of the following:

(1) An acute os peroneum fracture or a diastasis of a multipartite Os peroneum, either of which may result in a discontinuity of the peroneus longus tendon;
(2) Chronic (healing or healed) Os peroneum fracture or diastasis of a multipartite Os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis;
(3) Attrition or partial rupture of the peroneus longus tendon, proximal or distal to the Os peroneum;
(4) Frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the Os peroneum; and/or
(5) The presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion.

Suggestion for clinical diagnosis:
Clinical diagnosis of the painful Os peroneum syndrome can be facilitated by localization of tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel by the following two tests.
1. Single stance heel rise and varus inversion stress test
2. Resisted plantarflexion of the first ray

Clinical features of Warner Syndrome

Werner syndrome is a rare autosomal recessive disorder characterized by clinical signs of
1. Premature aging,
2. Short stature,
3. Scleroderma-like skin changes,
4. Endocrine abnormalities,
5. Cataracts,
6. Increased incidence of malignancies.
7. Musculoskeletal manifestations: extensive musculoskeletal manifestations including
i. Osteoporosis of the extremities,
ii. Extensive tendinopathy,
iii. Osteomyelitis of the phalanges,
iv. Abundant soft-tissue calcification,
v. And dense ossified soft-tissue masses etc

Friday, August 29, 2008

Patellofemoral pain syndrome: evaluation of location and intensity of pain and it's clinical implication.

To identify the sites and intensity of pain in patients with patellofemoral pain syndrome Gerbino PG et al did a study. This study was conducted at an academic sports medicine practice in Boston, Massachusetts.

A single sports medicine orthopaedic surgeon examined a consecutive sample of patients with patellofemoral pain not explained by one of several well-defined anterior knee pain diagnoses. The study group consisted of 100 patients (75 females, 25 males) with median age of 14 years.

Patients reported intensity of pain using a 0- to 9-point ordinal scale.
Following are the findings on sites of pain, pain intensity etc:
1. The most common site of pain was the patella during anterior-posterior compression (90 patients), followed by the distal pole of the patella, the medial plica, and the nonarticular medial femoral condyle.
2. Median "worst pain" intensity was 6 out of a possible 9.
3. The most common site of "worst pain" was also the patella in compression (63 patients).
4. Median duration of symptoms was 10 months, with an interquartile range of 3 to 20 months. Pain intensity was inversely correlated with duration of symptoms.
Significance and implications of these findings:
In these patients with patellofemoral pain syndrome, the major source of pain was the patella subchondral bone.

Plantaris may be a cause of patellar pain !!!

The plantaris muscle has been given little attention from us. Our anatomy teachers have said that plantaris is a rudimentary muscle. The function is negligible. It is most commonly mentioned only when absent from a specimen. In a cadaveric study of 46 samples Freeman AJ et al found: the muscle conformed with standard descriptions (n = 26; 56.52%), was present but varied from previous descriptions (n = 14; 30.44%), or was absent (n = 6; 13.04%).
Standard origin and insertations are given below:
Origin: 1. lower part of the lateral supracondylar line of femur 2. oblique popliteal ligament of femur.
Insertion: long and thin muscle lies between gastrocnemius and solius. It crosses from lateral to medial side. It is inserted to posterior surface of calcanium, medial to tendocalcanium.
How the variation presentated in Freeman’s study?
The variations consisted of distinct interdigitations with the lateral head of the gastrocnemius muscle (n = 9; 19.57%) and a strong fibrous extension of the plantaris muscle to the patella (n = 5; 10.87%).
What is suggests?
1. The presence of interdigitations strengthen the argument that the plantaris muscle supplement the activity of the lateral head of the gastrocnemius muscle whereas the patellar extension suggests an involvement with patellofemoral dynamics and may play a role in the various presentations of patellofemoral pain syndrome.
2. According to me the posterior heel pain must also be reviewed and chances of enthesis pain arising from plantaris muscle must also be investigated.

Saturday, August 23, 2008

What scapular dysfunction can lead to?

Dysfunction or weakness of the scapular stabilizers often results in altered biomechanics of the shoulder girdle. The altered biomechanics can result in (1) abnormal stresses to the anterior capsular structures, (2) the increased possibility of rotator cuff compression, and (3) decreased performance.

A discussion on Osteitis pubis

Remember Laxmipathy Balaji the Indian bowler in cricket. His carrier was hit by Osteitis pubis. So lets us discus what is it.

Osteitis pubis is a painful, chronic syndrome that affects the symphysis pubis, adductor and abdominal muscles, and surrounding fascia.

If misdiagnosed or mismanaged, osteitis pubis can run a prolonged and disabling course.

The important point to remember is that the abdominal and adductor muscles have attachments to the symphysis pubis but act antagonistically to each other, predisposing the symphysis pubis to mechanical traction microtrauma and resulting in osteitis pubis.

Advices for sports physios: emphasize on proper worm ups, stretching and core stability.

Thursday, August 14, 2008


ANS: non-neural causes, deural/root causes (adhesion)
ANS: time to recoil (clue- creep property of muscle)

Tuesday, August 12, 2008


Progressive resistance exercise (PRE) is a method of increasing the ability of muscles to generate force.
Systematic reviews on PRE and randomized trials FOUND PRE is highly applicable on major areas of physical therapy: cardiopulmonary, musculoskeletal, neuromuscular, and gerontology. Across conditions, PRE was shown to improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities.
1. The potential negative effects of PRE.
2. How to maximize carryover into everyday activities.

Sunday, August 10, 2008


Non-exercise activity thermogenesis (NEAT) is the energy expended for everything we do that is not sleeping, eating or sports-like exercise. NEAT can be measured by one of two approaches.

The first approach is to measure or estimate total NEAT. Here, total daily energy expenditure is measured and from it, the basal metabolic rate-plus-thermic effect of food is subtracted. { TEE-(DIT+BMR) }

The second approach is the factoral approach whereby the components of NEAT are quantified and total NEAT calculated by summing these components.

The amount of NEAT that humans perform represents the product of the amount and types of physical activities and the thermogenic cost of each activity.

The factors of human's NEAT are biological factors such as : 1. weight, 2. gender and 3. body composition and 4. environmental factors such occupation or dwelling within a "concrete jungle."

It appears that changes in NEAT accompany changes in energy balance and may be important in the physiology of weight change. NEAT and a sedentary lifestyle may thus be of profound importance in obesity.

Saturday, August 9, 2008


hey blogs,
when i was in graduation i saw my seniors fly like free birds to USA. i have seen them attending interview calls in institute hostel (in sv NIRTAR). when i graduated THE POKHARAN TEST happen and later the WTO event. more over there was some stiffening of health budget of USA towards rehab medicine that squeezed my chances. then English language tests ware not enforced. and at least 4 states provided temporary licence.
now what ever i am seeing from Internet, the requirements of the staffing companies i hope there will be large openings in USA soon but one has to go through English language test and licensing tests. be sure that you make your recruiter pay for the credential evaluation.


The incidence of isolated distal tibiofibular syndesmotic ruptures in acute ankle sprains lies between 1% and 11%.
It is misdiagnosed as anterolateral rotational instability of the ankle and often become apparent through protracted courses.
The pathomechanics and extent of syndesmotic injuries have been systematically described by Lauge-Hansen and Weber.
PATHOMECHANICS: Tibiofibular diastasis secondary to chronic syndesmotic instability leads to external rotation of the talus. In combination with a valgus position of the talus, this instability leads to a decrease in the contact area which results in posttraumatic arthritic changes.
These complex injuries are treated surgically to ensure sufficient and stable healing of the syndesmosis besides correct alignment of the distal fibula.
To restore the stability of the ankle mortise and alignment of the fibula in the tibiofibular incisura to ensure limitation of talar rotation.


Possible causes for heel pain include:
  1. Paratenonitis,
  2. Tendinitis, tendinitis with partial rupture,
  3. Insertional tendinitis,
  4. Subachilles and retroachilles bursitis,
  5. Haglunds deformity and calcaneal spur.

Symptoms may be triggered by

  1. Pes plano valgus,
  2. Lateral ankle instability,
  3. Hyperlaxity,
  4. Malalignement of the lower extremity,
  5. Forefoot or hip disorders.
  6. In obese patients the deforming forces on the rear foot position and thereby overuse of the achillis tendon due to the overweight are increased.
  7. Lack of training with loss of muscular compensation or forefoot disorders also favor overuse problems.
  8. A sudden increase of load in an attempt of loosing weight by unaccustomed exercise, without giving the tissue adequate time for adaptation may lead to the start of the symptoms.

Therapy of Achilles tendinitis is preferably conservative, in chronic cases operative therapy depends on the structures involved.


Two popular theories have been proposed to account for this condition: tibial bending and fascial traction.
The role of fascial traction in medial tibial stress pathomechanics:
In one study, the amount of strain present in the tibial fascia adjacent to its distal medial tibial crest insertion during loading of the leg was investigated as a descriptive laboratory pilot study using three fresh cadaver specimens.
Strain in the distal tibial fascia was measured using strain gauges placed in the fascia at its medial tibial crest insertion.
As tension on the posterior tibial, flexor digitorum longus, and soleus tendons increased, strain in the tibial fascia increased in a consistent linear manner.
This study concluded that fascial tension may play a role in the pathomechanics of medial tibial stress syndrome.

Friday, August 8, 2008

Relationship of posteroanterior spinal stiffness to lumbar disk height.

In an interesting radiological study Colloca CJ (2003) tried to corroborate the relationships between dynamic PA spinal stiffness and radiographic measures of lower lumbar disk height and disk degeneration.
Anterior disk height ratios (ADHR = ADH/AVH) and posterior disk height ratios (PDHR = PDH/PVH) were calculated from the disk height measurements and were compared to L4 and L5 posteroanterior spinal stiffness obtained using a previously validated mechanical impedance stiffness assessment procedure.
**Posterior disk height (PDH), vertebral body height (PVH), anterior disk height (ADH), and vertebral body height (AVH)
This study suggested Posteroanterior L5 vertebral stiffness was found to be significantly correlated to the L5 PDHR.

A new clinical test to diagnose Superior labral injury

Several clinical tests for detecting superior labral injury of the shoulder have been reported, some of the maneuvers involved are complicated and diagnosis is still inaccurate.
Nakagawa S (2005) reported forced shoulder abduction and elbow flexion test as a new simple clinical test to detect superior labral injury in the throwing shoulder.
The test:
The forced abduction test was defined as positive when pain at the posterosuperior aspect of the shoulder on forced maximal abduction was relieved or diminished by elbow flexion.
According to Nakagawa; the sensitivity, specificity, and accuracy of the forced abduction test were 67%, 67%, and 67%, respectively. It was one of the most useful tests, along with the crank test and O'Brien's test (crank test, 58%, 72%, 66%; O'Brien's test, 54%, 60%, 57%; respectively).


In sports doping is rampant. With the help of nutrients, drugs, frozen packed cells people have tried to augment their performances illegally to have an undue advantage over other athletes. Assisted ventilation may reduce respiratory muscle fatigue and hence can aid to prolong long drawn performances. Is it a case of mechanical doping?

Thoraco lumbar junction syndrome: a case report.

Maitland has described L1 buttock pain. I have seen many cases of UL or BL radiation of buttock pain from LPA or CPA of L1. this area is thoroughly associated with many symptomatic cases with buttock pain. While examining the L5 one must include L1 if the implications are strong.
Following is a case report by Deepak Sebastian, 2006 (the manual therapy book fame, JAYPEE)
This case report describes a 46-year-old female who experienced symptoms of low back pain with pain radiating into the right gluteal area. Initial intervention addressed mechanical dysfunction at the lumbosacral junction. Reduction in symptoms was observed following manual therapy procedures that addressed the lumbosacral junction; however, the right gluteal pain persisted with recurrence of back pain. Subsequent examination revealed non-neutral dysfunction at the thoracolumbar junction. Treatment was continued with manual therapy procedures that addressed facet restriction and soft tissue dysfunction in the thoracolumbar junction. A marked relief in symptoms was reported thereafter, with a decrease in right gluteal pain and improved functional ability.

Thursday, August 7, 2008

Similarities of upper trapezius trigger point pain & chronic tension type headache

Referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache.
In one study referred pain and pain characteristics evoked from the upper trapezius muscle was investigated in 20 patients with chronic tension-type headache (CTTH).
Both upper trapezius muscles were examined for the presence of myofascial trigger points. The local and referred pain intensities, referred pain pattern, and pressure pain threshold (PPT) were noted.

The results show that:

  1. In CTTH patients, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual headache pain, consistent with active upper trapezius.
  2. This study further suggests that spatial summation of perceived pain and mechanical pain sensitivity exists in CTTH patients.

Counterstrain is an effective treatment in plantar fasciitis.

Osteopathic manipulative treatment based on counterstrain produces a decrease in the stretch reflex of the calf muscles in subjects with Achilles tendinitis. Wynne MM (2006) studied the effects of counterstrain on stretch reflex activity and clinical outcomes in subjects with plantar fasciitis.
  1. Clinical improvement occurs in subjects with plantar fasciitis in response to counterstrain treatment. The clinical response is accompanied by mechanical, but not electrical, changes in the reflex responses of the calf muscles.
  2. A comparison of pretreatment and posttreatment symptom severity demonstrated significant relief of symptoms that was most pronounced immediately following treatment and lasted for 48 hours.

A single thoracic spine manipulation can alter neck pain in subjects presenting with mechanical neck pain.

  1. One study of case series demonstrated a clinically significant reduction in pain at rest in subjects with mechanical neck pain immediately and 48 hours following a thoracic manipulation.
  2. The same study demonstrated increases in all tested ranges of motion but none of them reached statistical significance post-treatment point and end range pain for all tested ranges, with the exception of pain at the end of forward flexion at 48 hours.
  3. More than one mechanism likely explains the effects of thoracic spinal manipulation. Future studies will tell whether thoracic manipulation is an important addition to protocols of all mechanical neck pain disorders.

Mulligan.B & also Deepak Kumar called a response “MAGICAL RESPONSE” do you know what they mean? Read the following:

O’Leary S (2007) reported specific therapeutic exercise of the neck induces immediate local hypoalgesia.
O’Leary S et al (2007) compared effects of 2 specific cervical flexor muscle exercise protocols on immediate pain relief in the cervical spine of people with chronic neck pain. In addition, they study evaluated whether these exercise protocols elicited any systemic effects by studying sympathetic nervous system (SNS) function and pain at a location distant from the cervical spine.
They found that specific exercise of the cervical spine can impart an immediate local mechanical hypoalgesic response.
So it is imperative to understand the pain-relieving effects of exercise. That will assist the clinician in prescribing the most appropriate exercise protocols for patients with chronic neck pain.

IV disc degeneration reduces vertebral PA motion responses.

In an animal experimental animal study by colloca CJ (2007) found:
1. Dorsoventral displacements increased significantly with increasing mechanical excitation pulse duration.
2. Displacements and L2-L1 acceleration transfer were significantly reduced in the degenerated disc group compared with control.

Manual bowel milking effects in the obstructed small bowel:

Mechanical intestinal obstruction is a frequently encountered problem in general surgery. One of the frequently used techniques for surgical decompression, so-called milking, is to caress the intestinal contents cephalad into the stomach or caudally into the colon.
Torer N et al (2008) examined the functional, morphologic, and microbiologic effects of manual bowel decompression (milking) in the obstructed small bowel.
They found although manual bowel decompression reduces muscle contractility a milking procedure in an intestinal obstruction model
1. Does not cause peristaltic deterioration.
2. Does not cause histopathologic or inflammatory changes, or
3. Does not cause alterations in the degree of bacterial translocation.

Tuesday, August 5, 2008


THREE major eating disorders within the general population:
Anorexia Nervosa, Bulimia Nervosa,
Binge eating disorders

Anorexia Nervosa

Anorexia Nervosa is failing to eat an adequate amount of food to maintain a reasonable body weight. In Anorexia Nervosa there is avoidance of food, engaging in excessive vigorous exercise
These subjects typically, weigh less than 85% of their normal weight. It is associated with:
Dry skin
Reduced bone mass
Brittle nails
Carotene pigmentation (yellowish appearance of the palms and soles of the feet)

Bulimia Nervosa

Bulimia Nervosa is characterized by continual episodes of binge eating followed by purging.
A binge involves eating large amounts of food in a discrete period of time. After a binge, vomiting is induced and/or laxatives are used. In these cases involve excessive exercise as a form of purging. Body weight is often normal in these cases. A secretive eating pattern is also seen in them. Usually nervous or agitated behavior is seen immediately after eating. There is either loss or gain of extreme amounts of weight.

Binge Eating Disorder (BED)

Binge Eating Disorder involves ingesting large amounts of food without purging. It leads to obesity in most cases. The factors involved in the development of this type of eating disorder include:
Dissatisfaction with body image
Distortions in thinking
Perfectionist beliefs
Excessive self-criticism
Fear of fat
Excessive dieting
Preoccupation with food

Consequences of Dieting
Cultural pressures to be thin and the stigma of being overweight have resulted in many young people engaging in dieting and abnormal eating behaviors. Chronic dieting can lead to:
Retardation of physical growth
Menstrual irregularities in females
Lowered metabolic rate
Development of eating disorders


1. That all schools in the City are urged to include in the curriculum a lesson on practical cooking skills and their contribution to healthy living.
2. That advice is provided to all parents on healthy options for snack lunches.
3. That all schools are encouraged to progress healthy options for all school meals.
4. The municipal corporation undertake a cost appraisal for improving facilities in parks to encourage easier and free use for exercise such as playing field provision and improving linear pathway access.
5. A research project is undertaken within the City to consider the link between living styles and deprivation.
6. That the municipal corporation and its partners consider how to encourage ‘walk not ride’ initiatives.
7. The municipal corporation and its partners maximise the funding opportunity for initiatives such as Clockwork Orange to be retained.
8. The municipal corporation and its partners monitor the effectiveness of policies in respect of encouraging a greater take-up of exercise in the City.

My doughters lunch Box- IS IT HEALTHY?

In India, school meals and the response have not been on the whole very successful but these menus have been externally assessed as meeting national nutritional standards. Staff in schools have identified that lunches provided by many parents for their children are unhealthy. Chocolate, crisps and confectionary are the main items in many children’s lunchboxes. Where this has been seen as a problem, schools are providing workshops, advice and information to parents on healthier lunchbox options.

Sunday, August 3, 2008

Palpation errors- so many times we fail to deliver but be blame other factors.

One study by Harlick JC et al was to determine the accuracy of manipulative physiotherapists in palpating radiologically identified lumbar spinous processes (SPs). Five experienced manipulative physiotherapists were each allocated a cohort of 15 consecutive low back pain (LBP) patients presenting for X-rays and were asked to use surface palpation to identify the L1, L3 and L5 SPs.
72% accurately located the nominated SP or consistently within one SP of the nominated level.
A greater SP height at L3 and L5, and decreased soft tissue thickness over L5, were associated with an increase in palpation accuracy levels.
Yet the patient variables of age, sex and body mass index (BMI) had no effect on palpatory accuracy.
The manipulative physiotherapists used in this study appear to be moderately successful in either palpating a nominated SP or being no more than one spinal level in error.

Work-related thumb pain in physiotherapists!!!

Pain is common in the thumbs of physiotherapists. Physiotherapists specially mobilizing spine through their thumb by maitland techniques is a common site in any part of the world. I my self is quite relentless in administering these techniques for last 10 years. In a sense we physios torture our thumb that provides treatment to patients. Wajon A et al did a study and the purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain.

The study:
1) After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed.

2) There was an association (p<0.05)>

3) These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

Treatment of chronic coccydynia

There are 4 different prominent pathologies for coccydynia. There are many popular approaches such as DTFM of cyriax, Graded oscillation of Maitland, per anal manipulation. Many prefer US therapy as an electrotherapy procedure.
My experience with all of them is very frustrating. Reference texts are limited and so also research data base in comparison to the case load of coccydynia in our clinic. Maigne JY et al found a mild effectiveness of intrarectal manipulation in chronic coccydynia.
The main predictors of a good outcome were stable coccyx, shorter duration, traumatic etiology, and lower score in the affective parts of the McGill and Dallas questionnaires.

Effects of different cervical traction weights on neck pain and mobility.

Traditionally we have been giving 1/6th of the body weight for cervical spine traction and 1/3rd of the body weight for lumbar spine traction. Akinbo SR investigated the effects of 3 different traction weights on neck pain and range of motion/mobility and they 10% TBW CT as the ideal weight with minimal side effects and with highest therapeutic efficacy.
Therefore clinicians could adopt this weight in managing neck disorders requiring traction.

Myths of lumbar intradiscal pressure- want to incorporate this following into your data base ask a peer.

Studies of lumbar intradiscal pressure (IDP) in standing and upright sitting have mostly reported higher pressures in sitting. From my student carrier I have known that sitting transmits 11 times more pressure than standing (on central spinal pillar).
It is assumed clinically that flexion of the lumbar spine in sitting relative to standing, caused higher IDP, disc degeneration or rupture, and low back pain. IDP indicates axial compressive load upon a non-degenerate disc, but provides little or no indication of shear, axial rotation or bending.
Claus A et al found that IDP is often similar in standing and sitting. Current studies indicate that IDP in sitting is unlikely to pose a threat to non-degenerate discs, and sitting is no worse than standing for disc degeneration or low back pain incidence.
If sitting is a greater threat for development of low back pain than standing, the mechanism is unlikely to be raised IDP.

McKenzie assessment & centralization of pain from spinal origin

1) The centralization phenomenon is the migration of low back and/or radiating pain to the spinal midline in response to specific positions or movements, for instance during a McKenzie mechanical assessment.
2) Pain location and the time to centralization still remains the controversial areas of centralization standardization.
3) Centralization correlates strongly with a positive discography and as a sign of diskogenic pain but an indicator that surgery is needed remains highly controversial.
4) Nevertheless, centralization may indicate a high likelihood of diskogenic pain and may provide therapeutic guidance.
5) Centralization is associated with better outcomes after nonsurgical treatment, even in patients with nerve root pain, its presence may constitute an argument against surgical treatment.
6) Finally, the McKenzie assessment may induce pain relief, albeit to a modest extent and for no longer than 3 months!!


Many of us are using prone traction on our LBA with possibly slip dics. I use it in the same case with the decreased lordosis. Beattie PF et also wanted to check the outcomes after administration of a prone lumbar traction protocol. The study population consisted of total of 296 subjects with low back pain (LBP) and evidence of a degenerative and/or herniated intervertebral disk at 1 or more levels of the lumbar spine.

An 8-week course of prone lumbar traction, using the vertebral axial decompression (VAX-D) system, consisting of five 30-minute sessions a week for 4 weeks, followed by one 30-minute session a week for 4 additional weeks.
Roland-Morris Disability Questionnaire (RMDQ) were completed at preintervention, discharge (within 2 weeks of the last visit), and at 30 days and 180 days after discharge.

A total of 250 (84.4%) subjects completed the treatment protocol. On the 30-day follow-up, 247 (83.4%) subjects were available; on the 180-day follow-up, data were available for 241 (81.4%) subjects. We noted significant improvements for all postintervention outcome scores when compared with preintervention scores (P<.01).

How ever the authors are vary cautious about generalizing the result. They have stated “Causal relationships between these outcomes and the intervention should not be made until further study is performed using randomized comparison groups”

Know how of the mediations that the patient rub on to their skin overlying the painful part.

1) A new term “targeted peripheral analgesics” has been suggested to replace the term topical analgesics, but is not in widespread use.
2) Ther is a huge difference between topical and transdermal analgesics are discussed in this article.
3) Topical analgesics exert their analgesic benefit locally and without significant systemic absorption.
4) The mechanism of the topical analgesic is unique to the specific medication.
Recent data suggest that at least one topical analgesic, although applied peripherally, may result in central nervous system alterations of pain processing.

Saturday, August 2, 2008

Prescription validity of NSAIDs by physiotherapists & responsibilities of prescribing such medication

Read the following article by Biederman RE of American Board of Podiatric Surgery, San Francisco, CA, USA.
“Pharmacology in rehabilitation: nonsteroidal anti-inflammatory agents”
Nonsteroidal anti-inflammatory agents (NSAIDs) are the most commonly encountered over-the-counter (OTC) and prescription medications in physical therapy practice. Worldwide, over 73000000 prescriptions for nonsteroidal agents are written yearly. NSAIDs produce a wide range of beneficial effects to the physical therapy patient, enhancing the outcome of treatment. Helpful effects of NSAIDs include analgesia, antipyretic, anti-inflammatory, and antithrombotic properties. However, NSAIDs are also associated with frequent and significant side effects that are deleterious to treatment outcome, including delay in soft tissue and bone healing, renal and liver toxicity, hemorrhagic events, gastric irritation and ulceration, and central nervous system effects.
Understanding of the pharmacological properties of these drugs, exemplified by aspirin, and the individual pharmacokinetics of specific preparations will help the therapist to screen patients for potential side effects, develop more effective plans of care, and, where allowed, effectively and safely prescribe NSAIDs.


Prolotherapy is an injection-based treatment of chronic musculoskeletal pain. Limited high-quality data supports the use of prolotherapy in the treatment of musculoskeletal pain or sport-related soft tissue injuries.

The Hyaluronic acid know how for physios

Many keen physiotherapists know that orthopedic surgeons inject Hyaluronic acid (HA) to osteoarthrosed joints commonly the Knee. The following discussion is a summary of HA it’s chemical nature and other applications.
What is Hyaluronic acid (HA)?
Hyaluronic acid (HA) is a glycosaminoglycan composed of alternating N-acetyl-D-glucosamine and D-glucuronic acid moieties.
Properties of use:
1) HA is an ubiquitous component of connective tissue where it forms matrix and plays an important role in the maintenance of matrix structure and water balance.
2) The viscoelastic properties of HA derivatives and non-immunogenicity has provided its use in a number of pharmaceutical applications.
1) Skin: ability of HA to create and fill space by organizing and modifying the extracellular matrix is widely used for soft tissue augmentation to limit age-related and photoinduced skin aging, but also may be used for correction of facial lipodystrophy and to prevent reccurence of hypertrophic scars or keloids.
2) Eye: HA may be employed as a surgical aid in ophthalmology
3) Joints: To reduce knee pain and joint motion in patients with osteoarthritis.
4) Pediatrics: In children HA may become an alternative to the open surgery for the management of vesicoureteral reflux.


It is believed lumbar degeneration begins in the disc, where desiccation and collapse lead to instability and compensatory facet arthrosis.
Eubanks JD et al (2007) explored the contrary contention that facet degeneration precedes disc degeneration by examining 647 skeletal lumbar spines in a postmortem study. Using facet osteophytosis as a measure of facet degeneration and vertebral rim osteophytosis as a measure of disc degeneration
1) Specimens younger than 30 years of age had a higher prevalence of facet osteophytosis compared with vertebral rim osteophotosis at L1-L2 and L2-L3.
2) Specimens aged 30 to 39 years showed more facet osteophytosis than vertebral rim osteophytosis at L4-L5.
3) Specimens older than 40 years, however, showed more vertebral rim osteophytosis compared with facet osteophytosis at all levels except L4-L5 and L5-S1.
This study suggested:
Facet osteophytosis appears early in the degenerative process, preceding vertebral rim osteophytosis of degenerating intervertebral discs. However, once facets begin deteriorating with age, vertebral rim osteophytosis overtakes continued facet osteophytosis.
These data challenge the belief that facet osteophytosis follows vertebral rim osteophytosis; rather, it appears vertebral rim osteophytosis progresses more rapidly in later years, but facet osteophotosis occurs early, predominating in younger individuals.

Morphologic changes in the VMO in patients with osteoarthritis of the knee.

Specimens of vastus medialis muscle from 78 patients with end-stage OA of the knee undergoing total joint arthroplasty were examined histopathologically in one study by Kink B et al in 2007.
1) The study revealed all muscle specimens exhibited atrophy of type 2 fibers. In 32% of the patients, atrophy of type 1 fibers was also noted. Selective atrophy of type 2 fibers might reflect pain-related immobilization of a limb. 68% of the specimens was interpreted as possibly resulting from pain-associated disuse.

2) Changes such as neurogenic muscular atrophy, muscle fiber degeneration, and regeneration might contribute as cofactors in the development or progression of OA.

3) Soft tissue changes indicating long-term disease, such as calcification, fibrosis, and lipomatosis, were frequently observed (in 69%, 71%, and 94% of the patients, respectively).

4) This study also revealed a significant association between degenerative muscle changes and the presence of a varus deviation of the leg axis.


Gout may mimic conditions as diverse as:
1) Joint and soft tissue infections,
2) Skin malignancies,
3) Nerve compression syndromes and
4) Soft tissue tumors.
Upper limb involvement is unusual in gout. But cases of gout in the hand and wrist masquerading as a soft tissue tumor, nodular extensor tenosynovitis, septic arthritis of the wrist and acute and chronic median nerve compression are also reported.


Working with trigger points associated with whiplash-associated disorders, fibromyalgia, nontraumatic chronic cervical syndrome, and endogenous depression Ettlin T et al (2008) found:
Patients with whiplash showed a distinct pattern of trigger point distribution that differed significantly from other patient groups and healthy subjects. The semispinalis capitis muscle was more frequently affected by trigger points in patients with whiplash.
They examined for trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus, and masseter muscles bilaterally.

Friday, August 1, 2008

Musculoskeletal disorders associated with obesity

To date, the majority of research has focused on the impact of obesity on bone and joint disorders, such as the risk of fracture and osteoarthritis. However, emerging evidence indicates that obesity may also have a profound effect on soft-tissue structures, such as tendon, fascia and cartilage.

Although the mechanism remains unclear, following is the possible mechanism:

functional and structural limitations imposed by the additional loading of the locomotor system in obesity have been almost universally accepted to produce abnormal mechanics during locomotor tasks, thereby unduly raising stress within connective-tissue structures and the potential for musculoskeletal injury.