Dr Satyajit Mohanty blogs

TODAY'S TOPICS ARE TARGETD TO INDIAN PHYSIOS. WE IN OUR CORRICULLUM ARE DEFIENT IN FUNDAMENTAL UNDERSTNDING OF FASCIA & IT'S STATIC/DYNAMIC BEHAVIOUR MYOFASCIAL RELEASES WE BELIEVE THEY ARE HIGHLY EFFECTIVE TECHNIQUES & MUST BE INCLUDED IN OUR SYLLABUS. INTRODUCTION Myofascial Release is a form of soft tissue therapy which includes, but is not limited to, structural assessments and manual massage techniques for stretching the fascia and releasing bonds between fascia, integument , muscles , and bones are applied with the goal of eliminating pain, increasing range of motion and balancing the body. The fascia is manipulated, directly or indirectly, which allows the connective tissue fibers to reorganize themselves in a more flexible, functional fashion. In addition, Myofascial release (note the lower case r) may be considered a general manual massage technique any 'lay person' can use to eliminate general fascial restrictions on a living mammalian body. Fascia...

Introduction Fascia is a specialized connective tissue layer surrounding muscles, bones and joints and gives support and protection to the body. It consists of three layers - the superficial fascia, the deep fascia and the subserous fascia. Fascia is one of the 3 types of dense connective tissue (the others being ligaments and tendons) and it extends without interruption from the top of the head to the tip of the toes. Fascia is usually seen as having a passive role in the body, transmitting mechanical tension, which is generated by muscle activity or external forces. Recently, however some evidence suggests that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics. Obviously, if this is verified by future research, any changes in the tone or structure of the fascia could have significant implications for athletic movements and performance. This research notwithstanding, the occurrence of trigger points within dense ...

How do pain and function vary with compartmental distribution and severity of radiographic knee osteoarthritis? In OA affected knee identified by positive X-ray picture, how does radiographic severity and pattern of compartmental involvement influence symptoms? In a Population-based study of 819 adults aged >/=50 yrs with knee pain, Duncan R et al tried to find the answers. He found: 1. It is the severity of radiographic disease within a compartment, rather than the distribution of radiographic disease between compartments that is associated with symptoms. 2. Positive X-ray in the PF joint is associated with symptoms, emphasizing the importance of radiographic changes in his joint. How we must target physiotherapy for patellofemoral joint osteoarthritis? The patellofemoral joint (PFJ) is one compartment of the knee that is frequently affected by osteoarthritis (OA) and is a potent source of OA symptoms. However, there is a dearth of evidence for compartment-specific treatments for P...

I have often found that when a subject confuses me, or when I have partial knowledge of an area of my work, the best way of really getting to grips with the problem is to write a book about it - a process that virtually guarantees sufficient research and study to really understand it by the time the book is finished! Leon Chaitow, DO

During the past decade application of extracorporal shock waves became an established procedure for the treatment of various musculoskeletal diseases in Germany. Extracorporeal shockwave therapy (ESWT) has been in use for the treatment of tendinopathies since the early 1990s. Mechanism of working: The exact mechanism by which ESWT relieves tendon-associated pain is not known; however, there is an increasing body of literature that suggests that it can be an effective therapy for patients who have had repeated non-surgical treatment failures. Controversies surrounding ESWT: There is still much debate over several issues surrounding ESWT that have not been adequately addressed by the literature: high- versus low-energy ESWT, shockwave dosage and number of sessions required for a therapeutic effect. Further research is needed to ascertain the most beneficial protocol for patient care. ESWT is employed in following conditions with high degree of success by physios even in fairly resistant ...

Introduction: Many studies show that; given a more proximal root compression (for example root compression at cervical transverse foramina) less involvement of the median nerve across the carpal tunnel was required to produce symptoms of CTS (carpal tunnel syndrome). The surgical outcome of carpal tunnel release in this double crush group is poorer than in that group with isolated carpal tunnel involvement. It is important to preoperatively identify those patients who may have double crush lesions and thus anticipate a less than optimal result from surgical release of the peripheral nerve. So let us review what a double crush syndrome means? The double-crush syndrome was initially described by Upton and McComas in 1973. Multilevel lesions along a peripheral nerve trunk do occur. In the double crush syndrome as postulated by Upton and McComas, the presence of a more proximal lesion does seem to render the more distal nerve trunk more vulnerable to compression. Concrete support of exist...

Introduction: Of late we have seen many INDIAN physios especially young ones are getting fascinated by Osteopathic manipulative treatments. Study 3 discussed below just gives us an idea where osteopaths employ spinal manipulations. A few CPD/paid seminar providers though moderate in their cost; are currently providing module courses on the same. I doubt many young physios even know when they slip from a physiotheputic domain to Osteopathic domain. No doubt techniques such as myofascial releases, MET are quite helpful but what about different spinal manipulations? Do they have any current scientific evidence to induct them in our day to day clinical practice? Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal man...

In a study by von Knorring AL et al (2008) of Department of Neuroscience, Uppsala University, Sweden ( anne-liis.von_knorring@bupinst.uu.se ) showed Daily touching by massage lasting for 5-10 min could be an easy and inexpensive way to decrease aggression among preschool children.

What is centralization? Centralization refers to the abolition of distal pain emanating from the spine in response to therapeutic exercises. According to a review article in Manual Therapy 2004 Aug;9(3):134-143; authored by Aina A et al focused on prognostic significance along with prevalence and reliability of assessment. The prevalence rate of pure or partial centralization was 70% in 731 sub-acute back patients, and 52% in 325 chronic back patients. Points to remember: 1. It is a symptom response that can be reliably assessed during examination. 2. Centralization is consistently associated with a range of good outcomes, and failure to centralize with a poor outcome. 3. Centralization appears to identify a substantial sub-group of spinal patients; it is a clinical phenomenon that can be reliably detected, and is associated with a good prognosis. 4. It is recommended that centralization should be monitored in the examination and reexamination of spinalpatients.

NSAIDs are some of the most widely consumed medications in the world. Painful conditions i.e. mostly acute conditions of athletes are treated with non steroidal anti-inflammatory drugs (NSAID). While NSAIDs have become synonymous with the management of acute musculoskeletal injuries, their efficacy has yet to be proven. The major goal of clinicians when treating acute musculoskeletal injuries is to return athletes to their pre-injury level of function, ideally in the shortest time possible and without compromising tissue-level healing. 1. According to Fournier PE et al (2008), there is a lack of high-quality evidence to use NSAIDS. 2. According to Fournier PE et al (2008), the adverse effects of NSAIDS medications include potential negative consequences on long-term healing process. According to Mehallo CJ et al NSAIDs are not recommended in the treatment of completed fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle injury. According to Al...

Sharma KR (2001) studying on Median sensory nerve conduction velocity: found digit 1 to wrist is more sensitive than the median sensory nerve conduction velocity distoproximal ratio in the diagnosis of mild CTS. However, Electrodiagnostic studies have significant false-positive and false-negative rates in CTS, and therefore provocative tests remain important in its diagnosis. Tinel's (nerve-percussion test), Phalen's(wrist-flexion test,), Reverse Phalen's and carpal tunnel compression tests (tourniquet test) are more sensitive and very commonly employed for physical diagnosis of CTS. In a study consisting of 50 control subjects with electrodiagnostically proved carpal-tunnel syndrome found following: The sensitivity and specificity of each test of the above were calculated. The wrist-flexion test was found to be the most sensitive while the nerve-percussion test, although least sensitive, was most specific. The tourniquet test was quite insensitive and not very specific, a...

The shear is normally resisted by the annulus fibrosus, compression of the facets at the apophyseal joints, and by tension in the anterolateral layers of cortical bone in the pars interarticularis. 1. The failure strength and the anterior shear-strength of the disc, spinal ligaments are very high. 2. The ariculation of facet joints (Capacity of the pars for resisting tensile forces anteriorly at L4 and L5 has been reported at up to 2500 N) 3. In case of retrolysthesis; even the posterior displacement of the inferior facets reported to be 6.5 mm at failure. Anterior displacement in spondylolisthesis is a slow process. The forces contributing to anterior shear arise from following things: 1. from vertical load on the spine above the lesion 2. from activity in the muscles of the spine and trunk 3. from the effects of movements.

Many patients report to us with hip and groin pain (usually unilateral) with pain only on crossed sitting and less often with walking stairs, squatting or getting from squatting. FABER test for inguinal pain is positive & SLR is 80 degree suggests that there is no involvement of SI or lumbar spine. I am surprised that it does not match with any common or remote possible pathologies of hip. If FABER is the only sign what the therapist should do? Let us discuss. The FABER test: Passively flex, abduct, and externally rotate the hip of the lower extremity that is to be tested while subjects is in a supine position, so that the lateral malleolus of the tested lower extremity rests just superior to their opposite extended knee. The test response for hip disorders is an inguinal pain. Similarly the test response for SI disorder is LBA or posterior sacral pain. For physio researchers: Measurement can be done like the following way: the vertical distance between a fixed mark on the latera...

1. Skeletal muscle is the largest organ in the human body. In modern society, myofascial pain is a major cause of morbidity. 2. Any of these muscles may develop pain and dysfunction. It may present as regional musculoskeletal pain, as neck or back pain mimicking radiculopathy. It may also present as shoulder pain with concomitant capsulitis, and hip or knee pain with concomitant osteoarthritis. 3. The condition is treatable. However, it is often under-diagnosed and hence undertreated. Traditional medical training and management of musculoskeletal pain have focused much attention on bones, joints and nerves. 4. During history taking and physical examination, precipitating and perpetuating factors, taut bands, trigger points, tender spots and sensitised spinal segments have to be accurately located for successful institution of treatment. 5. There is also a high recurrence rate unless appropriate exercises are prescribed, with active participation from the patient, to restore flexib...

How to assess physical activity? How to assess physical fitness? I have discussed this issue in detail my forthcoming book. Regular aerobic physical activity (PA) increases exercise capacity and physical fitness (PF), which can lead to many health benefits. Accurate quantification of PA and PF becomes essential in terms of health outcome and effectiveness of intervention programmes. Three types of PA assessment methods can be distinguished: criterion methods, objective methods and subjective methods. 1. Criterion methods like doubly labelled water, indirect calorimetry and direct observation are the most reliable and valid measurements against which all other PA assessments methods should be validated, but they also hold important drawbacks. 2. Objective PA assessment methods include activity monitors (pedometers and accelerometers) and heart rate monitoring. 3. Finally, questionnaires and activity diaries are considered subjective methods . For the assessment of PF, we distingu...

JOASSIN R et al (2008) reported 3 cases. They elaborated the diagnosis and treatment of adhesive capsulitis of the hip as follows: Diagnosis: 1. Adhesive capsulitis of the hip is a supposedly rare but probably underestimated condition which predominantly affects middle-aged women. 2. Clinical assessment reveals a painful limitation of joint mobility. (may be capsular pattern) 3. The diagnosis is confirmed by arthrography, where the crucial factor is a joint capacity below 12ml. DD: 1. Osteoarthritis and 2. complex regional pain syndrome type 1 are the two main differential diagnoses. The treatment: The first-line treatment consists of sustained-release corticosteroid intra-articular injections and physical therapy. Arthroscopy and manipulation under anaesthesia

ACL injury rehabilitation; conservatively or after reconstruction, is both difficult and time taking. It may take as long as a year before the athlete returns to competitive sports. For a athlete ACL injury is a shattering experience. Anterior cruciate ligament (ACL) injuries are common in athletes participating in sports requiring jumping and pivoting maneuvers i.e. often during landing from a jump or making a lateral pivot while running where knee joint movement overcomes both the static and the dynamic constraint systems. 70% ACL injuries occur in non-contact situations. It is estimated that 80,000 anterior cruciate ligament (ACL) tears occur annually only in the United States. The highest occurrences are seen in the individuals 15 to 25 year age groups. Estimated treatment cost of treatment in ACL injuries of almost a billion dollars per year only in USA. Few authorities have developed screening protocols for the identification of high-risk athletes. Potential risk factors such a...

ASK ME ABOUT THE BOOK & ON THE CONTENTS OF THE BOOK IN FOLLOWING ADDRESS: satyajit.mohanty@rediffmail.com satyajit.mohanty74@gmail.com Who require this book? 1. Obesity and body composition analysis is taught as a syllabus subject in following streams: Undergraduate medicine syllabus (MBBS): obesity is covered in General medicine (through out India)- As a referral book 2. UG physiotherapy, PG in sports physiotherapy/ sports medicine: body composition analysis & weight management (all universities imparting this course)- As a text & refferal book 3. Other fields requiring this book (where diet & exercise consultation is a primary part of the consultation): (As a text book) 4. Fitness & nutrition sciences Sports & exercise sciences PG in physical education Weight reduction professionals (an absolute must-have) A futuristic out look of this book: In many universities of UK, obesity management is a PG (2 year) & PG diploma (1 year) course ***Order through thi...

In research studies specially epidemiological studies trying to find out incidence; say incedence of a pirticular injury in females may be influenced by a gender gap. the paricipation of males and females are not uniform across all the sporting faculties hence assuming homogenity of sports participation in both sexes may lead to errors of incidences of a pirticular injury say the ACL injury is seen 4-6 times more in females. this kind of error can be assigned to gender gap.

Major causes of non-discogenic sciatica (NDS) both from infective and are as follows: 1. lumbar radicular herpes zoster, 2. lumbar nerve root schwannoma, 3. lumbar instability, 4. facet hypertrophy, 5. ankylosing spondylitis, 6. sacroiliitis, 7. sciatic neuritis, 8. piriformis syndrome, 9. intrapelvic mass and 10. coxarthrosis (coax = hip) The pain pattern and accompanying symptoms were the major factors suggesting a non-discogenic etiology. How to go about diagnosis: 1. Detailed physical examinations with special attention paid to the extraspinal causes of sciatica and to pain characteristics are the major components of differential diagnosis of NDS. 2. Investigations: Pelvic MRI and CT scans, and sciatic nerve magnetic resonance neurography were the main diagnostic tools for diagnosis of NDS. 3. The treatment of choice depended on the primary diagnosis.

1.1 Work related or occupation related pain is called repetitive stress injuries (RSI) or cumulative trauma disorders (CTD). They are usually caused by poor posture while working, poor work place accessories such as inadequate chair and table height, tension related due to work, working more than scheduled hours etc. 1.2 According to a Cochrane review 1. Incidence: In the USA, cumulative trauma disorders account for between 56 and 65% of all occupational injuries. 2. Prevalence: Overall, the estimated prevalence of these injuries is approximately 30% and the incidence is rapidly increasing. 1.3 Interventions: Conservative interventions such as physiotherapy and ergonomic work-place adjustments play a major role in the treatment. Research input suggests: 1. That there is positive effect of exercise when compared to massage 2. Adding breaks during computer work helps 3. Massage adds to the treatment out come of manual therapy, manual therapy as add-on to treatment by exercises 4. Changin...

New developments in frozen shoulder therapy gaining popularity 1. Bowen therapy (a complementary therapy) 2. Subcsapular trigger point injections 3. Subscapular nerve block 3. Arthroscopic capsular distension 4. Arthroscopic capsular release 5. thoraco brachial abduction device 6. interscalene brachial plexus block 7. Oral steroids: Two placebo-controlled trials and one no-treatment controlled trial provides "Silver" level evidence (www.cochranemsk.org) that oral steroids provides significant short-term benefits in pain, range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks.

Special cases of only posterior capsular contracture revealed in the throwing athletes: In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. In adhesive capsulitis posterior capsule is said to be more affected but in my opinion the entire capsule is affected and the arthrokinematic evaluation of joint plays must decide which is the part more affected. An article on Posterior capsular contracture was published in journal of American academy of orthopaedic surgeons. The points to remember about posterior capsular contracture are as follows: 1. Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. 2. Increased anterosuperior tr...

THE DEBATE TOPIC: Descending neuro-hormonal mechanism does not produce hypoalgesia in manual therapy induced pain relief. It was earlier claimed that this above said statement is only true for spinal manual therapy procedures NOT for peripheral manual therapy/ mobilization procedures. THE ANSWAR: Recent research has shown that Mulligan's Mobilization With Movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia (48% increase in pain-free grip strength). This above said hypoalgesic effect with Mulligan’s MWM is far greater than that previously reported with spinal manual therapy treatments, prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques. Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control m...

Study 1: A novel 3D analyzing system for the relative motions of individual vertebrae using 3D MRI; analyzed 3D in vivo intervertebral motions of the lumbar spine during trunk rotation revealed following data: 3D MRI of the lumbar spine was done in 9 positions with 15 degrees increments during trunk rotation (0 degree, 15 degrees, 30 degrees, 45 degrees, and maximum). 1. The mean axial rotation of ten healthy volunteers of each lumbar spinal segment in 45 degrees trunk rotation to each side ranged from 1.2 degrees to 1.7 degrees. 2. Coupled flexion with axial rotation was observed at the segments from L1/2 to L5/S1. 3. Coupled lateral bending of the segments from L1/2 to L4/5 was in the opposite direction of the trunk rotation, while that of T12/L1 and L5/S1 was in the same direction. 4. The direction of the coupled lateral bending in the present study was different from that in the previous cadaver study only at L4/5. Study 2: Clinically, lumbosacral list is a common posture. Ra...

The intervertebral motion measures were all interrelated. There was considerable variation in intervertebral motion. Intervertebral level and total gross rotation between C2 and C6 significantly affected all measures of intervertebral motion. Evaluating various aspects of intervertebral motion may improve the clinical efficacy & also will be helpful as the basis for understanding abnormal conditions. A MRI studies reveal; in 3-D intervertebral motions of the subaxial cervical spine during head rotation; in healthy volunteers, following data 1. The subaxial cervical spine in maximum head rotation a. Mean axial rotation with Maximum head rotation = 69.5 degrees. b. C2-C3 = 2.2 degrees c. C3-C4= 4.5 degrees d. C4-C5= 4.6 degrees e. C5-C6= 4.0 degrees f. C6-C7= 1.6 degree g. C7-T1= 1.5 degrees 2. Coupled lateral bending with axial rotation was observed in the same direction as axial rotation at all levels h. C2-C3 = 3.6 degrees i. ...

ASK ME ABOUT THE BOOK & ON THE CONTENTS OF THE BOOK IN FOLLOWING ADDRESS: satyajit.mohanty@rediffmail.com satyajit.mohanty74@gmail.com Who require this book? 1. Obesity and body composition analysis is taught as a syllabus subject in following streams: Undergraduate medicine syllabus (MBBS): obesity is covered in General medicine (through out India)- As a referral book 2. UG physiotherapy, PG in sports physiotherapy/ sports medicine: body composition analysis & weight management (all universities imparting this course)- As a text & refferal book 3. Other fields requiring this book (where diet & exercise consultation is a primary part of the consultation): (As a text book) 4. Fitness & nutrition sciences Sports & exercise sciences PG in physical education Weight reduction professionals (an absolute must-have) A futuristic out look of this book: In many universities of UK, obesity management is a PG (2 year) & PG diploma (1 year) course ***Order through this...

Introduction: The purpose of this following article is introduce new concepts emerging in trigger point hypothesis and describe new resulting approaches to the treatment of TrPs. Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and actuates movement against inertia. Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading. Muscular pain is often attributed to a myofascial pain disorder, a condition originally described by Drs Janet Travell and David Simons. Definition: Within each trigger point is a hyperirritable spot, the 'taut-band', which is composed of hypercontracted extrafusal muscle fibres. Two important clinical characteristics of trigger points, referred pain and local twitch response, can be elicited by mechanical stimulation (palpation or needling). Disease epidemiology: Among patients seeking treatment from a variety of medical spec...