Dr Satyajit Mohanty blogs

Is Fibromyalgia a disease? 1. According to Goldenberg DL Fibromyalgia is considered a controversial diagnosis as the disorder is a ‘non-disease’, due in part to a lack of objective laboratory tests or medical imaging studies to confirm the diagnosis. 2. As the criteria accurately diagnosing such an entity (Fibromyalgia) has not yet been thoroughly developed. According to Yunus MB, the recognition that fibromyalgia involves more than just pain has led to the frequent use of the term "fibromyalgia syndrome". History & meaning: Historically Fibromyalgia is considered either a musculoskeletal disease or neuropsychiatric condition, evidence from research conducted in the last three decades has revealed abnormalities within the brain CNS regions. Fibromyalgia (new lat., fibro- fibrous tissue, Gk. myo- muscle, Gk. algos- pain), meaning muscle and connective tissue pain (also referred to as FM or FMS). S/S: Fibromyalgia is a disorder classified by the presence of chronic widespr...

Introduction: Generically, neck-tongue syndrome is an acute presentation brought about by rapid neck movements, and involves a distribution of symptoms only within the face/head, most often reported as numbness in the tongue. This is usually caused by an acute subluxation (partial dislocation) of the top two vertebrae of the neck, which causes abnormal input to cranial nerves and can cause symptoms in the cranium (head). Definition: According to McGraw-Hill Concise Dictionary of Modern Medicine; NTS is a condition characterized by sharp pain and tingling of the upper neck and/or occiput on sudden neck rotation, with numbness of the ipsilateral half of the tongue; the NTS is attributed to stretching the C2 ventral ramus, which contains proprioceptive fibers from the lingual nerve to the hypoglossal nerve and 2nd cervical root. There are 2 categories of NTS: complicated NTS due to the presence of an underlying disease process (inflammatory or degenerative) and uncomplicated NTS (idiopath...

A butterfly vertebra, which is an uncommon congenital spinal anomaly needs to be identified correctly as confused with other pathologic conditions like fractures, infections, and metastases (2). Garcia F et al reported 2 patients, who had injuries to the dorsal spine with diagnosed compression wedge fracture. Similarly a study presented by Patinharayil G et al showed anterior wedging (2). In both a careful study of the anteroposterior radiographs showed that the presumed injury was a butterfly vertebra. This rare congenital anomaly, which is usually without clinical significance, may be mistaken for a wedge fracture unless the anteroposterior view is correctly assessed (1). Butterfly vertebra: an uncommon congenital spinal anomaly. Butterfly vertebra presents with: 1. Complaints of low back pain (non-specific) 2. Spinal deformity such as (abnormal bony prominence) 3. Usually routine examination of the motor and sensory system usually is normal. Investigations of importance: Ra...

Work of Lethem et al (2): Lethem et al. introduced a so-called 'fear-avoidance' model to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. Off late a number of investigations have refined the fear-avoidance model. Role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability: 1. The possible precursors of pain-related fear include the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity. 2. A number of fear-related processes including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and p...

Veronica Yu, B.Sc., D.Ac., D.C. ( www.familyhealthoptions.com/ uploads/Admin/Sta... ) says that all trauma, strains and stresses are stored in your body. Over time this build up can lead to restricted functioning and other health problems. BODY is comprised of physical, mental, spiritual and emotional components that are integrated together. Which is so true to it's core. Most of us can study the impact of acute & chronic insults on physical aspects. Remember bloggers we are trained to perceive indifferent aspects as different entities & mostly good at studying one aspect only. I just ponder how necessary for holistic therapies to start functioning globally?

Change in movement pattern: The muscles can often serve as “windows” to the function of the CNS. The CNS regulates 2 muscle groups: The tonic muscle group and the phasic muscle group. These muscle groups oppose each other in function. The tonic muscle group functions as a facilitator, the phasic muscle groups inhibition. Pain, pathology or adaptive changes in the system result in compensations or adaptations that lead to systemic and predictable patterns of muscle imbalance. “Altered movement pattern” is a movement pattern in which a change occurs in the coordination of the muscle firing sequences for a specific group of muscles, facilitating a specific joint movement. The primary muscle responsible for specific joint movement may become weak and inhibited, causing a synergistic muscle/muscles to become hyperactive. As a result, a different sequence of muscular contractions occurs. This is a sign of muscle imbalance in the body because of muscular dysfunction. When any component of the...

Upper Cross Syndrome is a terminology used by V.Janda that refers to a chronic postural error i.e. Upper Cross Syndrome describes a compromise in the musculoskeletal system which tightens or facilitates the anterior compartment of the “upper” torso while at the same time weakening the posterior. While the majority of muscles involved in Upper Cross Syndrome are anterior to the shoulders there are a few posterior elements to consider as well. The chest muscles & the neck muscles (both posterior and anterior compartments) become tight and shortened (see the diagram). Consequently, you have a weakening or elongating of the scapular muscles. The tight muscles: Anteriorly, you have a tightening/shortening of the Pectoralis Major, Pectoralis Minor, Anterior Deltoid fibers, Sternocleidomastoids, and Scalenes. Posteriorly, you have tightening/shortening of the Levator Scapulae, Teres Major, Upper Trapezius, and Suboccipitals. The weak muscles are: The weakening of the Scapular muscles incl...

Finding a abdominal trigger point is a hall mark in diagnosing a chronic pelvic pain (CPP). The test that is done to find a abdominal trigger point is called Carnett's sign. Carnett's sign: (see the picture ) The examiner places his or her finger on the tender area of the patient's abdomen and asks the patient to raise both legs off the table. An increase in the patient's pain during this maneuver is considered a positive test.

See the above link of poor posture to facio-dental abnormalities. this diagram is credited to following site: www.scielo.br/.../ clin/v64n1/a11fig01.gif

History & prevalence: According to Mut M et al of Turkey Intraradicular disc herniation is a special type of intradural disc herniations (7). The mechanism of the tearing of the dura mater by a herniated disc is not known with certainty (6). Akdemir H et al (1997) presented case in which a fragment of herniated lumbar disc was found within the sheath of the right S1 nerve root (5). How ever before 1997 there have been reports of such cases. According to a paper by Nazzal MM et al in journal of spinal disorder (1995) Intradural disc herniation accounts for Clinical signs & symptoms: The Intraradicular disc herniations may present from no symptoms (!!!) to symptoms presenting with profound neurological deficits (see the case studies below). Lakshmanan P presented 2 case studies one of them presented with no neurological deficit. Hence they have concluded that diagnosis of posterior epidural migration of the sequestrated discs may be difficult even it may be present with subtle cl...

Grades of Evidence I: Evidence obtained from at least one properly designed randomized controlled trial. II-A: Evidence obtained from well-designed controlled trials without randomization. II-B: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group. II-C: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Levels of Recommendations Level A — Recommendations are based on good and consistent scientific evidence. Level B — Recommendations are based on limited or inconsistent scientific evidence. Level C — Recommendations are based primarily on consensus and expert opinion.

Intradural disc herniation is a serious complication of intervertebral disc rupture. Intradural disc herniations are thought to be rare events, and there have been relatively few literature reports of intradural disc herniations. CT finding of epidural gas indicates Intradural disc herniation? Intradural disc herniation associated with epidural gas (1). According to Hidalgo-Ovejero AM et al possibility of an intradural herniated disc must always be considered in a patient whose CT scan reveals the presence of epidural gas. They also suggest, in the event where no clear disc herniation is found to justify the clinical symptoms or the previous radiologic findings, an intradural exploration may be indicated. The study by Hidalgo-Ovejero AM et al: Hidalgo-Ovejero AM et al in the year1998, presented a case study that cautioned spine surgeons of the possible association of intradural disc herniation and epidural gas, to prevent overlooking intradural disc fragments during surgery. This spine...

The purpose of this article is to introduce the reader to pudendal neuropathy & physical therapy treatment options. Chronic pelvic pain can present in various pain syndromes (1). PPOD (pelvic pain and organic dysfunction) is not an uncommon finding in the low back pain patient. Women appear to be more frequently involved than men (2). 3 types of pelvic pain syndromes (1): 1. Pudendal neuralgia, 2. Piriformis syndrome, and 3. "Border nerve" syndrome (ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy). Piriformis syndrome is an uncommon cause of buttock and leg pain. Chronic neuropathic pain arise from the lesion or dysfunction of the ilioinguinal nerve, iliohypograstric nerve, and genitofemoral nerve (1). Pudendal neuralgia commonly presents as chronic debilitating pain in the penis, scrotum, labia, perineum, or anorectal region. The pudendal nerve is located between the sacrospinous and sacrotuberous ligaments at the level of ischial spine (1). The resu...

Historically, the bicycle has evolved through the stages of a machine for efficient human transportation, a toy for children, a finely-tuned racing machine, and a tool for physical fitness development, maintenance and testing (2). The underlying principle of positioning a cyclist on a bicycle is to remember that the bicycle is adjustable, and the cyclist is adaptable (1). Proper bicycle fit requires (1) 1. Careful review of bicycle selection, 2. Saddle height for proper leg extension, 3. Fore-and-aft positioning of the knee over the pedal, 4. Saddle tilt, 5. Handlebar position, and 6. Positioning of the upper body for optimum comfort and performance. 7. Maintaining an aerodynamic position for extended periods of time (Recently, major strides have been made in the aerodynamic design of the bicycle. These innovations have resulted in new land speed records for human powered machines. N.B. fatigue patterns in lower and upper body musculature play an important role in ...

The description of pain or altered sensation in the involvement of autonomic nesvous system especially sympathetic nervous system are as follows: 1. feeling of foreign body 2. feeling of a stake 3. feeling of a lump within 4. feeling of heaviness of the part 5. feeling of a tennis ball within 6. feeling of a gnawing 7. a crawling feeling *Pain in CRPS i.e. RSOD (reflex sympathetic osteodystrophy) must also be compared to above said description.

Introduction: Among unusual abnormalities of the lumbar spine reported since the introduction of Computed Tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated (7). The finding of gas within the vertebral disc space (vacuum phenomenon) is relatively common. This disorder often presents major diagnostic and therapeutic challenges, especially in the presence of multiple degenerative changes and chronic back pain in elderly patients. Kloc W (8) describes pathophysiology and diagnostics of gaseous degeneration associated with the herniated disc. Degenerative spine disease, gaseous degeneration of the intervertebral disc and epidural gas can be disclosed by imaging studies. The presence of epidural gas is attributed to gaseous disc degeneration. This pathology may cause radicular pain similar to sciatic pain produced by disc herniation. Surgery might be indicated in these cases. The initial reports on epidural gas (6): The author...

Epidural engorged veins due to inferior vena cava obstruction or occlusion cause sciatica and low back pain. Pathology: Abnormalities or pathological changes of epidural venous network may give rise to symptoms similar to or mimicking lumbar disc herniation or spinal stenosis. Multiple lumbar epidural varices can cause nerve root and thecal sac compression. Lumbar epidural varices have been infrequently described in the literature. To date, the cause of anterior epidural venous enlargement has been poorly understood, and both congenital and acquired causes have been proposed. This report describes enlarged epidural veins in patients with inferior vena caval thrombosis or obstruction presenting with radicular syndromes. About the study: Paksoy Y have examined 9640 patients experiencing back pain or sciatica, using MRI. There were 13 (0.13%) patients who had radicular symptoms that clinically mimicked lumbar disc herniation or spinal stenosis. All of these patients had inferior vena cava...

Foot drop is a common and distressing problem that can lead to falls and injury. Causes: 1. Most frequent cause is a (common) peroneal neuropathy at the neck of the fibula, 2. Anterior horn cell disease, 3. Lumbar plexopathies, 4. L5 radiculopathy and 5. Partial sciatic neuropathy. 6. Habitual leg crossing may well be the most frequent cause and most patients improve when they stop this habit. Even when the nerve lesion is clearly at the fibular neck there are a variety of causes that may not be immediately obvious. A meticulous neurological evaluation goes a long way to ascertain the site of the lesion. Basic investigations: 1. Nerve conduction and electromyographic studies are useful adjuncts in localising the site of injury, establishing the degree of damage and predicting the degree of recovery. 2. Imaging is important in establishing the cause of foot drop if it is at the level of the spine, along the course of the sciatic nerve or in the popliteal fossa; Imaging...

Pedaling has been shown to be an effective rehabilitation exercise for a variety of knee disorders. Recently, backward gait has been shown to produce greater knee extensor moments and reduced patellofemoral joint loads compared to forward gait. No study has examined the efficacy of backward pedaling as a safe alternative to forward pedaling in rehabilitation programs. Neptune RR et al compared the knee joint loads while knee is performing during forward and backward pedaling. The aim was to determine whether backward pedaling offers theoretical advantages over forward pedaling to rehabilitate common knee disorders. The study: 1. This study primarily quantified Tibiofemoral and Patellofemoral joint reaction forces. 2. Lower tibiofemoral compressive loads, but higher patellofemoral compressive loads, were observed in backward pedaling. 3. Lower protective anterior-posterior shear force was observed in backward pedaling near peak extension. Clinical notes for implementation: 1. B...

The usefulness of continuous passive motion after total knee arthroplasty remains controversial. The reported benefits include: 1. Decreased rates of knee manipulation, 2. Decreased rates of deep vein thrombosis, 3. Decreased rates of postoperative use of analgesics, 4. Greater range of motion. The reported disadvantages include: Many studies have reported 1. Increased wound complications, bleeding, and pain. Confusion & debate on use of CPM: Lack of consensus on the use of continuous passive motion exists because reported studies include many confusing variables. Advocating for use of CPM: 1. Several studies have shown that continuous passive motion in the hospital decreased the rate of knee manipulation from as high as 21% to as low as 0%. However, many studies show that range of motion may improve more rapidly with continuous passive motion but the ultimate range of motion at follow-up is unchanged. 2. Continuous passive motion is used three times per day (...

Postoperative stiffness is a debilitating complication of total knee arthroplasty. Preoperative risk factors include limited range of motion, underlying diagnosis, and history of prior surgery. Intra-operative factors: 1. Improper flexion-extension gap balancing 2. Oversizing or malpositioning of components 3. Inadequate femoral or tibial resection 4. Excessive joint line elevation 5. Creation of an anterior tibial slope and 6. Inadequate resection of posterior osteophytes. Postoperative factors: 1. poor patient motivation 2. arthrofibrosis 3. infection 4. complex regional pain syndrome (CRPS) and 5. heterotopic ossification. The first steps in treating stiffness are mobilizing the patient and instituting physical therapy . If these interventions fail, options include manipulation, lysis of adhesions, and revision arthroplasty. Closed manipulation is most successful within the first 3 months after total knee arthroplasty. Arthroscopic or modified open ...

Yercan HS et al investigated the prevalence of stiffness after total knee arthroplasty, and the results of the treatment options. Yercan HS et al performed 1188 posterior-stabilized total knee arthroplasties between 1987 and 2003. They found: 1. The prevalence of stiffness was 5.3%, at a mean follow-up 31 months postoperatively. The average age was 71 years (range, 54-88). 2. The patients with painful stiffness were treated by two modalities: manipulation and secondary surgery. 3. In the manipulation group (n:46), the mean range of motion improved from 67 degrees before manipulation to 117 degrees afterward. This improvement was maintained at final follow-up as 114 degrees. 4. There was no significant difference between the motion, immediately after manipulation and at final follow-up. However, motion at final follow-up was better for those manipulated early to those done later (p=0.021). 5. In the secondary surgery group (n:10), the mean gain in motion was 49 degrees at...

Hamstring strains can be of 2 types with different injury mechanisms, 1 occurring during high-speed running and the other during stretching exercises. In a study involving Case series (prognosis); Askling CM et al found Stretching exercises can give rise to a specific type of strain injury to the posterior thigh. A precise history and careful palpation provide the clinician enough information to predict a prolonged time until return to pre-injury level. One factor underlying prolonged recovery time could be the involvement of the free tendon of the semimembranosus muscle. About the study: 1. 15 professional dancers with acute first-time hamstring strains were prospectively included in the study. 2. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. 3. The clinical follow-up period was 2 years. How & where injury occurred: 1. All dancers were injured during slow hip-flexion movements wi...

Proximal joint stability leads to controlled execution of distal joint motions & functions. Hence decreased hip strength may be associated with poor control of lower extremity motion during weight-bearing activities, leading to abnormal Patellofemoral motions and pain. Studies exploring the presence of hip strength impairments in subjects with PFPS have reported conflicting results. In a cross-sectional (female only study) Robinson RL et al investigated whether females seeking physical therapy treatment for unilateral patellofemoral pain syndrome (PFPS) exhibit deficiencies in hip strength compared to a control group. Sample & method: 1. 20 aged 12 to 35 years, participated in the study. Ten subjects with unilateral PFPS were compared to 10 control subjects with no known knee pathologies. 2. Hip abduction, extension, and external rotation strength were tested using a handheld dynamometer. 3. A limb symmetry index (LSI) was used to quantify physical performance for all tests. Re...

Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique. Iverson CA et al tried to determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. Sample & method: 1. 50 subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. 2. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). 3. The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pa...

Data regarding validity of clinical and radiographic findings in diagnosing patellofemoral pain syndrome are inconclusive. 1. 5 clinical tests in patellofemoral pain syndrome are: 1. Vastus medialis coordination test 2. Patellar apprehension test 3. Waldron's test 4. Clarke's test 5. Eccentric step test. Nijs J et al examinied the validity of five clinical patellofemoral tests used in the diagnosis of patellofemoral pain syndrome (PFPS). Nijs J et al examinied above said 5 clinical tests in Likelihood ratio. (See below for interpretation of likelihood ratio) Sample size: 45 knee patients were divided into either the PFPS or the non-PFPS group, based on the fulfilment of the diagnostic criteria for PFPS. Focus points: 1. The positive likelihood ratio was 2.26 for both the vastus medialis coordination test and the patellar apprehension test. 2. For the eccentric step test, the positive likelihood ratio was 2.34. Hence a positive outcome on either the vastus mediali...