Physio Charlie - reflection

New website!!

noreply@blogspirit.com (PhysioCharlie) — Mon, 09 Mar 2009 19:22:00 +0100

I have a new website!!

http://physiocharlie.vpweb.co.uk

Vertebroplasty

noreply@blogspirit.com (PhysioCharlie) — Mon, 06 Oct 2008 13:44:00 +0200

I wrote on the iCSP today on this discussion:

Osteoporotic fractures

Added by: hailstoner
Posted: 19 September 2008 10:30

I am looking into ways of managing back pain in the community following osteoporotic fractures / collapse.

All ideas welcome! Especially interested in peoples views on ultrasound, TENS, accupressure and corsets.
Thank you

Title:	Pain management in osteoporosis
Added by:	kevinanthony
Posted:	19 September 2008 13:10

This is a really good question that has sparked some debate in my own mind. Up until now I have referred back to the GP for medical management. In most cases this is probably the most appropriate form of action. That said, if we look at the evidence TENS is only effective for mild to moderate pain and that would probably exclude a lot of our clients. Acupressure / puncture in another thought, as are other forms of electrotherapy. I am going to monitor this debate. Thank you for raising it

Title:	Medical/Surgical Rx
Added by:	hughesgp
Posted:	19 September 2008 21:41

I agree that medical management has a lot of merit. I've tried TENS on a few patients, but its effectiveness was fairly short-lived.

I have found that in the patients with wedge/crush fractures that their paraspinal muscles are usually very tight - this puts me in a bit of a quandary - do I try and release muscles which are tight/spasming for pain relief, or will that actually take away some of the structural support to the spinal column and cause more pain with an arthrogenic origin. After all, the pain is there for a reason.

I've tried postural advice, and it works if adherence is good - but perhaps going down the route of modified Alexander Technique with gentle exercise would be OK - though I have read in the OP guidelines that trunk flexion and/or excessive rotation can make things worse.

A surgical option suggested by my senior was kyphoplasty - there is probably a surgeon/specialist in your area - worth a look at if the pain is not getting better with conservative treatment. I've not reviewed enough patients of this type to be offering more in-depth options, but I hope this sparks a bit more interest and discussion for you.

Title:	gibbus management and old TB spine....
Added by:	KarenML
Posted:	23 September 2008 13:35

Hi (this is a little lateral!)
Your question is one that is important to me, as I see quite a lot of old TB spine - which also causes wedge compression (and disk degeneration on top of it), and they present with quite marked deformities, although often not a lot of pain. I am investigating the best management options for long term biomechanic management, and would also value input. I spoke to an orthopod who is not keen on bracing as longer term x-rays apparently don't show any benefits, however I would be interested in any findings related to Physio outcome measures.
Thanks, Karen

Title:	Pain management in elderly spines
Added by:	vivblackwell
Posted:	26 September 2008 13:47

I am afraid, going on my own mother who is 93, and various patients, the only thing that really helped was weekly morphine patches. Nothing that I could offer really helped.
They haven't made her drowsy.

Title:	Managing pain in osteoporotic fractures
Added by:	lucy
Posted:	29 September 2008 11:35

I have found that the basics of good explanation/reassurance, good medical management from the GP and exploring alternative positioning strategies is usually successful, even when patients are reduced to minimal function due to severe pain. Tips on core stability work for difficult manouveres like lying to sitting, standing to sitting is useful (using transversus in preparation for difficult movements). I then work through a graded reintroduction of function programme which includes seating assessments and advice on opening bowels or any tasks that tend to cause extra pressure and therefore pain.

Lucy Simmons
Community Physiotherapy

Title:	Vertebroplasty
Added by:	charliecotterill
Posted:	06 October 2008 12:16

I had a patient who was in intense pain with what turned out to be osteoporotic fractures in his Tx. I referred him back to his GP and he was sent to orthopaedics. He eventually had vertebroplasty and returned to see me a year later for another problem and was pain free in his Tx.

See my blog:

http://physiocharlie.blogspirit.com/lx/

Charlie

Rotator Cuff tears

noreply@blogspirit.com (PhysioCharlie) — Wed, 10 Sep 2008 10:00:00 +0200

Rehabilitation of Patients with Massive Rotator Cuf Tears, Bobby Ainsworth F.C.S.P, Consultant Physiotherapist.

The Torbay protocol from Bobby Ainsworth is an eccentric deltoid programme instead of using standard r/cuff strengthening exercises:

http://bobbyainsworth.com/resources/CuffTear.pdf

or http://www.shoulderdoc.co.uk/article.asp?section=855&article=1028

A prime objective of the programme is to give the patient a good understanding of the cause of their shoulder problem and to ensure that they are aware of the goals of the rehabilitation programme.

• Improved scapula position- backward tilting of the scapula to increase subacromial space

• Strengthening anterior deltoid

• Activation and strengthening of teres minor

• Functional elevation to try and reduce impingement of the humeral head under the acromion process

• The focus of this rehabilitation programme is based around muscle imbalance principles. These principles were developed from clinical observations rather than scientifically proven theories.

Rotator cuff tests

Positive Humeral Thrust Test

Hold the acromion between your thumb and first finger. Place your middle finger over the humeral head and then ask the patient to flex the shoulder by 40 degrees. The humerus will thrust forward under your middle finger rather than rolling back under the acromion if the test is positive.

Napoleon’s Sign, (Belly Press Test) Testing for subscapularis function

• Normal – both elbows come in front of the body when pressing abdomen and bringing elbows forward

• Abnormal – unable to bring elbows forward

Hornblower’s Sign, Testing for teres minor function

• Normal – able to raise hand from mouth to external rotation in 90 degrees of scaption

• Abnormal – unable to externally rotate shoulder to perform the manoever

Infraspinatus Lag, Testing for infraspinatus function

• Passively take arm into external rotation and ask patient to hold the position when you let go. If the arm swings back to neutral, this is a positive lag sign

Subscapullariis Lag, Testing for subscapularis function

• Passively take arm away from the body behind the back. If the patient is unable to hold the position when you let you, the lag sign is positive

Ruptured Long Head of Biceps

• The right biceps shows the typical “golf ball” appearance. The left long head of biceps is intact

Treatment

Military Press

Once the patient can easily and painlessly attain 90o then the arm should be moved in a controlled manner through an arc of 40o

The weight held by the patient can be varied according to their ability. A plastic 1 litre drink bottle is a useful home tool as the weight can be adjusted by the changing the quantity of liquid.

• Progress these exercises into a more vertical position by gradually raising the bed when the exercise is easy and painless in supine.

Elevation in sitting is an important functional activity, but it must be done with a short arm lever. Power and control can be improved by repeating the stretch in elevation

Wall slides

Wall slides are far more useful than walking the fingers up the wall when the patient is unable to achieve elevation in a vertical position. Work can be done then to achieve eccentric control on lowering from elevation.

Lateral rotators strength and stretch

It can be useful to work on strengthening lateral rotation with the patient in supine as well as in sitting. It is important to control the lateral rotators eccentrically with the resistance band.

The range of lateral rotation can become very restricted due to the difficulty with initiating the movement. It is important that the patient learns to stretch the arm out into lateral rotation

Internal rotator stretch

Stretches into internal rotation can be carried out in half side lying if the patient is able to lie in this position. For those who are unable to lie in this position then gently stretches behind the back using a towel may be used. These need to be within the patients limits of pain.

References

Worland RL, Lee D, Orozco CG, SozaRex F, Keenan J. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South Orthop Assoc. 2003 12(1) 23-26

• Arcuni SE. Rotator cuff pathology and subacromial impingement. Nurse practitioner 2000. 25(5), 61, 65-66

• Milgrom C, Shaffler M, Gilbert S, van Holsbeeck M. Rotator cuff changes in asymptomatic adults. The effects of age, hand dominance and gender. Journal of bone and joint surgery 1995. 77(2). 296-298

• Bertolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clinical orthopaedics and related research 1994. 308. 90-97.

• Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM. Surgical repair of chronic rotator cuff tears. A prospective long-term study. Journal of bone and joint surgery 2001. 83A. 71-77

• Olsewski JM, Depew AD. Arthroscopic subacromial decompression and rotator cuff debridement for stage II and stage III impingement. Arthroscopy 1994. Vol 10, 61-68

• Rodgers JA, Crosby LA. Rotator cuff disorders. American family physician 1996. 54(1). 127-34

http://bobbyainsworth.com/

Tuberculosis of the shoulder joint

noreply@blogspirit.com (PhysioCharlie) — Fri, 05 Sep 2008 16:20:00 +0200

I had a patient today who at 36 years old had had a painful and stiff shoulder for over a year. She was a diabetic and was c/o weight loss and fever, especially at night. AROM and PROM fl,ab; 90 degrees, lat rot 10 degrees. Despite physio she still remained in pain and her reduced AROM was ISQ. I was very suspicious that it could be tuberculosis of the shoulder joint or some kind of infection like pyogenic osteomyletis. See below:

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W90-4GSBF0V-3&_user=7214447&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_version=1&_urlVersion=0&_userid=7214447&md5=af0351ea401010dd04a48dd5c40cbfe8

"Tuberculosis of the shoulder can be difficult to diagnose in the early stages. If not diagnosed early, bony tuberculosis may reduce the quality of life. Therefore, tuberculosis should be suspected in cases of long-standing pain in the shoulder. It is necessary to keep tuberculosis in the differential diagnosis of several osseous pathologies".

Coccydinia

noreply@blogspirit.com (PhysioCharlie) — Wed, 03 Sep 2008 13:36:05 +0200

I participated in an iCSP discussion today:

Coccydinia

Added by: Kathryn1
Posted: 03 September 2008 10:28

Hi

I apologise for emailing this but I'm seeing 2 patients next week with Coccydinia who appear to have similar findings and would be really grateful if anyone could offer me help with them before I see them again.

I saw both patients this week and it's made me realise how little I know about assessing and using manual therapy for coccydinia.

They both had similar findings, insidious onset of pain which has continued for a number of years, pinpointed to the coccyx, worse with sitting or lying supine. There was nothing to find in the lumbar spine and all innominate and sacral bony landmarks and movement tests were normal. There was tenderness over the sacro-coccygeal joint and on PA glide of the coccyx

I am keen to learn manual techniques that might help as my understanding from doing some searching on the web is that they can be very effective, however I can't find many details on how to do them. Can anyone help please?

Thank you
Kathryn

Title: Coccydinia
Added by: nicola burrows
Posted: 03 September 2008 11:43
I have always found a standard PA mob and US very effective but I think there is also an AP manouevre but I have never done it. Good luck.

Title: Coccydinia
Added by: stephenbunting
Posted: 03 September 2008 12:19
If you are unable to find a pelvic mechanical / positional fault and coccyx AP mobilisation is inneffective then it may be that manual therapy may not be helpful and an orthopaedic referral for injection / or coccyxectomy may be indicated. If there is a history of PA trauma (usually direct blow from a fall) then PA mobs are probably not indicated. There is an AP mobilisation which is done PR and as such tends to be done under anaesthetic (at least at our trust) and therefore an orthopaedic referral may be the best bet again. We can't cure everything !!

Title: Coccydinia
Added by: charliecotterill
Posted: 03 September 2008 12:32
You may have already used this website for your research:

http://www.coccyx.org/

There is a useful section on manual rx:

http://www.coccyx.org/treatmen/manual.htm

However, keep an open mind as I had a young 21 year old female patient who had coccyx pain, insidious onset, pain on sitting, Lx, SIjt NAD. Palpn; tenderness, red and swollen over the coccyx. It turned out she had an infected sebaceous gland and antibiotics sorted her out.

Charlie

A/C jt dislocation

noreply@blogspirit.com (PhysioCharlie) — Tue, 26 Aug 2008 13:40:53 +0200

I was researching what can be done for a bad dislocatoin of the A/C jt. I found this:

http://www.larsligament.com/LARS-Shoulder.html

Foot pain

noreply@blogspirit.com (PhysioCharlie) — Thu, 07 Aug 2008 11:41:06 +0200

I had a 66 yr old female patient with an insidious onset of Left foot pain. Planter flexion was limited by 10 degrees and painful as well as pain on palpation over the 3rd matetarsal/lateral cuneiform bones. I wondered if she had sustained a stress fracture, but there were no signs of this. I carried out ultrasound to confirm this and there was no sharp pain elicited. I then wondered if it was a flare up of OA in the tarsometatarsal joint.

I really had to recap on my anatomy, so I went to:

http://cache.eb.com/eb/image?id=99107&rendTypeId=4

Wafarin, Anaemia and shoulder pain

noreply@blogspirit.com (PhysioCharlie) — Tue, 05 Aug 2008 12:35:00 +0200

Today I saw a 62 year old asian female who presented with bilateral shoulder pain of an insidious onset. She had been on Warfarin for over 30 years after having a mitral valve replacement. She was anaemic and was taking iron tablets as well as co-amilofruse, digoxin and calcium.

The patient looked yellow/pale and very skeletal. She was c/o generalised weakness and tiredness, loss of appetite (she was 40Kg and had lost weight over the last year) feeling the cold++ and dizziness. Vas scale constant 1-10/10 especially pain at night which kept her awake.

AROM/PROM bilateral GHjt: FROM pain through range. Resist: All GHjt & elbow movts;-4/5 no pain. Palpn: hypersensitive to any palpation generally. I was only able to do a basic ax as she was so weak.

Her husband asked if Warfarin could be giving her shoulder pain, at first I was sceptical. Then I had a look at the side effects of warfarin and of course one of those is haemorrage. All the signs were there, could it be that that bleeding was causing her shoulder pain? I thought this was quite a random hypothesis but then I researched this and came up with "Kehr's sign" see below:

http://www.emedmag.com/html/pre/cov/covers/011502.asp

http://en.wikipedia.org/wiki/Kehr's_sign

From Wikipedia:

Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classical symptom of a ruptured spleen. May result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury or ectopic pregnancy.

Kehr's sign is a classical example of referred pain: irritation of the diaphragm is signalled by the phrenic nerve as pain in the area above the collarbone

Spontaneous intra-peritoneal bleeding secondary to warfarin, presenting as an acute appendicitis: a case report and review of literature. (2006) Sagar et al, BMC Blood Disorders 2006, 6:7

http://www.biomedcentral.com/1471-2326/6/7

"Warfarin is a life saving drug, extensively used in the treatment and the prophylaxis for the various clinical conditions including deep vein thrombosis, pulmonary embolism, valvular heart disease, atrial fibrillation, recurrent systemic emboli, recurrent myocardial infarction, prosthetic heart valves and prosthetic implants. However, it is associated with the serious adverse effects such as the haematuria, soft tissue bleeding and haematoma, intra cerebral bleed, skin necrosis, purple toe syndrome and abdominal bleed. Theoretically, the bleeding can occur in any part of the body following any kind of the anticoagulation therapy. Bleeding in the gastrointestinal tract is by far the most common complication of the warfarin therapy. Bleeding may occur intra-, extra- or retroperitoneally, but the intramural bowel haematoma is the most common cause of the abdominal pain in the patients who are on anticoagulantion therapy."

"The other learning point in this case is the history of occasional pain in right shoulder at time of presentation. This may be due to the blood under the diaphragm causing irritation of the phrenic nerve, causing referred pain in the shoulder (well known as Kehr's sign) but this became evident retrospectively only."

So I referred her back to her GP urgently for an opinion and a recommendation of possible hospitalisation for internal haemorrage.

?Morton's neuralgia

noreply@blogspirit.com (PhysioCharlie) — Mon, 30 Jun 2008 15:49:59 +0200

I had a 21 year old female patient today presenting with a swollen and painful MTP. She had experienced no trauma and had not been running or dancing. No LBP or sciatica. Her Left first toe was numb and she experienced pins and needles into that toe. Bearing weight hurt her MTP, 1st toe ext was weak Gd IV- with decreased sensation all around the 1st toe. Compression of the metatarsals was positive for increasing her pain and pins and needles. I wondered whether this was Morton's neuralgia, but my research suggested that it was rare to happen in the first toe. I have sent her back to the GP for assessment.

Arthritis blog

noreply@blogspirit.com (PhysioCharlie) — Wed, 11 Jun 2008 10:48:34 +0200

I have just volunteered to update an "Arthritis Blog" see:

http://talk.nhs.uk/blogs/arthritis/default.aspx

I'll be putting my posts on here as well. Watch this space!....