Physio Charlie

I have a new website!!

http://physiocharlie.vpweb.co.uk

Yesterday I took supervision with my junior on Cx clinical reasoning.

We looked at two sets of notes then did some practical:

Notes 1.  26 yr old female, RTA 3/12 ago when she fell of her motorbike. Injury to L sh and bilat wrists.

Sx: RTA details need to expand ie. speed? any LOC? to A+E in ambulance? wearing helmet? X-rays of wrists, sh, Cx? where was RTA in UK or Poland?

Body Chart: Need Constant or I/M defining ie. 0-8/10 or 8-10/10.  24 hr; which pain has a pattern? 5 D's, 3 N's

Ox: AROM Sh: Flx FROM Pa @ EOR or T/O ROM. PROM L rot if decreased = capsular pattern, Sp tests: VBI/ Alar/ Transverse Lig// NAD.  Palpn: Trp's in upper traps, get position correct for Cx palpn.  Passive sh girdle elevation with and without Cx L or RSF = ? upper traps or Cx origin of pain

Yesterday I had supervision with my junior on clinical reasoning for the Lx and Tx:

Tx Pathologies:

scoliosis/kyphosis, T/O syndrome, spondylosis, osteoporosis/ #, tumours, TB, Sheurmanns disease, Ankylosing Spondylitis

Lx Pathologies:

spondylosis, trauma/ #, tumours, Ankylosing Spondylitis, spondylolythesis, disc heriation, nerve root impingement, muscular/ligament damage, SI jt problems, Hip pathology, visceral referral; gynae, GI, AAA

Clinical reasoning:

We took 2 sets of notes and went through her reasoning on the Lx.

Sx:   Asterix (*) important info for re-ax

HPC/ PMH: use shorthand 3/12 instead of months

DH: think of the analgesic ladder http://www.formulary.cht.nhs.uk/pdf,_doc_files_etc/MMC/02... or http://www.scinfo.org/PAINN2002/sld029.htm

SQ's: Fever? how often?

SH: Income? FT, PT job? Benefits? JSA, income support, incapacity benefit, ?previous work, ?asylum seeker.

Beliefs: Do they think they have Ca, slipped disc etc, have they "DAMAGED" their back = yellow flags    

www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidel...

Expectations: PT as masseuse?

Body Chart: Constant pain? sleep patterns?

Ox:   Asterix (*) important info for re-ax

Neuro: if no problems put NAD

SI jt: kinetic tests x 3 // NAD

A:  1. MLBP with or without yellow flags, 2. nerve root pathology, 3. red flags

Rx: Examples;  Lx PA (use arrow) GdII L3, L4, 3 x 30 sec // increased Flx ROM by ? or Lx rotation (use circle with arrow) Gd III in R or L sd ly, 3 x 30 sec // increased Flx ROM by ?

Myself and my senior went over Lx Ax today.  Interesting learning points were:

1.  Cross over sign for a space occupying lesion: nerve impingement from a disc will give this sign

2.  Mckensie progressions: Pillow under pelvis prone, without pillow, prone on elbows, or use supine supported hip and knee flx on a chair

3.  Lx Trx using a seatbelt in supine hip and knee flx on a chair.

See Acute Low Back Pain Problems in Adults: Assessment and Treatment: http://www.chirobase.org/07Strategy/AHCPR/ahcprclinician....

I took supervision for our Junior today and we looked at Lx Ax:

Age: Disc prolapse more likely in the mid 20's age range, spondylosis and disc degeneration more likely in 50's and older. 

Sx:

HPC; Traumatic - high impact collision or fall from height, or non traumatic in pts with OP = Red flag = imaging.  Insidious or sudden onset? Rx's? Compensation = yellow flag. 

PMH; previous Hx of LBP? Red flag if over 70 and never had LBP before.  Previous Rx? Chronic LBP?  Other Illnesses, Op's, injuries?

SQ's; THREAD, OP, WL, Naus, Fever

DH; St's long term = OP liable to # Tx and poss Lx

Invests: Bld tests, MRI's, X-rays

SH; Job?  Benefits? Off work for how long? - better to be back to work asap for simple LBP.  Work sadness = yellow flag

Beliefs; worrying if it's Ca?

Expectations; passive rx = yellow flag

BODY CHART:

Discussed normal and abnormal pins and needles and numbness and what needs to be written on the body chart, include SIN factor.  Somatic referred LBP does not refer beyond the knee whereas radicular or nerve root pain refers below the knee usually with a neuro component.

Ox:

Obs; posture, lordotic? Kyphotic.

Function: able to walk on toes, heels, squat?

AROM Lx: Don't look at rotation in Lx as very little occurs here, concentrate on how the patient moves into Flx, ext, LSF, RSF

AROM hip: capsular pattern

SI jt; 3 x Kinetic tests

Neuro: Patterns of myotomal, dermatomal and reflex loss, hyper and hypo reflexia, babinski, clonus, SLR: reproduce leg pain with DFlx

Waddells: Axial rot, Axial Pressure, Distracted SLR, Non anatomical pain, increased pain behaviour, increased sensitivity to touch; >3 = yellow flags.

Palpn: PAIVM's: Feel for hypo, hypermobility, PA, Unilateral, PPIVM's: Feel for hypo, hypermobility

A: 

3 diagnostic criteria:  1: Simple mechanical LBP with or without yellow flags, 2: Nerve root pathology, 3: Red Flags

Rx:

Advice and Ed re: back to normal function asap if simple LBP, AROM Exs for Lx, Lx rotational mobs in different grades, Mckensie extension exercises, MWM's in sitting for Flx, Ext with seatbelt, PA mobs.

I took a supervision session with my Junior today and we went over shoulder Ax and Rx:

Shoulder pain is a common problem with a reported prevalence of 6.9 to 34% in the general population and 21% in those over 70 years of age. It accounts for 1.2% of all general practice encounters, being third only to back and neck complaints as musculoskeletal reasons for primary care consultation


Subacromial joint. Not a true “anatomical” joint, Includes the subacromial bursa
Frequently the site of pain in “impingement” syndromes
The subacromial space contains the subacromial bursa and the tendon of the supraspinatus muscle (which together with three other muscles, comprise the rotator cuff and grasp the humeral head), and the long tendon of the biceps muscle. Shoulder complaints presumed to have been caused by disorders of subacromial structures are described in the literature under the names subacromial syndrome, entrapment syndrome, impingement syndrome, painful arc syndrome, or PHS.
According to Neer, the entrapment syndrome is the result of anatomical variations in build, strain, and repetitive microtrauma. The terms 'impingement' and 'entrapment' refer to the presumed trapping of anatomical structures between the broad greater tuberosity of the humeral head and the acromion during abduction. This would cause a process of degeneration of the rotator cuff, coupled with oedema, bleeding, fibrosis, and calcification. Ultimately this could cause ruptures, osteophyte formation, and spur formation. The 'typical' clinical picture would be characterized by a painful arc during abduction, while other movements of the upper arm painless.

Primary – anatomical narrowing of the subacromial space, ie hooked acromion
Secondary – functional narrowing of the subacromial space, ie muscle imbalance
No test to separate Primary Secondary
Bigliani Classification (1991)
Many causes have been proposed for subacromial impingement syndrome (Aoki M et al. 1986, Bigliani et al. 1986, Codman 1990, Bigliani et al. 1991, Edelson & Taitz 1992, Burns & Whipple 1993, Hutchinson & Veenstra 1993, Davidson et al. 1995). These factors can be broadly classified as intrinsic or intratendinous factors, which are related to the intrinsic theory on the origin of impingement, and extrinsic or extratendinous factors, which are related to the mechanical theory. They can be further characterised as primary or secondary. A primary aetiology — either intrinsic or extrinsic — causes the impingement process by decreasing the subacromial space or by causing a degenerative process of the rotator cuff tendons (Duke & Wallace 1997). A secondary aetiology is the result of another process, such as instability, neurological injury, tight posterior capsule of the glenohumeral joint and muscle dysfunction (Bigliani & Levine 1997, Duke & Wallace 1997). The net effect of secondary causes is usually an anterosuperior translation of the humeral head, which causes impingement of the cuff against the coracoacromial arch (Duke & Wallace 1997).


Aetiology of SIS is multifactoral, challenges Neer, Lewis et al (2001).
It has been suggested that an intrinsic contractile tension overload on the muscle rather than primary impingement is the major factor in the aetiology of rotator cuff tendinitis (Nirschl 1989). When the arm is in the overhead position, eccentric contraction of the supraspinatus decelerates internal rotation and adduction of the arm, causing an overload (Bigliani & Levine 1997). This phenomenon is most dramatic in persons who go in for overhead sports, and it may also occur in manual labourers who use overhead motions in their work (Bigliani & Levine 1997). The proximal migration of the humeral head has also been associated with muscle fatigue, injury and degenerative changes in the rotator cuff tendons (Jerosch et al. 1989, Leroux et al. 1994).
Decrease in proprioceptive sense with muscle fatigue may play a role in decreasing athletic performance and in fatigue-related shoulder dysfunction (Carpenter et al. 1998). Some functional analysis of rotator cuff muscles has shown disturbances in strength in different pathological conditions, including impingement syndrome (Nirschl 1989, Warner et al. 1990, Leroux et al. 1994). Imbalance of the rotator cuff muscles in athletes, who have developed it as a result of training or sport activities, has generally been found to be a predisposing factor or a consequence of impingement syndrome (McMaster et al. 1991, Burnham et al. 1993, Ticker et al. 1995).
The diagnosis of overuse syndrome can be made after possible extrinsic factors related to the coracoacromial arch that may contribute to the process has been ruled out (Bigliani & Levine 1997). This syndrome also occurs commonly in young competitive athletes and manual labourers who use overhead motions in their work (Bigliani & Levine 1997). Inflammation resulting from repetitive microtrauma increases the area occupied by soft tissues in the subacromial space and leads to friction and wear against the coracoacromial arch (Uhthoff et al. 1988, Jobe et al. 1989, Ark et al. 1992, McCann & Bigliani 1994). However, inflammation of the subacromial bursa may also result from a systemic disease, such as rheumatoid arthritis (Steinfeld et al. 1994, Reveille 1997). The findings of Soslowsky et al (Soslowsky et al. 2000) described in animal tendons changes that result from overuse activity, and they are believed to occur in rotator cuff tendons, too.


Kibler 1998 has described that a scapula positioned in excessive downward rotation due to poor muscular control would reduce acromial elevation which may lead to impingement. Weak lower traps or pec minor or levator scapula short.
Ludewig and Cook 2000 carried out an EMG study and found that the impingement group had more anterior tipping, less upward rotation and greater upper and lower traps activity than non impingement group. 9% reduction in serratus function.
Wandsworth, Bullock Saxton 1997 studied impingement in swimmers and found delayed serratus activity in impingement group.
Lukasiewicz 1999, studied 3D movement with impingement and normals. Impingement 8-9% increase in anterior tipping of the scapula.
Lateral Kibler slide test – dist between the inferior point of the scapula and the corresponding spinal vertebrae in 3 different positions; neutral, hands on hips and 90 degrees of GHjt abduction. Hands on hips best reliability (McKenna 2004).


Kibler 2003
A, Type I dyskinesis, with inferior medial border prominence (left scapula). B, Type II dyskinesis, with prominence of the entire medial border (left scapula). A: Type III dyskinesis, with prominence of the superior medial border (left scapula).
Alterations in scapular position and motion occur in 68% to 100% of patients with shoulder injuries.

Hawkins’ sign. A provocative test where pain is suggestive
of impingement syndrome.


Neer’s sign. A provocative test where pain is suggestive
of impingement syndrome.


It is generally assumed that disorders of the cervical or cervicothoracic spine can create not only neck pain but also radiating pain in the shoulder area. In an observational study among 101 patients with shoulder complaints, Sobel et al. were unable to determine an intrinsic cause in 20% of the cases. However, manual examination of the cervical and thoracic spine and the adjoining ribs did reveal abnormalities, which they called dysfunctions of the cervical and thoracic spine. They suggested that their findings concur with the observations of Stenvers & Overbeek and Jirout, who showed a direct relationship between movements of the upper arm and rotation of the lower cervical and upper thoracic vertebrae. A study by Norlander et al. showed that reduced mobility of the cervicothoracic spine in individuals without complaints tripled their chances of developing neck or shoulder complaints. Furthermore, this study showed that the mobility of the cervicothoracic spine was reduced in 84% of all patients with shoulder complaints. In active rheumatoid arthritis, shoulder complaints can develop as a result of synovitis of the glenohumeral joint. Testing of movement of the shoulder joint reveals primarily restriction of exorotation.
Bilateral pain and stiffness in the shoulder and/or pelvic girdle in older patients (usually >50 years) may indicate polymyalgia rheumatica, which is one of the rheumatic diseases. The cause is unknown, but presumably the pain is caused by inflammation of the shoulder and/or pelvic joints. The ESR is usually highly elevated. Unexplained shoulder complaints in a patient with a history of a malignancy may indicate metastasis or spread of the malignancy to structures in the shoulder area, such as the brachial plexus, spine, or apex of the lung. Shoulder mobility is not always abnormal. Malignancy should also be considered in other patients with a progressive pattern of symptoms and similar clinical findings.


Dislocated shoulder

The natural course of SIS is poorly described, but evidence suggests that the condition is not self-limiting. The initial management of shoulder impingement has traditionally included physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injection. A recent systematic review of 8 randomized controlled trials (RCTs) evaluated the efficacy of corticosteroid injection in the treatment of rotator cuff tendonitis (Koester MC, Dunn WR,Spindler KP, Kuhn JE. Does corticosteroid injection improve short term outcomes for rotator cuff tendonitis? A systematic review [unpublished]). Two of the trials also evaluated NSAIDs versus injection and placebo. Only 2 of the 8 trials showed clinically relevant improvements in pain and range of motion in the injection groups as compared with placebo. However, in both of these studies the outcomes of patients treated with injection and oral NSAIDs were equivocal. Physical therapy is frequently implemented to lessen pain and improve function in SIS. A systematic review of manual and physical therapy treatment in SIS by Desmeules et al. revealed only 7 RCTs that met their criteria for review. They reported a lack of uniformity in defining, evaluating, and treating SIS. Each of the reviewed trials was scored on methodological design and each scored relatively poorly. The few trials that were moderately well designed offered limited evidence to support the efficacy of physical therapy in SIS.

Kibler2003
Rehabilitation should start at the base of the kinetic chain, which usually means correcting any strength or flexibility deficits in the low back and thoracic levels before starting on the scapular component. This phase includes exercises for flexibility, strengthening the trunk, and correction of postural abnormalities. Intermediate-stage scapular "clock" exercises (arrows indicate direction of scapular motion). A and B, Elevation and depression (12- and 6-o’clock positions, respectively). C and D, Retraction and protraction (9- and 3-o’clock positions).
"Wall washes" for scapular rehabilitation. The hand slides on a smooth-surfaced wall. Trunk extension and rotation and scapular motion are emphasized. Rotator cuff punches with weights. The weight should create a load but allow the arm to be extended. The exercise should start with hip and trunk extension and scapular retraction (B) and then proceed to arm punches at different levels of arm elevation
“Living within a window”
In addition to physical therapy and medications, activity and workplace modifications must be discussed. Patients should attempt to discontinue overhead activities until symptoms diminish. It may be helpful to discuss “living within a window” in which they consciously attempt to keep their hands within an area in front of their body during activity. The “window” should be from chest to waist and 2 to 3 feet wide, allowing the patient to avoid reaching overhead, away from the body, or behind the back, all of which will exacerbate their symptoms


Instead of diagnosing specifically which is impossible, we could be focusing on: Movement Impairment Syndromes – Sahrmann (2002) ie scapular downward rotation syndrome, scapular depression, scapula winging and tilting syndrome, humeral anterior glide syndrome, humeral superior glide syndrome, shoulder medial rotation syndrome.

References:

This is part of a supervision session I did today on posture

The 4 main types of Bad Postures are Kyphotic, Lordotic, Flat Back, and Sway Back.  There is also the cervical "Upper crossed syndrome" and the lumbar or "pelvic crossed syndrome.  Also scoliosis is a common postural abnormality.

 http://posture-exercises.blogspot.com/2008/01/bad-posture...

Kyphotic Posture
Kyphotic is the medical term for an increased curve of the upper back. It is very common, but not limited to elderly ladies.

Causes: tuberculosis, vertebral compression fractures, Scheuermann's disease, ankylosing spondylitis, senile osteoporosis, tumors, compensation in relation to lordosis and congenital abnormalities. 
Summary
Head – the head is usually forward of the shoulders
Neck – the neck is hyperextended
Shoulder Blades – the shoulder blades are pulled around the upper back towards the arms giving a rounded shoulder appearance
Upper Back – the upper back has an increased convex backwards curve
Lower Back – the lower back has an increased convex forward curve
Pelvis – top of pelvis is titled forward
Hip Joints – the hip joints are slightly bent
Knee Joints – the knees are slightly hyperextended
Ankle Joints – the angle of the ankle joint (between the leg and the sole of foot) is greater than 90 degrees

Weak & Over Stretched Muscles
The head is protruded forward. This puts the Front Neck muscles in a longer position than desired. This sustained lengthened position effects the contractile capability of the muscle, which in turn causes the muscle to lose strength.

The increased curve of the Upper Back puts the Upper Back muscles in a lengthed position and therefore causes weakness in these muscles. In this position these weakened muscles can not adequately support the upper back.

The External Oblique muscles (one of the two side abdominal muscles) are also over stretched and therefore weak caused by the forward tilt of the pelvis.

The tilt of the pelvis can also lengthen and weaken the Hamstrings.

If the External Oblique and Hamstrings were working properly they would maintain the pelvis in a neutral position.

Tight & Overly Strong Muscles
The Hip Flexors (muscles at the front of the hip) may be tight or too strong pulling the top of pelvis forward.

The Back of Neck muscles are tight tilting the back of the head backwards, causing the head to protrude forward.

Posture Exercises
Exercises that Strengthen the Front Neck muscles, the Upper Back muscles, External Obliques and Hamstrings; while stretching the Hip Flexors and Back of Neck muscles are appropriate for someone with this type of posture.

Sway Back

Sway Back posture can often be one of the more tricky postures to recognize. It looks similar to Lordotic posture except the pelvis is in a neutral position.  This type of posture is characterized by a forward displacement of the hips. If you were to draw a vertical line upwards from the front of the ankle bones, the hips will be in front of this line. The Upper Back is displaced backwards to counter balance the forward position of the hips. Commonly someone with this type of posture will have poorly defined gluteal (backside) muscles. This type of posture is common in both men and women.
Summary
Head – the head is forward of the shoulders
Neck – the neck is slightly extended
Upper Back – the Upper Back has an increased curve, convex backwards. The upper back is displaced backwards in regards to the lower back
Lower Back – the Lower back has a decreased (flatten) curve
Pelvis –the top of pelvis is titled backwards
Hip Joints – both hips are generally hyperextended with hips forward of ankles and knees
Knee Joints – both knees are hyperextended
Ankle Joints – the ankles are in a neutral position, i.e. the leg is at right angles to the sole of the foot

Weak & Over Stretched Muscles
The forward displacement of the hips causes the Hip Flexors & External Obliques (side abdominal muscles) to be in a lengthened position. These muscles should be preventing the pelvis from tilting backwards. Due to the increased curve of the Upper Back, the Upper Back muscles are over stretched and weak. The head forward position causes the Front Neck muscles to be over stretched and weak.

Tight & Overly Strong Muscles
The backwards tilt of the pelvis causes the Hamstrings & Internal Obliques (another side abdominal muscle) to be tight and overly strong.

Overly Strong Muscles but not Tight
The Lower Back muscles are overly strong but generally not tight due to the neutral position of the pelvis.

Posture Exercises
Exercises that strengthen the Hip Flexors, External Obliques, Upper Back muscles and Front Neck muscles; while stretching the Hamstrings & Internal Obliques would be of benefit.  Strengthening the Gluteal Muscles will also help balance the overly strong Lower Back Muscles.

Lordotic posture

Lordotic Posture or Lordosis is the medical term for an increased forward curve of the lower back.

Summary
Head – the head is usually in a neutral position, i.e. not tilted forward or backwards.
Neck – there is usually a normal curve in the neck
Upper Back – there is usually a normal curve in the upper back
Lower Back – the lower back as an increased curve, convex forward
Pelvis – the top of pelvis titled forward
Knee Joints – the knees are slightly hyperextended
Ankle Joints – the angle between the leg and the sole of foot is greater than 90 degrees

Weak & Over Stretched Muscles
The forward tilt of the pelvis increases the distance between the top of the pelvis and the ribs. This puts the Front Abdominal muscles is a lengthened weak position. The front abdominal muscles should counteract the forward tilt of the pelvis keeping it in a neutral position. Since the hamstrings insert into the back of the pelvis, the forward tilt of the pelvis puts the hamstrings in a lengthened position. The hamstrings may or may not be weak but should also help prevent the forward tilt of the pelvis.

Tight & Overly Strong Muscles
An increase curve of the Lower Back will put the Lower Back Muscles in a shortened position. These muscles can also be overly strong helping pull the back of the pelvis upwards causing a forward pelvic tilt. The Hip Flexors (muscles at the front of the hip) can also be tight and overly strong, also helping tilt the top of the pelvis forward.

Posture Exercises
Exercises that Strengthen the Abdominal Muscles and Hamstrings, while stretching the Lower back Muscles and Hip Flexors would be of benefit to someone with this type of alignment.

Flat back 

This type of posture is characterized by a flat lower back. This type of posture is common in both men and women.
Summary
Head – the head is forward of shoulders
Neck – the neck is slightly extended
Upper Back – the upper part of the Upper Back has an increased curve, convex backwards. The lower part of the Upper Back is flat
Lower Back –the Lower Back has a decreased curve or no curve, i.e. flat
Pelvis – the top of pelvis is titled backwards
Hip Joints – both hips are extended
Knee Joints – both knees are generally extended, although sometimes can be slightly bent
Ankle Joints –the angle between the leg and the sole of foot is greater than 90 degrees

Weak & Over Stretched Muscles
The Hip Flexors (muscles at the front of the hip) can be weak and long. This muscles should prevent the top of the pelvis from tilting backwards.

Tight & Overly Strong Muscles
The hamstrings, that attach to the back of the pelvis, can be tight and overly strong pulling the back of the pelvis down causing it to tilt backwards. Frequently the abdominal muscles are too strong, pulling the front of the pelvis upwards, also contributing to the backwards tilt of the pelvis.

Posture Exercises
Exercises that strengthen the Hip Flexors and lengthen the Abdominal & Hamstrings muscles are of benefit to someone with this type of posture.

Upper crossed syndrome

A habitual poking chin can cause an "upper crossed syndrome" Janda 1994.  The deep neck flexors, rhomboids, serratus anterior and often the lower traps are weak.  Opposite these weak muscles are tight pec major and minor, upper traps and levator scapulae.

Pelvic crossed syndrome

In this syndrome the weak muscles are the abdominals and glute max, the tight muscles are the hip flexors and back extensors and hams.  This often seen with the upper crossed syndrome and together are called the layer syndrome.

Scoliosis Taken from: http://www.prodigy.nhs.uk/patient_information_lea...#