সোমবার, ২৯ ফেব্রুয়ারী, ২০১৬

Meniscal injury of the knee

Meniscal injury of the knee


 

How do they occur?
In the knee there are two menisci (Cartilage pads) the medial (sitting on the inside of the knee) and the lateral meniscus (on the outer side of the knee joint). The medial meniscus is more commonly injured than the lateral meniscus.
The most common mechanism of injury is a twisting injury with the foot anchored on the ground, often by another player’s body. The twisting component may be a relatively slow speed. It is commonly seen in footballs, basketballers and netballers. The degree of pain associated with this injury varies, some people report a tearing sensation at the time of the injury, a small tear may cause no immediate symptoms but typically pain and swelling increases over time (24hrs). Small tears may also occur in the older population with only very minimal twisting or trauma as a result of degenerative changes to the Meniscus.
A severe meniscal injury e.g. long radial tear called a “bucket handle” tear, can be severely painful and restrict range of motion. Intermittent locking may occur as a result of a torn flap impinging between the articular surfaces. This may unlock spontaneously with a clicking sensation.
Meniscal injuries often occur with ACL tears. The most common sign is tenderness along the knee joint line, presence of a joint effusion (swelling within the joint capsule). There is usually a restriction of range of motion in the knee joint, this can be due to the torn meniscal flap or the effusion. Pain is normally present with squatting.
Your physiotherapist will be able to perform a few tests to determine whether there is a meniscal injury. However not all meniscus injuries are positive on testing and an MRI scan may be necessary to diagnose the injury.
What can physiotherapy do?
The treatment of meniscal injuries varies considerably depending on the severity of the injury. Normally small tears or degenerative tears can be treated conservatively with physiotherapy this includes:
  • Reducing the effusion using electrotherapeutic modalities, soft tissue techniques and compression.
  • Restoring range of motion through manual techniques, gentle movement and stretching.
  • Improve weight bearing ability/ gait.
  • Guidance for strengthening surrounding muscles.
  • Graduated return to running and agility work.
  • Progressive return to sport.
If the meniscal injury is large and causing a locked knee it may require an arthroscope to preserve as much of the meniscus as possible; this can mean either suturing the tear or removing the torn flap depending of the location and severity of the tear.
Following surgery physiotherapy can assist in the following ways:
  • Reduce pain and swelling.
  • Restore range of motion in the joint.
  • Graduated weight bearing exercises.
  • Progressive strengthening
  • Maintain strength and fitness of other parts of the body
  • Return to function activities
Reference link:


Cervical Headache

Cervical Headache
Headaches can literally be a pain in the neck. They are frequently caused by joint or muscular dysfunction in the neck, poor posture, emotional tension or a combination of these. Headaches originating from or relating to neck dysfunction can be very successfully treated & prevented by Physiotherapy.
What is a Cervical Headache?
Cervical headaches or cervicogenic headaches are headaches caused by abnormalities in the cervical (neck and head) region, the cause is variable as described above. The mechanism of production of the headache is also variable. It can be referred from the upper cervical nerve roots, segments of the cervical spine which can irritate some of the sensory nerves. Headaches can be caused by trigger points in the neck muscles and head muscles.
Cervical headaches are those that can be most successfully treated by Physiotherapy. These headaches may present as:
    • Pain & tension in the neck
    • Pain, ache & pressure in the forehead and back of the head
    • Tension in the temple and jaw area
    • Pain that is made worse with sustained and repeated postures
    • (especially sitting) and movement of the neck
    • A headache with a feeling of light headedness or dizziness
    • Pain usually on the same side of the head as neck pain
How do these headaches present?
Cervical headaches are usually described as a constant, steady, dull ache. It can be to one side or both sides. It can be to one side or both sides. It can also feel like a pulling or gripping feeling, sometimes a tight band around the head. The headache usually is felt at the base of the skull and can be referred to the front of the head to the temple area or over and behind the eyes. The headaches usually come on over a period of time, gradually getting worse. The headaches may be present for days, weeks even months. Sometimes there may be a history of an acute trauma such as whip-lash injury or repetitive trauma associated with work or a sporting activity.
Cervical headaches are often associated with neck pain and stiffness. They may be aggravated by neck and head movements. There may be a feeling of light headedness, dizziness, ringing in the ear and nausea. An inability to concentrate, impaired normal functioning and depression may also be reported.
Physiotherapy Management
Physiotherapy management requires assessment and treatment of all the abnormalities found in the joints, muscles and neural structures. As well as education on posture and work practices.
Postural Assessment and Advice – Education on optimal trunk posture and postural retraining is vital. Without postural correction cervical headaches can linger for extended periods.
Mobilization – Stiff joints in the neck should be mobilised to restore range of movement. Stiffness in the jaw joints can aslo be problematic and should be mobilised if needed.
Stretching – Stretching of the neck and shoulder muscles can help alleviate headaches.
Strengthening – cervical muscle retraining is vital. Your physiotherapist will show you how to retrain your deep neck muscles to restore the normal muscle balance and recruitment
Stress and tension management – Identification and reduction of the sources of stress and tension need to be incorporated as this commonly leads to tightness in the upper back and neck muscles.
Soft tissue work and massage – Your physiotherapist may use different massage and soft tissue techniques to help the muscles in your neck and upper back.
Acupuncture – Acupuncture is the placement of very think needles into specific locations in the body. It is often used to help alleviate headaches.
Workplace and ergonomic assessment – A poor chair, a desk at the wrong height or wrong set-up or badly placed computer may result in poor posture contributing to strain on the neck. Your Physiotherapist can advise on office and workplace set up, bedding and pillows.
Neural stretching – Abnormal neural tension can also contribute to cervical headaches. Your physiotherapist will assess this and provide appropriate stretches as needed
Your physiotherapist will advise you and provide you with the most appropriate treatment plan and techniques for you.
Remember
  • Seek treatment at an early stage
  • Ensure you physiotherapist provides you with methods of self treatment and management.
Reference link:


Range of motion

Range of motion

Types of ROM Exercises

1. Passive ROM
“Movement of a body segment within the unrestricted ROM that is produced entirely by an external force”.
 There is no/little voluntary muscle contraction
 External force → gravity, machine, another person/body part
2. Active ROM
“Movement of a body segment within the unrestricted ROM that is produced by active contraction of muscles crossing that joint”.
3. Active-Assisted ROM
“Type of A-ROM involving manual/mechanical assistance provided by an outside force because the prime mover muscles need assistance to complete the motion”.

Indication of ROM Exercises

1. Passive ROM
 Acute inflamed tissue → 2-6 days
 Comatose/Paralyzed/Completely bed-ridden patient
2. Active & Active-Assisted ROM
 Active muscle contraction → Active ROM
 Aerobic conditioning program → Active ROM
 Region above & below the immobilized segment → Active ROM
 Weak musculature → Active- Assisted ROM
 Control gained → Manual/Mechanical Resistance Exercise → Improve muscle performance

Goals of ROM Exercises
Passive ROM
Primary Goal
 Decrease complications of immobilization i.e. Cartilage degeneration, Adhesion & Contracture formation, Sluggish circulation

Specific Goals
 Maintain joint and connective tissue mobility
 Minimize the effects of the formation of contractures
 Maintain mechanical elasticity of muscle
 Assist circulation and vascular dynamics
 Enhance synovial movement for cartilage nutrition and diffusion of materials in the joint
 Decrease or inhibit pain
 Assist with the healing process after injury or surgery
 Help maintain the patient’s awareness of movement

Other uses
 Determine limitations of motion, to determine joint stability, and to determine muscle and other soft tissue elasticity.
 Demonstrate the desired motion for an active exercise program.
 Used preceding the passive stretching techniques.

Active & Active-assisted ROM
Primary Goal
 Similar to PROM in absence of inflammation & contraindication

Specific Goals
 Maintain physiological elasticity and contractility of the participating muscles
 Provide sensory feedback from the contracting muscles
 Provide a stimulus for bone and joint tissue integrity
 Increase circulation and prevent thrombus formation
 Develop coordination and motor skills for functional activities

Limitations of ROM Exercises
Passive ROM
 Prevent muscle atrophy
 Increase strength or endurance
 Assist circulation to the extent that active, voluntary muscle contraction does

Active ROM
 Maintain or increase strength in a strong muscle
 Develop skill or coordination except in the movement patterns used.

Contraindications
 After acute tears, fractures, surgery
 Disruption to the healing process
 Increased pain & inflammation

Precautions
 MI, CABAGE, Percutaneous transluminal coronary angioplasty
 Venous stasis & thrombus formation

Principles & Procedures of Application
1. Examination, Evaluation, & Treatment planning
2. Patient Preparation
3. Application of Techniques

Self-assisted ROM → S-AROM
Used to protect healing tissue when more intensive muscle contraction is contraindicated i.e. Post-surgical or Post-trauma
Forms of S-AROM
 Manual
 Equipment
 Wand or T-bar
 Finger ladder,Wall climbing, Ball rolling
 Pulleys
 Skate or Powder board (Hip abd: & adduction, Shoulder Horizontal flexion & extension)
 Reciprocal Exercise devices → Bicycle, Upper/Lower body ergometer etc

Continuous Passive Motion (CPM)
“Passive motion performed by a mechanical device that moves the joint slowly & continuously through a controlled ROM”.
 Beneficial healing effects on diseased/injured structures

Benefits
↓ Negative effects of immobilization→ Arthritis, Contractures, Intra-articular fractures
↑Recovery rate & ROM―post-surgical

Demonstration by Salter
 Prevents development of adhesions and contractures and thus joint stiffness
 Provides a stimulating effect on the healing of tendons and ligaments
 Enhances healing of incisions over the moving joint
 Increases synovial fluid lubrication of the joint and thus increases the rate of intra-articular cartilage healing and regeneration
 Prevents the degrading effects of immobilization
 Provides a quicker return of ROM
 Decreases postoperative pain
 Decreases postoperative blood drainage & increases analgesia


Neck Muscle Movements

Neck Muscle Movements


The stretches in this chapter are excellent overall stretches; however, not all of these stretches
may be completely suited to each person’s needs. The muscles involved in the various neck
movements appear in the following table. To stretch specific muscles, the stretch must involve
one or more movements in the opposite direction of the desired muscle’s movements. For
example, if you want to stretch the left scalene, you could extend the head both backward
and laterally to the right. When a muscle has a high level of stiffness, you should use fewer
simultaneous opposite movements (you would stretch a very tight right scalene by initially
doing just left lateral extension). As a muscle becomes loose, you can incorporate more

simultaneous opposite movements.

Neck Flexor and Rotation Stretch

Neck Flexor and Rotation Stretch

When the neck flexors become flexible, progress from stretching the
right and left sides simultaneously to stretching the opposite sides individually. To do this, follow this procedure:

Technique

Stand or sit upright. Place right hand on the forehead.
Pull the head back and toward the right so that the head points toward the shoulder.
Keep the head straight; do not lay the head down to either side.

Muscles Stretched

Most-stretched muscle: Left sternocleidomastoid.
Lesser-stretched muscles: Left longissimus capitis, left semispinalis capitis, left

splenius capitis.

Neck Flexor Stretch

Neck Flexor Stretch



Technique

Sit or stand upright. Interlock hands and place the palms on the forehead. Pull the head back so that the nose points straight up to the ceiling.

Muscles Stretched

Most-stretched muscle: Sternocleidomastoid.
Lesser-stretched muscles: Longissimus capitis, semispinalis capitis, splenius capitis, scalene.

Commentary


You can do this stretch either while sitting or while standing. A greater stretch is applied when seated. Standing reduces the ability to stretch because reflexes come into play to prevent a loss of balance. During the stretch, make sure not to reduce the stretch by hunching up the shoulders. Also, try to point the chin as far back as possible.

Neck Extensor and Rotation Stretch

Neck Extensor and Rotation Stretch

When the neck extensors become flexible, progress from stretching the right and left sides simultaneously to stretching the opposite sides individually. To do this,
follow this procedure:

Technique

Sit or stand upright. Place the right hand on the back of the head near the crown. Pull the head down toward the right and try to touch the chin as close as possible to the right shoulder.

Muscles Stretched

Most-stretched muscles: Left upper trapezius, left sternocleidomastoid.
Lesser-stretched muscles: Left longissimus capitis, left semispinalis capitis, left

splenius capitis, left scalene.

Neck Extensor Stretch

Neck Extensor Stretch

Technique

Sit or stand upright. Interlock hands on the back of the head near the crown.
Lightly pull the head straight down and try to touch the chin to the chest.

Muscles Stretched

Most-stretched muscle: Upper trapezius.
Lesser-stretched muscles: Longissimus capitis, semispinalis capitis, splenius capitis, scalene.

Commentary

You can do this stretch either while sitting or while standing. A greater stretch is applied when seated. Standing reduces the ability to stretch because reflexes come into play to prevent a loss of balance. During the stretch, make sure not to reduce the stretch by hunching up the shoulders. Also, keep the neck as straight as possible (no curving). Try to touch the chin to the lowest possible point on the chest.


Stretching

Stretching

Types of Stretching
In general, any movement that requires moving a body part to the point at which there
is an increase in the movement of a joint can be called a stretching exercise. Stretching
can be done either actively or passively. Active stretching occurs when the person doing
the stretch is the one holding the body part in the stretched position. Passive stretching
occurs when someone else moves the person to the stretch position and then holds the
person in the position for a set time. The four major types of stretches are static, proprioceptive
neuromuscular facilitation (PNF), ballistic, and dynamic. The static stretch is used
most often. In static stretching, one stretches a particular muscle or group of muscles by
slowly moving the body part into position and then holding the stretch for a set time.
Since the static stretch begins with a relaxed muscle and then applies the stretch slowly,
static stretching does not activate the stretch reflex (the knee jerk seen when the tendon
is tapped with a mallet). Activation of the stretch reflex causes the stretched muscle to
contract instead of elongate. This contraction of the muscle is directly opposite of the intent
of the exercise. PNF stretching refers to a stretching technique in which a fully contracted
muscle is stretched by moving a limb through the joint’s range of motion. After moving
through the complete range of motion, the muscle is relaxed and rested before resuming
the procedure. The combination of muscle contraction and stretching serves to relax the
muscles used to maintain muscle tone. This relaxation allows for increased flexibility by
“quieting” the internal forces in both the muscles that assist and the ones that oppose the
movement of the joint in the desired direction. Ballistic stretching uses muscle contractions
to force muscle elongation through bobbing movements where there is no pause at any
point in the movement. Although the bobbing movement quickly elongates the muscle
with each repetition, the bobbing also activates the stretch reflex (or knee jerk) response.
Since the stretch reflex stimulates the muscle groups to contract after the stretch is finished,
ballistic stretching is usually discouraged. Dynamic stretching refers to the stretching that
occurs while performing sport-specific movements. Dynamic stretching is similar to ballistic
Stretching in that both use fast body movements to cause muscle stretch, but dynamic
stretching does not employ bouncing or bobbing. Additionally, dynamic stretching uses
only the muscle actions specific to a sport. Practically speaking, dynamic stretching is similar
to performing a sport-specific warm-up (that is, performing the movements required for
the activity but at a lower intensity).
Benefits of Stretching
The following are several chronic training benefits gained from using a regular stretching
program:
Improved flexibility, stamina (muscular endurance), and muscular strength. The degree
of benefit depends on how much stress is put on the muscle. Medium or heavy
stretches are recommended. You can do this by building up to doing long stretches
of high intensity (see the next section for a detailed explanation of light, medium,
and heavy stretching).
Reduced muscle soreness, aches, and pains. Use only very light stretches if muscle
soreness prevails.
Improved flexibility with the use of static or PNF stretches. Medium or heavy stretches
are recommended.
Good muscular and joint mobility.
More efficient muscular movements and fluidity of motion.
introduction vii
Greater ability to exert maximum force through a wider range of motion.
Prevention of some lower back problems.
Improved appearance and self-image.
Improved body alignment and posture.
Better warm-up and cool-down in an exercise session.
General Recommendations
Try to include all the major muscle groups in any stretching program.
Do at least two different stretches for each joint movement.
Before any physical activity, use light stretches as part of the warm-up.
After an exercise routine, cool down with medium-intensity stretches.
If muscles are sore after exercising, use only light stretches two or three times with a
5- to 10-second hold for each stretch performed.
If muscle soreness persists for several days, continue using light stretches two or three
times with a 5- to 10-second hold for each stretch performed.
The majority of the stretches should be static.
Stretching Programs
The following programs can be prescribed for anyone who is interested in improving flexibility,
strength, and strength endurance. To make changes to any of these areas, you need
to be involved in a regular stretching program, preferably as a daily routine or as close to
that as possible. Changes will not come in a day or two but rather after a dedicated effort
of several weeks. You can incorporate these programs with or without any other kind of
exercise routine. According to the latest research, heavy stretching, even without any other
exercise activity, can bring about changes in flexibility, strength, and muscular endurance.
As in any other exercise program, progression is an integral part of a successful stretching
program. The stretching progression should be gradual, going from a lighter load with
less time spent on each stretch to a heavier load with more time spent on each stretch. For
the programs outlined in this introduction, you should begin with the initial program, or
level I, and then progress through to level V. However, you may customize this program
according to your current level of experience and flexibility. Generally, working through each
level at the recommended speed will result in meaningful and consistent workouts. After
such workouts, you will find improved flexibility in the muscles you worked as well as the
satisfaction of having done something beneficial.
Intensity is always a critical factor when you want changes and improvements to come
from an exercise program. In a stretching routine, intensity is controlled by the amount of
pain associated with the stretch. Using a pain scale from 0 to 10, initial pain is light (scale of
1 to 3) and usually dissipates as the time of stretching is extended. Light stretching occurs
when you stretch a particular muscle group only to a point where you feel the stretch with
an associated light pain. Moderate stretching (scale of 4 to 6) occurs when you start to feel
increased, or “medium,” pain in the muscle you’re stretching. In heavy stretching (scale of
7 to 10), you will initially experience a moderate to heavy pain at the start of the stretch,
but this pain slowly dissipates as stretching continues. Research studies have shown that
heavier stretches rather than lighter stretches provide greater improvements in flexibility
and strength. Thus, you are the key to your own success, and how well you are able to
monitor stretch intensity and tolerate the pain level determines how quick and large the
improvements will be.
Because of the complexity of muscle attachments, many stretching exercises simultaneously
affect a variety of muscle groups in the body and stretch the muscle groups around
multiple joints. Thus, a small change in body position can change the nature of a stretch on
any particular muscle. To get the maximal stretching benefit in any muscle, it is helpful to
know joint movements that each muscle can do. Putting the joint through the full range of
each motion allows for maximal stretching.
You can customize the exercises in this book, which will allow for numerous stretch
combinations. Also, this book illustrates only a portion of the available stretches. You are
encouraged to experiment with these stretches by following the explanations provided.
Information is also provided to enable you to explore a variety of positions in order to stretch
the muscle by slightly altering the angles and directions of the various body positions. Thus,
you can adapt the stretching exercises to fit your individual needs and desires. For example,
if you have soreness in only one of the muscles or just a part of the muscle, you can adapt
each exercise to stretch that particular muscle. If the explained stretch or particular body
position does not stretch a particular muscle as much as you want it to, then experiment
by slightly altering the position. Keep making alterations in the position until you reach the
desired level of stretch (using a pain scale rating).
In the programs that appear in the following section, specific instructions are given relating
to the time to hold the stretch and time to rest between each stretch, as well as the number
of repetitions you should do. You should follow these instructions in order to get the benefits
described. For example, if the instructions indicate that you should hold a stretch position for
10 seconds, time (or count out) the stretch to ensure that you hold it for the recommended
time. Also, you should incorporate only two to four heavier stretching days in each week
and have a lighter stretching day in between each of the heavier stretching days.
Finally, for any stretch involving sitting or lying down, you should do the stretch with a
cushion underneath you, such as a carpet or athletic mat. Cushioning makes the exercises
more comfortable to perform. However, the cushioning should be firm. Too soft of a cushion
will reduce the effectiveness of the stretches.
Recommended Programs
The following programs are specific stretching recommendations and are based on your initial flexibility. In addition to following the programs listed, you should follow the general recommendations listed previously. Stay on each level for two to four weeks before going to the next level.
Level I
Hold the stretching position for 5 to 10 seconds.
Rest for 5 to 10 seconds between each stretch.
Repeat each stretch two times.
Use an intensity level on the scale from 1 to 3, with light pain.
Duration is 15 to 20 minutes each session.
Stretch two or three times per week.
Level II
Hold the stretching position for 10 to 15 seconds.
Rest for 10 to 15 seconds between each stretch.
Repeat each stretch three times.
Use an intensity level on the scale from 2 to 4, with light to moderate pain, one or two times per week.
Use an intensity level on the scale from 1 to 2, one or two times per week.
Duration is 20 to 30 minutes each session.
Stretch three or four times per week.
Level III
Hold the stretching position for 15 to 20 seconds.
Rest for 15 to 20 seconds between each stretch.
Repeat each stretch four times.
Use an intensity level on the scale from 4 to 6, with moderate pain, two or three times per week.
Use an intensity level on the scale from 1 to 4, two or three times per week.
Duration is 30 to 40 minutes each session.
Stretch four or five times per week.
Level IV
Hold the stretching position for 20 to 25 seconds.
Rest for 20 to 25 seconds between each stretch.
Repeat each stretch five times.
Use an intensity level on the scale from 6 to 8, with moderate to heavy pain, two or three times per week.
Use an intensity level on the scale from 1 to 6, two or three times per week.
Duration is 40 to 50 minutes each session.
Stretch four or five times per week.
Level V
Hold the stretching position for 25 to 30 seconds.
Rest for 25 to 30 seconds between each stretch.
Repeat each stretch five or six times.
Use an intensity level on the scale from 8 to 10, with heavy pain, two or three times per week.
Use an intensity level on the scale from 1 to 8, two or three times per week.
Duration is 50 to 60 minutes each session.

Stretch