العلاج الطبيعى لأمراض العظام والأصابات

PHYSICAL THERAPY FOR ORTHOPEDIC Disorders

First Edition 2008

CONTENTS

Physical therapy and fractures                                                          3

Clavicle fractures and shoulder dislocation                                      10           

    Elbow and forearm injuries                                                             16

   Physical therapy for post-traumatic complications                          28

Physical therapy for osteoarthritis                                                    34

Physical therapy for rheumatoid arthritis                                         42

Physical therapy for frozen shoulder                                                53

Physical therapy for amputation                                                       62

Physical therapy for cervical spondylosis                                        70

Physical therapy for cervical disc lesion                                          79

Physical therapy for lumbar spondylosis & spondylolithesis           85

Physical therapy for lumbar disc lesion                                            95

Physical therapy for ankylosing spondylitis                                    104

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Physical Therapy and fractures

Definition

 Fracture is an interruption of the continuity of the bone which may be a complete break or an incomplete break.

Classification

        There are two main types of fractures:

1)   Closed fracture:

There is no communication between the external surface of the body and the fracture.

2)   Open fracture:

There is a communication between the external surface of the body (skin) and the fracture. There is a possibility of infection.

Subdivisions of the types of fractures are named according to the position of fractured parts of the bone.

1-   Spiral fracture

2-   Transverse fracture

3-   Oblique fracture

4-   Compression (Crush) fracture

5-   Comminuted fracture

6-   Greenstick fracture (incomplete fracture in young children).

Causes of fracture

1) Trauma: It may be

a.   Direct blow

b.  Falling from a height

c.   Weight falling on hand or foot

d.  Indirect violence:

- Falling on an outstretched hand

- Foot caught in a hole when running

e.   Stress or fatigue fracture: are caused by repeated minor trauma as walking for a long distance

2) Pathological fracture:

These fractures occur as a result of a disease affecting the structure of bone making it liable to fracture even with minor trauma. These diseases are such as carcinoma, sarcoma, bone infection or osteoporosis.

Clinical features

1) Immediately after fracture

1.      Shock: according to severity of the injury.

2.      Pain.

3.      Deformity: displacement of bone fragments.

4.      Oedema: localized immediately after injury, and gradually become extensive.

5.      Marked local tenderness.

6.      Muscle spasm.

7.      Abnormal movement and crepitus.

8.      Loss of function: according to severity of the injury.

2) After reduction and fixation

1.      Pain may continue for a variable amount of time.

2.      Oedema: Temporary plaster or splint may be applied till reduction of edema. Oedema may be apparent below the level of plaster, so elevate the limb.

3.      Loss of function according to the type of fracture and fixation.

3) After removal of fixation

1.      Pain: It may be from fear of movement causing pain, stretching of adhesions, or complications such as Sudeck’s atrophy.

2.      Oedema: Once the plaster has been removed the week muscles may not provide adequate support or pumping action on the veins so swelling may reappear.

3.      Limitation of joint movement: The joint may be stiff due to adhesions or swelling. Movement may be also limited due to weak muscles. If the fracture has affected the joint surface it may limit movement which may not be possible to regain.

4.      Muscle weakness: There will be loss of power of the muscles which have not been used or not properly used for several weeks.

5.      Loss of function:

- In lower limb fractures, it may be possible to walk during the period of fixation with walking plaster, splint or bandage. Other patient may walk by non weight bearing for the affected leg using walker or crutches progressing to partial weight bearing with crutches or a stick to full weight bearing.

- In upper limb fractures: Full movement may be regained in a relatively short time.

Union of fractures

          The time taken for a fracture to be united is variable and depends on many variables:

1.    Type of bone

2.    Classification of fracture

3.    Blood supply

4.    Fixation

5.    Age

Delayed union: healing take longer time than normally expected

Non-union: there are distinct pathological changes and radiological evidence of non-union. The gab of the bone fragments may be filled with fibrous tissue.

Complications of fractures:

1.    Infection

2.    Avascular necrosis

3.    Mal-union

4.    Joint disruption

5.    Adhesions: intraarticular and/or periarticular adhesions.

6.    Injury to large vessels, muscles, nerves and viscera

7.    Sudeck’s atrophy.

Management principles:

1.    First aid: Aim is to prevent further damage.

2.    Treatment by the surgeon:

A.   Reduction:

·       Closed reduction.

·       Reduction by traction.

·       Open reduction.

B.   Immobilization: Methods of immobilization:

·       External fixation.

·       Internal fixation.

C.   Physical therapy management.

Physical Therapy for fractures

     This can be divided into management during immobilization and then after removal of fixation. The physical therapist must be careful to avoid anything that might delay repair or lead to non-union. Thus it is essential that the principles of fractures are understood and care should be taken for any particular precautions and complications.

1) Physical therapy during immobilization

The aims during this period are:

1. Reduce edema: It is very important to do this as early as possible to prevent adhesion formation, and to decrease pain.

2. Assist the maintenance of the circulation to the area.

3. Maintain muscle function by active or static muscle contractions

4. Maintain joint ROM

5. Maintain function as allowed by the fracture and the fixation.

6. Teach the patient to use crutches, sticks, frames.

       Assessment of the patient is essential in order to decide on the treatment required. It is not always necessary to treat a patient throughout this stage provided that the patient can be taught to do his own exercises. The patient must understand what is required and be motivated to carry it out. The physical therapist is responsible for monitoring the patient through this stage. If it is necessary to continue treatment this may be in the ward for an inpatient but outpatients may either be treated in a physiotherapy department or at home. Good treatment at this stage may prevent some of the problems that can occur when the fixation is removed.

Problems and physical therapy techniques:

·       Swelling should be reduced by elevating the limb and by active or static contractions of muscles thus minimizing the formation of adhesions and consequent stiff joints.

·       Active exercises by static or isotonic muscle activity will help to maintain a good blood supply to the soft tissues and aid in the reduction of swelling and prevent the formation of adhesions.

·       Muscles that cannot produce movement of a joint because of the fixation and do not work statically will waste very rapidly. Isometric or isotonic contractions performed correctly and repeated often enough will prevent excessive wasting.

·       Encouraging functional activity when possible also helps reduce the rehabilitation time after removal of fixation.

·       Patients must understand the importance of their treatment and physiotherapists must understand the problems and requirements of each patient.

2) Physical therapy after the removal of fixation

Assessment of the patient should be carried out to formulate a plan of treatment.

Factors to be considered during evaluation:

1.    Although certain clinical features can be expected after a particular fracture they will appear in different degrees in each patient and in some cases may not be present.

2.    Every patient presents different problems apart from the injury and these may relate to age, family, work, leisure and the psychological reactions of the individual. These factors must be taken into account in planning a program of treatment and evaluating progress.

The aims of treatment relating to the fracture will include:

1. To reduce any swelling.

2. To regain full range of joint movement.

3. To regain full muscle power.

4. To re-educate full function.

1) Swelling

     Swelling should not be a great problem if exercises and general activities have been carried out during the immobilization period. It may be a problem in the lower limb if the muscles are very weak and there is a loss of joint range as both factors will prevent an adequate pumping action on the veins. Any edema must be reduced as quickly as possible as this will hinder active movement and lead to the formation of adhesions thus extending the rehabilitation period.

2) Range of joint movement

Before attempting to regain any decreased range of movement the reason for the loss of range should be determined. It could be due to pain, edema, adhesions or weak muscles. If there has been disruption of joint surfaces this may prevent a return to full range.

3) Muscle power

The building of muscle power will depend on gaining maximal activity of the muscles and using them in all actions as prime mover, antagonist, fixator and associated movements with other muscle groups.

4) Full function

In the majority of cases it should be possible to regain full function but if not it is important to gain the optimum function, and the extent of this will depend on the complications preventing full recovery. Planning must also take into account the needs of the patient in relation to home, work and leisure. In preparing a patient to return to work it is important to understand that the patient may have to work all day and know what type of work is involved-heavy laboring, industrial work on a production bench requiring repetitive movements of the hand or foot or both, or office work which can require a variety of different activities. Similarly home and leisure activities must be considered so that the patient is fully rehabilitated.

Physical therapy techniques

·       These are given and must be carefully selected following the assessment of the patient.

·       The physical therapist must evaluate each treatment and change the techniques as required.

·       Treatment should be gradually intensive, particularly in the final stages of rehabilitation, but always within the capability of the patient.

·       Select the appropriate techniques and decide how they should be carried out. For example, with movement techniques judge carefully how many times each exercise should be performed and whether assistance or resistance is required.

Clavicle Fractures

Functions of the clavicle

·       The clavicle acts as a strut connecting the upper extremity to the trunk of the human body.

·       It offers  shoulder girdle stability

·       It allows the upper extremity to move freely about the thorax by positioning the extremity away from the body axis.

·       Mobility of the clavicle is important for normal shoulder mechanics.

·       It serves as an origin or insertion point for deltoid, upper trapezius, and pectoralis major muscles.

Pathomechanics

    Forces acting on the clavicle are most likely to cause a fracture of the bone medial to the attachment of the coracoclavicular ligaments. Intact ligaments aid in keeping fractures non-displaced and stabilized.

Injury Mechanism

1. Direct blow

2. Indirect:

 - Fall on outstretched hand

 - Blow to the point of the shoulder.

Rehabilitation Principles

1.     Early identification of the fracture is an important factor in rehabilitation

2.     Uncomplicated recovery is expected if stabilization occurs early, with minimal damage.

3.     Complicated injury is associated with ligamentous injury.

4.     Treatment of clavicle fracture includes approximation of the fracture and immobilization with figure-8 wrap for 6 - 8 weeks with the involved arm in a sling.

5.     When designing rehabilitation program for clavicle fracture consider the function of the clavicle.

Rehabilitation

1) During immobilization

·       For the first 6 – 8 weeks the patient is immobilized in a figure-8 brace and arm sling.

·       If good approximation and healing of the fracture occur at 6 weeks, begin gentle isometric exercises of the upper extremity below 90 degrees of elevation. This is to prevent excessive loss of ROM and muscle atrophy.

2) After the immobilization period

·       The patient should begin a program to regain full active and passive ROM.

·       Joint mobilization techniques are used to regain normal arthrokinematics.

·       The patient may continue to wear the sling for the next 3 - 4 weeks while he regains the ability to carry the arm in appropriate posture without the figure-8 brace.

·       The patient should begin a strengthening program utilizing progressive resistance when ROM improved.

·       Once full ROM is achieved, the patient should begin resisted diagonal PNF exercises.

·       Increase strength of the shoulder complex muscles to provide normal neuromuscular control of the shoulder.

Shoulder Dislocations

Definition

Shoulder dislocation is a temporary displacement of the humeral head from the glenoid labral fossa.

Types

·       Anterior dislocation

·       Posterior dislocation

·       Inferior dislocation.

Incidence

·       Shoulder dislocations represents up to 50% of all dislocations

·       Anterior dislocation is the most common occurring.

·       Posterior dislocation account for only 1 : 4 % of all shoulder dislocations.

·       Inferior dislocations are extremely rare.

·       From 85 to 90% of dislocations caused by direct trauma.

Pathomechanics

a)   In anterior dislocation

·       The head of humerus is forced out of its anterior capsule past the glenoid labrum and then rest down and under the coracoid process.

·       Torn Capsular and Ligamentous tissue, possibly tendinous avulsion of the rotator cuff muscles, and profuse hemorrhage.

·       A tear or detachment of the glenoid labrum may also be present

·       Injury of the brachial nerves and vessels may occur.

·       Rotator cuff tears may also arise.

·       Bicipital tendon may also displaced from its canal as a result of transverse ligament rupture.

B) In posterior dislocation

·       Tears of posterior glenoid labrum.

·       Fracture of lesser tubercle.

Mechanism of injury

a) Traumatic.

·       Anterior dislocation: Forced abduction, external rotation, and extension, or direct impact to posterior or posterolateral aspect of the shoulder.

·       Posterior dislocation: Forced adduction, and internal rotation.

b) A traumatic: sublaxation or dislocation episodes without trauma.

Clinical features

A) At time of injury

·       Intense sickening pain

·       Deformity: change of normal contour of the joint.

·       Inability to move the limb.

B) Later symptoms

·       Swelling

·       Bruising

·       Stiffness

·       Muscle weakness

Treatment

·       Immediate reduction to reduce pain and prevent further damage of soft tissues.

·       Elderly patient: the arm rested in a large arm sling for few days.

·       Young patient: the arm bandaged to the chest for 3 – 4 weeks to allow healing of soft tissues and to avoid recurrent dislocation.

Physical Therapy

1. During immobilization: static contractions for the muscles around the shoulder.

2.  Exercises may be initiated early, using caution not to increase the inflammation or disrupt healing of the capsule.

3.   After removal of the bandage: start ROM exercises.

4. To maintain normal joint mechanics, begin with isometric resistance exercises with the joint positioned in various ranges and progress to isotonic resistance exercises.

5. Strengthen the adductors and medial rotators after anterior dislocation.

6. Restrict activities that lead to risk of re-jury:

- Anterior dislocation→ avoid combined position of external rotation and abduction.

- Posterior dislocation → avoid combined position of internal rotation and horizontal adduction.

- Inferior dislocation   → avoid Full elevation.

7. Apply mobilization techniques to the shoulder joint to maintain and regain joint play.

8. Resuming normal activity is achieved within 12 weeks, with return to unrestricted activity within 20 weeks. 

Recurrent Shoulder Dislocations

Incidence

    Reports show high rate of recurrence for dislocations. Recurrent dislocation occurs more often in young because the initial trauma may be more severe.

Pathomechanics

     In some instances the damage caused by the dislocation does not heal and re-dislocation may occur. Once this happens further dislocations are likely. The damage involves the capsule being torn from the anterior rim of the glenoid cavity.

Treatment

     When re-dislocation is frequent and it upsets the normal activities of the person, surgery is advised. There are several procedures:

a.   Putti Platt operation: is commonly used, where the subscapularis muscle is shortened to limit lateral rotation.

b.  Bankart operation: This comprises reattachment of the capsule to the rim of the glenoid cavity.

·             Before surgery, the shoulder is immobilized for 3 – 4 weeks.

·       After surgery, the patient require rehabilitation program to regain ROM, muscle power and full function.

·       It may not possible to regain full lateral rotation due to the nature of the operation.

Role of physiotherapy in elbow and

forearm injuries

Elbow fractures and dislocations

Common injuries of the elbow include:

·       Fractures,

·       Dislocation,

·       Ligamentous sprain,

·       Medial or lateral epicondylitis.

     The following are some of fractures commonly affect the elbow:

1- Distal humeral fracture

2- Olecranon fracture

3- Head of radius fracture

4- Coronoid fracture

5- Elbow dislocation.

1-  Distal humeral fractures

Classification of distal humeral fractures

1) Extra-articular fracture

a.   Non-displaced fracture:     Brief immobilization  with early ROM

b.  Displaced  fracture: Open reduction and internal fixation( ORIF)

c.   Comminuted fracture: ORIF

          2) Intra-articular fracture: partial or entire articular fracture: ORIF.

The following are types of these fractures:      

1- Supracondylar fracture: in children:

a.   Flexion type:   Immobilized in near extension.              

b.  Extension type: Immobilized in flexion.                          

2- Intercondylar fracture:  in adults

          à ORIF

3- Epicondylar fracture

a- Lateral epicondylar fracture:

Brief splinting followed by early ROM exercises.

b- Medial epicondylar fracture (Fused at 15-20 y).

1- Undisplaced       2- Minimally displaced       3- Displaced

Treatment:

·       Closed manipulation, short term immobilization (10–14 days) with forearm pronated and elbow & wrist flexed.

·       ORIF when ulnar neuropathy is present.

·       Brief immobilization and activity modification for chronic stress fractures.

N.B.

Expected time of bone healing:

          8-12 weeks. Additional time may be required if the patient is diabetic or smoker.

Expected duration of rehabilitation:

          12-24 weeks

Methods of orthopaedic treatment:

1-   Cast or posterior splint.

2-   Percutaneous pinning with splint.

3-   Open reduction and internal fixation (ORIF).

4-   External fixation.

5-   Skeletal traction.

Associated injury:

          1) Nerves:

                   a) Ulnar nerve: most commonly injured nerve.

                   b) Radial nerve.

                   c) Median nerve.

Nerve injuries may occur with:

1-   Closed reduction.

2-   Percutaneous pain.

3-   Open or surgical treatment.

4-   Malunion of distal humerus fractures.

2) Vessels:

     The brachial artery may be injured or compressed. This may lead to compartment syndrome. The consequences of missed compartment syndrome include: Volkmann’s ischemic contractures or even loss of the limb.

Complications:

1-   Loss of elbow ROM due to capsular contractures or myositis ossificans. Surgical release of contractures or resection of mature myositis ossificans (by 1 year) is the treatment.

2-   Post-traumatic arthritis.

1. Olecranon fractures

Classification of olecranon fractures:

1-   Undisplaced

2-   Displaced:      a- Oblique  b) Transverse       c) comminuted.

3-   Fracture dislocation.

N.B.

Expected time of bone healing

          10-12 weeks.

Expected duration of rehabilitation

          10-12 weeks

Methods of orthopaedic treatment:

·       Closed reduction and splint or cast.

·       ORIF.

·       Excision of olecranon and triceps reattachment.

Associated injury

1-   Ulnar nerve (2% - 10% of cases).

2-   Fracture of Coronoid process.

3-   Injury of MCI.

Complications

1-   Triceps muscle is the primary extensor of the elbow. Displaced olecranon fractures disrupt the triceps mechanism and may result in weakness or loss of active elbow extension, and lack of terminal extension

2-   Heterotopic bone formation may reduce elbow ROM.

2- Radial head fractures

Types:

1-   Undisplaced fracture (25%).

2-   Marginal fracture with displacement.

3-   Entire head comminuted.

4-   With associated dislocation.

N.B.

Expected time of bone healing

          6 - 8 weeks (1.5 - 2 months).         

Expected duration of rehabilitation

          6 - 12 weeks (1.5 - 3 months).

     Once the fracture is stable, ROM may be initiated. Functional rehabilitation is the initial goal of rehabilitation, so early beginning of rehabilitation reduces the length of rehabilitation period.

Methods of orthopaedic treatment:

1-   Aspiration of elbow hemoarthrosis, sling, and early ROM.

2-   Excision of fracture fragments or entire radial head.

3-   ORIF.

      When the head of radius is fractured and cannot be repaired, it is excised. The patient can regain full pronation and supination despite loss of the head of radius. The radius remains stable because of the interosseous membrane and the distal radioulnar joint.

Associated injury:

1-   Posterior interosseous nerve injury.

2-   Median nerve.

3-   Brachial artery.

4-   Elbow dislocation.

5-   MCL.

Complications:

1-   Soft tissues ossification.

2-   Loss of motion and stiffness.

3-   Radial head excision lead to:

·       Weakness of grip strength.

·       Valgus instability.

·       Late ulnar palsy.

3) Coronoid fractures

1- Tip avulsion fracture

2- < 50% of coronoid process: short-term immobilization in flexion with early ROM exercises.

3- > 50% of coronoid process with recurrent elbow dislocation (elbow instability). It needs ORIF.

Elbow dislocation

Classification of elbow dislocation:

1- Posterior.                               2- Posterolateral.

        4- Posteromedial.                    3- Medial.

                   6- Lateral.           5- Anterior.

Common fractures associated with elbow dislocations:

1-   Medial and lateral epicondyle fracture

2-   Coronoid process fracture

3-   Head of radius and olecranon fracture

Complications associated with elbow dislocations:

1-   Loss of motion

2-   Loss of strength

3-   Chronic instability

4-   Redislocation

5-   Post-traumatic arthritis

6-   Neurologic or vascular injury

7-   Compartment syndrome

8-   Ectopic calcification of the capsule or collateral ligaments (75%)

9-   Ossification of the capsule (5%), collateral ligaments or brachialis muscle.

General treatment goals:

          To obtain a well-healed, stable joint with functional ROM.

1) Orthopaedic goals:

   Accurate alignment of the distal humerus to

          a) Avoid disability,

          b) Avoid cosmetic deformity associated with malunion and abnormal carrying angle.

          c) Reduce the risk of posttraumatic arthritis.

2) Goals for operative intervention:

          1- Proper anatomical fracture reduction.

          2- Fracture stabilization.

          3-Early rehabilitation, ROM exercises and return of function.

3) Rehabilitation objectives:

1- a) Restore and maintain full ROM of the elbow.

    b) Maintain full ROM of shoulder, wrist and hand joints.

2- Improve the strength of the following muscles:

    a) Elbow flexors and extensors.

    b) Other muscles:

              * Supinators and pronators,

                                          * Wrist flexors and extensors,

                                          * Shoulder muscles.

3- Functional goals: Restore activities that require flexion, extension, supination and pronation such as: feeding, personal hygiene, dressing. The first steps in achieving these goals are:

a)    A through history,

b)    Physical examination,

c)    Radiographic evaluation.

General treatment guidelines after elbow fractures:

A) Management during the period of immobilization:

Problems:

1.    Inflammation and swelling.

2.    Progressive muscle atrophy

3.    Contracture

4.    Decrease of circulation in the immobilized area

5.    Cartilage degeneration

6.    Overall limb weakness

7.    Functional limitation

Treatment goals and plan of treatment:

B) Management after the period of immobilization

Problems

1-   Decreased ROM

2-   Muscle atrophy

3-   Joint pain.

Treatment considerations:

1-   Activities should be initiated carefully in order not to traumatize the weak structures (muscle, cartilage).

2-   Begin exercise program with active assistive or active free exercises according to the patient’s tolerance.

3-   Initially, the patient will feel pain as movement begins, but it should progressively decrease as joint movement, muscle strength, and ROM progressively improve.

4-   Soft-tissue damage associated with a fracture will lead to scar formation which leads to decrease ROM or pain with stretch.

5-   Until the fracture site is radiologically healed, take care when stress is placed distal to the fracture site (e.g. resistance, stretch force or weight bearing). Once the bone is radiologically healed, the bone can withstand normal stress.

6-   Progress strengthening exercises gradually according to subacute and chronic stages.

C) Post operative management

Problems

1-   Postoperative pain because of disruption of soft tissues.

2-   Edema.

3-   Circulatory and pulmonary complications.

4-   Joint stiffness or limitation of motion due to soft tissue injury and postoperative immobilization.

5-   Muscle atrophy due to immobilization.

6-   Loss of strength.

7-   Decrease functional activities.

8-   Limitation of weight bearing.

9-   Potential loss of strength and mobility in unoperated joints.

Post-operative treatment goals and plan of care:

Post operative precautions

1-   Avoid specific motion for the operated elbow joint.

2-   Progress exercises gradually during the early post operative period.

3-   Avoid any stretching or resistance exercises to the muscles or tendons that have been incised and reattached during surgery for approximately 6 weeks to provide adequate healing and stability.

D) Treatment for chronic stage

Duration of treatment

          Treatment should be continued until the part is pain free with normal ROM and good strength.

Problems

          All, some, or none of the problems is present.

1-   Pain is felt only when stress is applied to the structures and after tissue resistance is met.

2-   Limitation of normal ROM or joint play due to adhesions.

3-   Muscle weakness.

4-   Decrease function of the injured arm.

Treatment goals and plan of treatment

Precautions in treating the injured elbow

1-   No elbow movements are allowed during the period of fixation,

2-   Patient should start active ROM exercises once the pain subsides.

3-   Avoid shoulder internal and external rotation until fracture union, because this stresses the fracture site. If there is any danger of displacement, shoulder movements should be allowed in very small ROM and with assistance of gravity.

4-   Avoid stiffness of fingers and shoulder during the immobilization period. Fingers hand and wrist must be exercised constantly.

5-   Avoid passive ROM exercises to the elbow to reduce the risk of myositis ossificans.

6-   Avoid motion against resistance until fracture healing is evident (8-12w).

7-   No supination or pronation is allowed if in a splint.

8-   No weight bearing is allowed on the affected extremity for 3 months, so it may be used for support. Full weight bearing should be possible if radiographic union is present.

9-   Most activities require elbow motion between 30˚ and 130˚, loss of extension is less significant than loss of flexion. It is of vital importance to gain full flexion and maintain it.

10-    Treatment of an elbow with severely limited ROM is difficult and the results are often poor. The best approach is prevention with adequate post-injury rehabilitation.

11-    Post-operatively gentle active assisted ROM should be started when incisional pain subsides.

12-    Protection is usually required until consolidation.

13-    With good progress of healing, gentle elbow movement may be given, after sling is lowered gradually.

14-    When the sling can be discarded increase activity gradually.

15-    Avoid stretching after recent fracture, acute inflammation, infection (heat, swelling) in or around elbow, whenever there is sharp, acute pain with joint movement or muscle elongation, when a haematoma or tissue trauma is present.

16-    The following signs must be watched:

· Any exacerbation of pain.

· Any limitation of ROM

· Any spasm of biceps.

These may indicate:    - myositis ossificans or 

                                      - Volkmann’s ischemic contracture.

17- Motions of the elbow influence both the shoulder and the forearm as a result of muscular and skeletal attachments. Injury to the elbow will therefore affect wrist and hand function distally and may interfere with normal shoulder function.

18- Carrying angle of 15˚-25˚ often cause ulnar nerve symptoms at the elbow because of the stretch of the ulnar nerve as it crosses the elbow. Elbow fractures in children may cause valgus deformities and late ulnar nerve palsy.

Physical therapy for post-traumatic complications

1) Myositis Ossificans

Definition:

    The terms myositis ossificans and heterotopic or ectopic bone formation are often used interchangeably to describe the formation of bone in atypical locations of the body.

Sometimes the term myositis ossificans is used to denote only ossification of muscle. More often, the term is used generally to characterize heterotropic bone formation in muscle-tendon unit, capsule, or ligamentous structures.

Etiology

          Although myositis ossificans is not a common phenomenon, the sites most frequently involved are the elbow region and thigh. In the elbow, heterotopic bone formation most often develops in the brachialis muscle or joint capsule as the result of trauma, such as a comminuted fracture of the radial head, posterior elbow dislocation, a fracture dislocation (supracondylar or radial head fracture) of the elbow, or a tear of the brachialis tendon. Patients with neurological impairments, specifically traumatic brain injury or spinal cord injury, as well as patients with burns to the extremities are also prone to develop this complication. It may also develop as the result of aggressive stretching of the elbow flexors after injury and a period of immobilization. When the brachialis muscle is injured, ossification of the injured tissue is a potential complication.

Symptoms

          Myositis ossificans is distinguished from traumatic arthritis of the humeroulnar joint in that

·       Passive extension is more limited than flexion,

·       Resisted elbow flexion causes pain,

·       Flexion is limited and painful when the inflamed muscle is pinched between the humerus and ulna,

·       Resisted extension in midrange causes pain in the brachialis muscle.

        Palpation of the distal brachialis muscle is tender. After the acute inflammatory period, heterotopic bone formation is laid down in muscle, between, not within, individual muscle fibers or around the joint capsule within a 2 to 4 week period of time. This makes the muscle extremely firm to touch.

Prognosis

        Although myositis ossificans can permanently restrict elbow motion, in most cases, the heterotopic bone to a large extent is reabsorbed over several months, and motion usually returns to near normal.

Management

1)         Contraindications: Massage, passive movement, passive stretching, and resistive exercise are contraindicated if the brachialis muscle is implicated after trauma.

2)         Conservative treatment: The elbow should be kept at rest in a splint, which should be removed only periodically during the day for active, pain-free ROM. Rest should continue until the bony mass matures and then resorbs.

3)          Surgical treatment: Surgical excision of heterotopic bone from the muscle or a total elbow arthroplasty, if the capsule is also involved, is necessary only in rare instances.

2) Elbow Joint Effusion

           All three joints of the elbow complex are affected because they have a common joint capsule. The joint swelling is most evident in the triangular space between the radial head, tip of the olecranon, and lateral epicondyle.

      The elbow is held in the loose packed position of about 70˚ flexion, because in this position the joints have maximal volume. Ice application, elevation, rest, and compression are primarily used for treatment. Static and isometric exercises are effective to reduce pain and effusion.

3) Volkmann’s ischemic contracture

Definition

             It is a massive infarction, mainly on the muscles and to a lesser degree on the other soft tissues.

Causes

           It is the result of a compartment syndrome. Compartment syndromes result when increased pressure within limited anatomic space compromises circulation to surrounding tissues. It is common after paediatric supracondylar humerus fracture treated with long arm cast with elbow placed in extreme flexion.

Pathology

            The lesion is a massive infarct, mainly on the muscles and to a lesser degree on the other tissues. It varies in length from a few centimetres, to the full length of the forearm. The severity of damage varies from mild fibrosis to total necrosis. The flexors are more affected than the extensors. The deep muscles of the forearm, the flexor digitorum profundus and flexor polices longus are more affected than the superficial muscles. Fibrosed muscles lead to contracture and deformity. The median nerve is liable to ischaemia more than the ulnar nerve.

Clinical Picture

1-   Deformity: Flexion of the wrist and interphalangeal joints, with extension of the metacarpo-phalangeal joints.

2-   Contracture: The flexors of the fingers are short. When the wrist is flexed, the fingers can be passively extended; when the wrist is extended, the fingers become flexed and cannot be passively extended.

3-   Atrophy: The forearm muscles become atrophied.

4-   Ischemic neuritis: Sensory loss along the distribution of the median nerve.

5-   Trophic changes in the fingers are often present.

Prevention

·       Early reduction of the fractures around the elbow to relieve any pressure of the brachial artery.

·       Position of fixation of supracondylar fracture should be in full elbow extension with the forearm supinated.

·       Avoid tight bandage.

·       Early treatment at the onset of ischaemia.

Treatment

A)  Non operative treatment:  Stretching of the contracture on a splint.

B)  Operative treatment followed by physical exercises to regain the ROM and muscle power as much as possible.

4) Shoulder-Hand syndrome (reflex sympathetic dystrophy)

Definition

   It is a painful shoulder with limited movement and symptoms of swelling, pain, stiffness, sweating, and color changes of the hand.

Causes

·       Myocardial infarction.

·       Post-hemiplegia.

·       Post-traumatic.

·       Post-herpetic.

·       Secondary to:

·       Cervical diskogenic disease or  

·       Shoulder pericapsulitis.

Clinical picture

1-   Circulatory impairment of the venous and lymphatic systems in the arm and hand.

2-   Limitation of shoulder movements.

3-   Edema and contracted collateral ligaments leading to limitation of metacarpo-phalangeal joints.

4-   Restriction of wrist movement and it is maintained in a flexed position.

5-   There may be involvement of the sympathetic nervous system leading to:

·       Pain and swelling in the hand.

·       Trophic skin changes.

·       Vasomotor changes.

·       Pain and limited ROM of the shoulder.

N.B.

The changes in the hand usually progress in three stages.

Management

This is a progressive disorder unless vigorous intervention is used. Treatment consists of:

a)    Encouraged motion of the hand and shoulder in spite of pain which increases with movement. Future immobilization leads to increased stiffness, contracture and atrophy of skin, bone and muscles.

b)    Sympathetic procaine blocks.

c)    Procaine and cortisone injections into the shoulder and trigger pain points.

d)   Physical therapy management:

1-   Paraffin baths to the hands.

2-   Increase limited ROM of the shoulder and hand by using:

·        Joint mobilization technique.

·        Muscle elongation and stretching.

·        Soft-tissue stretching.

3- Increase the activity of the upper limb through:

(a) Isotonic exercises and

(b) Functional activities.

4- Elevate and warp the extremity if there is edema.

5- Educate the patient the importance of the program of increased activity.

Prevention

Prevention is the best therapy, whenever there is shoulder involvement or referred pain to the shoulder, the entire upper extremity should be moved as soon as allowed, at a safe intensity for the condition.

Physical Therapy of Osteoarthritis

Definition

    Osteoarthritis (OA) is a common chronic progressive degenerative articular disorder among adults of unknown cause characterized by gradual deterioration and loss of the cartilaginous weight-bearing surfaces of joints, presence of sclerotic changes in subchondral bone, and proliferation of new bone at the joint margins. The proliferation of new bone is manifest as osteophytes and spurs, which are evident on radiographs.

Pathology of osteoarthritis

·       Weight-bearing joints of the lower limbs and spine are most commonly involved. The articular surface becomes rough and the cartilage in the affected area degenerates, particularly at the points of greatest pressure. While at the margins of the joint osteophytes are formed.

·       The lubrication mechanism of the joint is affected and it may become dry and creaky, even to the extent of the individuals being able to hear the joint crepitus. The muscles close to an affected joint may spasm as a protection mechanism to prevent painful movement, also muscles may be atrophied.

Incidence

·       Patients are usually over the age of 50.

·       Both men and women are affected but the joint distribution pattern is different.

    In man, the order of affected joints is hip, knee, spine, ankle, shoulder, and fingers. In women the order is knee, fingers, spine, hip, ankle, and shoulders.

Classification

1- Primary osteoarthritis: it develops spontaneously in middle age, and appears to be idiopathic. It can be localised or generalised

2- Secondary osteoarthritis has an underlying cause. It may develop in response to a number of different factors such as:

1-     Trauma after severe injury, resulting in fractures of the joint surfaces, ligamentous injuries and meniscal damage.

2-     Dislocation.

3-     Infection.

4-     Inflammatory arthritis

5-     Loss of full range of motion, poor muscular power and strength

6-     Loss of adequate joint alignment and deformity.

7-     Obesity.

8-     Hemophilia.

9-     Hyperthyroidism.

Causes of osteoarthritis

The cause is unknown but a number of predisposing factors may be considered:

1-     Conditions already mentioned in relation to secondary arthritis.

2-     Hereditary: There is a significantly higher incidence of the condition in families.

3-     Poor posture and altered biomechanics the joint.

4-     The ageing process in joint cartilage.

5-     Defective lubricating mechanism and uneven nutrition of the articular cartilage, recurrent synovial effusion, and hemoarthrosis

6-     Climate has not been shown to be related to the pathological changes but pain is greater in cold, damp climates.

7-     Crystals (calcium pyrophosphate and hydroxyapatite) have been associated with synovitis in osteoarthritic joints.

Clinical Features

A. Physical signs

1.    Increased warmth, redness and fluid swelling in the joint during active inflammation.

2.    Joint tenderness.

3.    Joint enlargement.

4.    Joint stiffness.

5.    Joint crepitus on movement.

6.    Reduction in the normal knee joint ROM

7.    Muscle weakness and wasting.

8.    Bony deformation as varus (bow leg) or valgus (knock- knee) may present in advanced cases of knee OA.

B. Symptoms

1.    Pain with or after movement: usually pain is exacerbated with activity and is worst at the end of the day and in bed at night.

2.    Joint pain decreased or relieved with rest.

3.    Swelling may be due to bony deformity such as osteophytes formation, or due to an effusion caused by synovial fluid accumulation after prolonged activity.

4.    Feeling of stiffness in the affected joints. e.g. early morning stiffness of less than 30 minutes.

5.    Reduced physical functioning.

Diagnostic investigations

1.    X-rays shows loss of joint space. There is subchondral sclerosis, altered shape of bone ends and osteophytes.

2.    Laboratory tests are normal, and blood tests are normal unless the osteoarthritis is due to a biochemical condition such as gout, or a rheumatic disease such as rheumatoid arthritis.

 Treatment of osteoarthritis

      Osteoarthritis cannot be cured but may be controlled with appropriate treatment. The goals of treatment are to relieve the symptoms and to manage the effects of progression of the pathologic process.

Benefits of treatment include the following

1.    Pain may be reduced or eliminated.

2.    Range of movement can be extended.

3.    Mobility can be improved.

4.    Personal independence can be enhanced.

5.    Further deterioration may be prevented.

Treatment is usually either conservative or surgical in nature:

I.   Conservative Treatment    

A. Rest may reduce compression and shearing on the joint and to allow inflammation to subside.

B. Drug therapy for relieving pain, including nonsteroidal anti-inflammatory drugs (NSAIDs) or a local injection of steroids where necessary.

C. Diet: Most patients need advice in weight reduction

D. Physical Therapy

Aims

1-     Relieve pain.

2-     Strengthen muscles.

3-     Mobilize joints.

4-     Teach maintenance of joint range and muscle power.

5-     Improve coordination.

6-     Minimize deformity.

7-     Train position sense to reduce postural stress.

8-     Advise rest/activity relationship.

9-     Help maintain and regain function.

Effective treatment of OA involves pain control and external force control.

1.    Pain control

a.   Thermal agents: paraffin path, US, IR, heat pads, hot packs.

b.  Hydrotherapy: hot or cold packs because ice packs over the joint reduce pain and inflammation especially in acute cases

c.   Electrical stimulation: (TENS, interferential, or didynamic).

2.    External force control is accomplished by

a.   Reduction of the patient's weight through diet and exercise regimes.

b.  Using assistive devices such as orthotics or ambulatory devices (a cane, crutches, or a walker) may be needed to reduce the weight-bearing load on the joint.

3.    The exercises recommended for OA are

a.   Free active exercises and mobilization by restoring mobility and improving circulation can contribute to pain relief.

b.  A muscle - strengthening program: The general principle is to work the muscles at a high repetition rate and against low resistance. The main muscles requiring strengthening are generally quadriceps, hip abductors and hip extensors. Knee extensor muscles should be developed and multiple angle isometric exercises are used to prevent muscle atrophy and to avoid excessive joint motion. Short-arc terminal extension exercises can be used to strengthen the quadriceps muscle.

c.   Strengthening exercises for all hip muscles (SLR, abduction LR, adduction LR, extension LR).

d.  Therapeutic strengthening exercises also include isotonic, and isokinetic exercises.

e.   Resisted exercises are important for the muscles of any joint in which there are osteoarthritic changes.

f.    Appropriate proprioceptive neuromuscular facilitation (PNF) techniques with slow reversals, repeated contractions, and stabilizations.

g.  Hold relax and repeated contractions are used to relax muscle spasm.

h.  Mobility of joints: Mobilization as either accessory or physiological movements is invaluable at the earlier stages of the condition. Stretching the capsule and applying rhythmical movement facilitates synovial sweep across the cartilage and may help to diminish degeneration by improving nutrition. Compression and distraction are useful for the same reason. Mobilizations may be applied in the hydrotherapy pool with great success (pain relief and increased function) especially for the hip and lumbar spine. Grades I and II relieve pain and grade III reduces resistance fibrous thickening and tightening.

i.    Group therapy can provide encouragement to lose weight, carry out home exercises, monitor muscle bulk and by providing moral support to enable the patient to cope with the pain.

4- Instructions and advice to patients:

Instruction for the patient in joint use and maintenance of range of motion:

·       Walking is good for lubrication and nutrition of the joint. Walk a little every day within limits of pain. Use walking aids to relieve pain and stress and to help balance.

·       Rest 5-10 minutes every hour but avoid being in one position for longer than half an hour. If this is not possible, e.g. in a train or car, then practise isometric muscle contractions every so often.

·       Exercise daily. If bed rest is necessary, as with ‘flu’ once the acute fever stage is passed and the joints have stopped aching try to move each joint in every direction every half hour or so. Also, practise isometric contractions.

·       Weigh regularly, at least once a week. Try to keep weight under control.

·       Avoid sitting with the knees crossed to prevent deformity.

·       Do not sit or lie with a pillow under the knees.

·       Avoid putting sudden strain on the joints, e.g. lifting heavy loads.

·       Use a bag on wheels for shopping. Try to do a little every day rather than one big exhausting ‘shop’ once or twice a month. Carry two small bags, one in each hand.

·       Do a little housework every day.

·       In cold weather, wrap up well; cold predisposes to muscle spasm. Do not exercises from cold, use a rubber hot water-bottle or electric heat pad to warm the muscles prior to exercise.

·       Use of a hot water-bottle is less dangerous than heat lamp and can mould to the part. A heat pad is more versatile.

·       Although there is no cure, the effects of OA can be minimized so that functional capacity can be maintained. Patients sometimes need to be reassured that OA is not crippling as rheumatoid arthritis.

II. Surgical Treatment

Main surgical techniques are:

1.    Joint arthroplasty or making a new joint.

2.    Osteotomy or the cutting of bone.

3.    Arthrodesis or permanent fusion of the joint.

Rheumatoid Arthritis

Definition

             Rheumatoid arthritis (RA) is an inflammatory polyarthritis with systemic manifestations. It is a condition characterized by exacerbation and remissions, some of which may be prolonged.

        RA is a systemic connective tissue disorder. It affects multiple joint systems throughout the body in a symmetric or bilateral presentation. The disease is characterized by inflammation in the synovial lining of joint complexes, which may be either acute or chronic, that result in articular cartilage and bone destruction. Such degenerative changes occur simultaneously in multiple joints, resulting in severe pain and limited mobility for activities of daily living.

Incidence

Females are more affected in a ration 3:1.

Aetiology

1.     Unknown.

2.     Immunological factors.  

3.     Genetic factors.

4.     Environmental triggers.

5.     Infectious triggers.

6.     Hormonal factors.

7.     Stress.

8.     Trauma.

9.     Smoking

10.      Diet

Pathology

Pathological changes occur in synovium, arteries, and information of subcutaneous nodules.

1- Synovium

 The main pathological feature is synovitis, i.e. inflammation of the synovial lining of joints, tendon sheaths and bursae. Excess fluid becomes trapped within joint capsules, causing swelling. If this continues the synovium thickens, and excess synovium and fluid increase pressure within the joint, stretching and weakening the joint capsules and ligaments. Inflammation also directly infiltrates and erodes the capsule, ligaments, cartilage and subchondral bone, which leads to joint destruction and the development of deformities.

     Acute synovitis for a short period usually dose not result in deformity. However, the longer a person has continuing synovitis, the more likely deformities are to develop.

 2- Arteries

          Arteritis may occur in

·       small end arteries around the nail bed

·       small arteries resulting in skin ulceration

·       Large arteries leading to gangrene

3- Subcutaneous nodules

     These are characteristic firm nodules occurring in 25% of patients with RA. The common site is the ulnar side of forearm, olecranon and heel. They are not tender except when inflamed.

Stages of the disease

·       Stage I:   Synovium only is involved.

·       Stage II:  Early articular cartilage involvement.

·       Stage III: Destruction of joint surface.

Clinical features

Onset of the disease

·       At any age.

·      Commonly, it begins in the fourth decades.

Course of the disease

       It is unpredictable.

Pattern of joint involvement

The joints most commonly affected in RA are:

·       Hands (MCPJ, wrist and PIP joints): 85%.

·       Feet (metacarpo-phalangeal, subtalar and ankle joints): 80%.

·       Knees: 80%.

·       Elbows: 70%.

·       Shoulder: 60%

·       Cervical spine: 35%.

·       Hips: 27%

·       Sacroiliac Joints

·       Temporomandibular joints (TMJ): 23%.

Symptoms

·       Pain & tenderness resulting from increased intra-articular pressure, leads to protective muscle spasm and restricts activity. It may occur with movement, but as the disease progresses it present at rest.      

·       Joint swelling causes stretching and weakening of joint capsules and ligaments, resulting in joint instability.

·       Warm feeling,                   

·       Erythema,

·       Decreased ROM

·       Joint stiffness develops from the formation of joint adhesions. Morning stiffness is so characteristic.

·       Muscle wasting results from reduced activity. The additional muscular work required of weaker muscles attempting to stabilize weakened joints results in muscles quickly fatiguing and aching.

·       Deformity,     

·       Loss of function,

·       Frustration, anxiety, depression  

·       Related diseases.

(A) Articular sings

1-      Synovial hypertrophy

2-      Sublaxation and joint instability: Joint sublaxation results from erosion of cartilage, subchondral bone and ligaments, and secondary osteoarthritis can develop. These changes, combined with the mechanical stresses of weight- bearing and muscular forces arising from daily activities, produce deformity.

3-      Characteristic deformities

Deformities in the hand

·       Ulnar deviation at the MCPJ.

·       Swan neck deformity of fingers.

·       Boutonniere deformity. Over one-third of people with RA have hand deformities, with impaired hand function within two years of onset.

Deformities in the wrist

·       Palmar flexion and ulnar deviation.

·       Dorsal sublaxation ('dinner-fork' deformity)

·       Wrist can no longer effectively achieve extension during power and other grips.

·       Grip strength is on average only 20% that of healthy women.

Deformities of the elbow

·       Flexion

Deformities of the shoulder

·       Flexion & adduction

Deformities of cervical spine

·       Instability with sublaxation of atlantoaxial joint

Deformities in the hips

·       Flexion deformity with external rotation.

·       Aseptic necrosis of femoral head.

Deformities in the knee

·       Flexion deformity with varus or valgus component.

Deformities in the feet

·       Dropped metatarsal heads.

·       Valgus deformity

·       Pes planus

       Deformities cause further difficulties in walking, standing, sitting, transferring and sustained upper limb activities.

(B) Extra- articular manifestations

1-      Fever, fatigue and weight loss.

2-      Lymph node enlargement.

3-      Subcutaneous nodules.

4-      Involvement of tendons and bursae.

5-      Arteries & vasculitis,

6-      Spinal cord compression.

7-      Peripheral neuropathy.

8-      Lungs and pleura.

9-      Skin.

10-  Anaemia.

11-  Myopathy.

12-  Eye inflammations,

13-  Heart & lung involvement,

14-  Peri-articular osteoporosis.

Radiological findings

·       Erosions.                                    

·       Soft tissue calcification.

·       Changes in joint space.

·       Osteoporosis.

·       Sublaxation of joints.

Disability

·       50% of patients have little or no residual deformity.

·       40% of patients have some disability.

·       10% of patients have severe disability.

Prognosis

          Males have a better prognosis than females.

Impact of the disease

1. RA can result in a wide range of impairments and dysfunction.

        2. Frustration with the difficulty of performing everyday tasks, continual joint pain and fatigue may have a detrimental effect psychologically.

Management

1)      Drugs.

2)      Rest.

3)      Physical therapy.

4)      Surgery.

(1) Drugs

·       Analgesics,  Non-steroidal anti-inflammatory (NSAIDs), and steroids

·       Disease-modifying anti-rheumatic drugs: as gold salts, hydroxychloroquine, penicillamine and methotrexate as Apetoid, Avara, Mabthera, are used early to

- Prevent or reduce the erosive effects of RA

- Pain relief,

- Control inflammation,

- Decrease disease process

 (2) Rest

              a) General rest: Adequate time between activities.

              b) Local rest: Complete immobilization is not preferred.

              c) Bed rest: in acute stages

              d) Hospitalization: in very severe disabling cases.

(3) Physical Therapy

Aims

1.    To evaluate the patient.

2.    Educate the patient and his family

3.    To relieve pain.

4.    To maintain and restore ROM and mobility.

5.    To maintain and restore muscle power.

6.    To prevent deformity.

7.    To correct deformity.

8.    To maintain optimum function & performance in all ADL.

9.    Increase joint stability.

10.     Promote independence.

Methods

1- Examination and assessment

The first step in good management. Frequent re-assessment is necessary, because the disease is rarely static.

·       Range of Motion: Goniometric measurement of passive ROM is indicated at all affected joints following a gross ROM assessment.

·       Strength: Application of standard manual muscle tests to assess strength in RA may be inappropriate because of pain at various points in the range. A functional test of strength, therefore, is more indicative or rehabilitation needs and will identify the required functional outcomes of strengthening programs prior to initiating treatment.

·       Joint Stability: The Ligamentous laxity of any affected joint should be fully investigated.

·       Functional Assessment: Functional assessments may include ADL, work, and leisure activities.

2- Patient education

          Explain carefully all about the disease, and the purpose of exercises and rest. The patient should learn to protect his joints, good posture and body mechanics.

3- Relief of pain

·       Heat: can be used by various methods as hot packs, paraffin wax baths, and infrared. It aims to reduce pain and relax the muscles. Heat is recommended during disease remissions and chronic and not for acutely inflamed joints. It is used for RA to prepare joints for exercises.

·       Cryotherapy: Cooling the muscle and skin to temperature low enough to affect conduction velocity of a nerve is most effective in reducing muscle spasm and in relieving pain. The most effective method is the application of ice towels or packs which are changed frequently.

·       Transcutaneous electrical nerve stimulation (TENS).

4- Maintenance and restoration of joint range and patient mobility

a) Maintenance of ROM

 Patients are encouraged to put their joints through ROM daily: 

·       Active movement is preferred

·       Active assisted movement may be necessary.

·       Passive movement is not indicated.

b) Restoration of ROM

·       Repeated active movements into the limited range are encouraged and should be performed several times daily.

·       Passive stretching for soft tissue limitations by using the force of gravity.

·       Techniques of hold relax, contract relax and repeated contractions

·       Hydrotherapy

·       Maintain the gained ROM with voluntary control.

·       Splints can be used to gain ROM.

c) Mobility of the patient and gait training

·       Reeducation of walking may be required. Walking aids may be chosen according to the state of upper limb joints. Sticks and elbow crutches with modifications can be used.

·       Independent ambulation is recommended.

5- Maintenance and restoration of muscle power

·       Strengthening exercises should be performed daily because the disease has long course with primary and secondary effects on the muscles.

·       The exercises should be designed according to patient’s needs.

·       Isometric and progressive resistive exercises are effective to improve muscle strength with careful supervision.

·       Ensure that the resistance is not exceeding the range or stress the joints.

·       The exercises must be within the limits of pain. If increased pain is felt and lasts more than two hours after exercise. Exercises should be decreased in amount and velocity.

6- Prevention of deformity

The methods used in preventing deformity are:

1- Patient education.         2- Exercise.

3- Passive stretching.        4- Splinting

Splints

a) Rest splints                  b) Working splints

          Splints may be used to:

·       Relieve pain

·       Reduce inflammation

·       Protect weak joints from stress

·       Preserve anatomic alignments

·       Enhance function.

7- Correction of deformity

- Conservative methods

-  Surgical intervention            

Conservative methods of correction

·       Serial splinting

·       Intensive muscle strengthening program.

·       Skin traction.

8- Maintenance of function & physical performance

    Aerobic-type exercise for at least 15 minutes performed at least three times per week is sufficient to improve the functional status of patients

9- Home program

·       Home program is essential in treating a RA patient.

·       It is specific for each patient according to the physical examination.

·       Teaching correct performance of an appropriate daily exercise program.

10- Community care

       RA is a long term chronic disease affecting the patients family and social life, and the provision of services is documented.

(4) Surgical Treatment

     Surgery may be both preventative and corrective, and plays an increasing role in the management of chronic RA.

Indications for surgery:

1)      Relief of incapacitating pain

2)      Restoration of stability

3)      Improvement of function

4)      Prevention of harmful stresses on other joints.

Common operations include:

1.    Synovectomy (e.g. wrist, MCPs) in1st stage of RA.

2.    Tenosynovectomy (e.g. finger flexors).

3.    Joint replacement, most commonly of the hips, knee and MCPs, and also of the elbow and shoulder.

4.    Arthrodesis or fusing the joint to eliminate pain and provide stability, especially in the ankles and spine where replacements have failed.

5.    Reconstruction, repair and tenolysis on tendons.

Frozen shoulder

(Adhesive capsulitis, Periarthritis)

Adhesive capsulitis and frozen shoulder are two of the terms commonly used to describe a painful and stiff shoulder joint.

Definition of adhesive capsulitis

     It is a chronic capsular inflammation with fibrosis of the capsule of the glenohumeral joint.

Etiology

It is unknown.

Types  

There are 2 types

1)   Primary adhesive capsulitis

   It is idiopathic and spontaneous. An unknown stimulus creates histological changes in the joint capsule that are different from the changes caused by immobilization or aging.

2)  Secondary adhesive capsulitis

     It is always preceded by an episode of trauma or immobilization (voluntary or involuntary), as a result of pain, soft tissue disorder around the joint or systemic disease (especially diabetes, hemiplegia).

Incidence of adhesive capsulitis

·       It is higher in           

o      Females                   

o      Persons in the age between 40-60 years.

·       It develops more commonly in the non-dominant arm.