Cervical Spondylosis

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EPIDEMIOLOGY

Evidence of spondylotic change is frequently found in many asymptomatic adults, with 25% of adults under the age of 40, 50% of adults over the age of 40, and 85% of adults over the age of 60 showing some evidence of disc degeneration. Another study of asymptomatic adults showed significant degenerative changes at 1 or more levels in 70% of women and 95% of men at age 65 and 60. The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5.

CAUSES

Possible causes of the condition include:

Degenerative Disc Disease

Bone Spurs

Herniated discs

Dehydrated Spinal discs

Injury (Acute/Chronic)

Ligament Stiffness

Overuse injury

Risk factors include :

Aging

Work related Activities putting excesse stress on neck

Repetitive Stress

Genetics

Smoking

Being overweight and physically inactive

CLINICAL FEATURES AND PATHOPHYSIOLOGY

Common symptom is pain around neck and shoulder blade. Some complain of radicular pain along the arm and also in the fingers . The pain might increase when:

standing
sitting
sneezing
coughing
tilting your neck backward

Another symptom is muscle weakness. Muscle weakness makes it hard to lift the arms or grasp objects firmly.

a stiff neck that becomes worse

headaches that mostly occurs in the back of the head

Tingling and Numbness that mainly affects the shoulders and arms, although it can also occur in the legs

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PHYSICAL EXAMINATION AND DIAGNOSIS

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Spurling Sign

https://youtu.be/3ZSNdv0o0yk

Lhermitte Sign

https://youtu.be/nIPIkaVTbrE

Other test includes

Cervical Distraction Test

https://youtu.be/uLdzgd5snmw

Another occasionally useful test is the pectoralis muscle reflex.

This is elicited by tapping the pectoralis tendon in the delto-pectoral groove, which causes adduction and internal rotation of the shoulder if hyperactivity is present. A positive result suggests compression in the upper cervical spine (C2-C4).

Plain radiographs of the cervical spine may show a loss of normal cervical lordosis, suggesting muscle spasm.

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PHYSIOTHERAPY MANAGEMENT

Mobilisation or manipulations in combination with exercises are effective for pain reduction and improvement in daily functioning in sub-acute or chronic mechanical neck pain with or without headache.

There is moderate evidence that various exercise regimens, like proprioceptive, strengthening, endurance, or coordination exercises are more effective than usual pharmaceutical care

Treatment should individualised, but generally includes rehabilitation exercises, proprioceptive re-education, manual therapy and postural education

Manual therapy

It is defined as high velocity, low amplitude, thrust manipulation or non thrust manipulation. Manual therapy of the thoracic spine can be used for reduction of pain, improving function, to increase the range of motion and to address the thoracic hypomobility

Thrust manipulation

Thrust Manipulation of the thoracic spine could include techniques in a prone, supine, or sitting position based on therapist preference. Also cervical traction can be used as physical therapy to enlarge the neural foramen and reduce the neck stress.

Non-thrust manipulation

It includes posterior-anterior (PA) glides in the prone position. The cervical spine techniques could include retractions, rotations, lateral glides in the ULTT1 position, and PA glides.

Postural education

It includes the alignment of the spine during sitting and standing activities.

Thermal or Heating therapy

It provides symptomatic relief only.

Soft tissue mobilisation

It was performed on the muscles of the upper quarter with the involved upper extremity positioned in abduction and external rotation to pre-load the neural structures of the upper limb.

Home Exercices

It includes cervical retraction, cervical extension, deep cervical flexor strengthening, scapular strengthening, stretching of the chest muscles via isometric contraction of flexor of extensor muscles to encourage the mobility of the neural structures of the upper extremity

For more info related Stretches and Exercises for Cervical Spondylosis visit

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Pain – Definition and Classification

The International Association of Study of Pain’s widely used definition describes pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

CLASSIFICATION OF PAIN

According to Pain Physiology

Clifford J Woolf suggests three classes of pain:

Nociceptive pain

Inflammatory pain

Pathological pain

NOCICEPTIVE

Nociceptive pain is caused due to an injury to the body tissue, this includes damage to muscle or bone such as bruises, cuts, fractures, burns, cancer and surgery. Pain reduces once the injury heals

Pain that is caused by the presence of a painful stimulus on nociceptors is called nociceptive pain. Nociceptive pain in its acute form usually serves an important biological function as it warns the organism of impending danger and informs the organism of tissue damage or injury

Nociceptive pain may also be divided into visceral, deep somatic and superficial somatic pain.

Visceral pain is diffuse, difficult to locate, often referred to a distant structures . It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull ache.

Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia and muscles, and is dull, aching, poorly -localised pain.

Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located.

NEUROPATHIC

Neuropathic pain is caused due to dysfunction or damage to the nerves, spinal cord or brain. It is characterised by a burning, pins and needles, electrical, tingling or stabbing sensation. Pain can last for a long period of time, even after the injury has healed.

ALLODYNIA

It is a pain experienced in response to a normally painless stimulus. It has no biological function and is classified by stimuli into dynamic mechanical, punctate and static. In osteoarthritis, NGF has been identified as being involved in allodynia.

PHANTOM LIMB PAIN

Phantom pain sensations are described as perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body. Limb loss is a result of either removal by amputation or congenital limb deficiency.

Phantom limb sensations can also occur following nerve avulsion or spinal cord injury.

PSYCHOGENIC

Psychogenic pain is caused by psychological factors. Pain usually occurs due to tissue or nerve damage, but increases and is prolonged because of stress, fear, anxiety or depression

Psychogenic pain, also called psychalgia or somatoform pain, is pain caused, increased, or prolonged by mental, emotional, or behavioral factors. Headache, back pain, and stomach pain are sometimes diagnosed as psychogenic.

BREAKTHROUGH PAIN

Breakthrough pain is transitory pain that comes on suddenly and is not alleviated by the patient’s regular pain management. It is common in cancer patients who often have background pain that is generally well-controlled by medications, but who also sometimes experience bouts of severe pain that from time to time “breaks through” the medication.

According to the Intensity

Pain Intensity can be broadly categorized as mild, moderate and severe. It is common to use a numeric scale to rate pain intensity where 0 = no pain and 10 is the worst pain imaginable:

Mild:

Moderate: 5/10 to 6/10

Severe: >7/10

According to the Time course (Pain duration)

Acute pain

Pain of less than 3 to 6 months duration

Chronic pain

Pain lasting for more than 3-6 months, or persisting beyond the course of an acute disease or after tissue healing is finished .

Acute-on-chronic pain

Acute pain flare superimposed on underlying chronic pain

PAIN SCALES

Alder Hey Triage Pain Score

Behavioral Pain Scale (BPS)

Brief Pain Inventory (BPI)

Checklist of Nonverbal Pain Indicators (CNPI)

Clinical Global Impression (CGI)

Critical-Care Pain Observation Tool (CPOT)

COMFORT scale

Dallas Pain Questionnaire

Descriptor differential scale (DDS)

Dolorimeter Pain Index (DPI)

Edmonton Symptom Assessment System

Faces Pain Scale – Revised (FPS-R)

Face Legs Activity Cry Consolability scale

Lequesne algofunctional index

McGill Pain Questionnaire (MPQ)

Neck Pain and Disability Scale –(NPAD)

Numeric Rating Scale (NRS-11)

Oswestry Disability Index

Palliative Care Outcome Scale (PCOS)

Roland-Morris Back Pain Questionnaire

Support Team Assessment Schedule (STAS)

Wong-Baker FACES Pain Rating Scale

Visual analog scale (VAS)

Multiple Pain Rating Scales

Varicose Veins

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EPIDEMIOLOGY AND CAUSES

Annual incidence of varicose vein is 2%

Life time prevalence approaches 40%

Varicose vein are more common in females than men with ration of 2-3:1

10-20% patients are highly symptomatic that complaint about lower leg varicose vein

CAUSES

Obesity

Pregnancy

Genetic Predisposition

Hormonal Imbalance

Large Exercise

Uncomfortable footwear

Prolonged Standing / Sitting

Improper dietary habits

CLINICAL FEATURES AND PATHOPHYSIOLOGY

Varicose veins may not cause any pain. Signs you may have with varicose veins include:

Veins that are dark purple or blue in color

Veins that appear twisted and bulging; often like cords on your legs

When painful signs and symptoms occur, they may include:

An achy or heavy feeling in your legs

Burning, throbbing, muscle cramping and swelling in your lower legs

Worsened pain after sitting or standing for a long time

Itching around one or more of your veins

Bleeding from varicose veins

A painful cord in the vein with red discoloration of the skin

Color change, hardening of the vein, inflammation of the skin or skin ulcers near your ankle, which can mean you have a serious form of vascular disease that requires medical attention

saphena varix is a dilatation of the saphenous vein at the saphenofemoral junction in the groin, it is commonly mistaken for a femoral hernia, suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.

PATHOPHYSIOLOGY

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PHYSICAL EXAMINATION AND DIAGNOSIS

Trendelenburg Test or Brodie-Trendelenburg test

It is a test which can be carried out as part of a physical examination to determine the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins

Perthe’s test

With the patient positioned supine, to assess the functioning of the deep veins

Place the tourniquet around the thigh

Ask the patient to raise their heels off the ground ten times

Look for collapse of the superficial veins

If the superficial veins collapse, indicates deep veins are functioning (as blood is returning through the deep system); if the superficial veins remain dilated, suggests there may be a problem with the deep system

Tap test

To assess the competency of the valves

Place one hand at the saphenofemoral junction and the other hand on any varicosity visible

Tap at the saphenofemoral junction and feel for the percussion with the other hand

Move distally down the varicosity until unable to feel the percussions

CEAP CLASSIFICATION

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PHYSIOTHERAPY MANAGEMENT

Compression Therapy

Wearing compression stockings is vital for preventing and treating varicose veins. They steadily squeeze your legs to help improve your circulation. They may also help to relieve pain, discomfort or swelling in your legs.

Walking

It encourages blood circulation in your legs.

Pedaling

Lie flat on your back. Place your hands out to your sides. If you prefer you can place them beneath your buttocks to prevent strain to the lower back. Lift your legs off the floor, and pedal them as if you were pedaling a bicycle. The more you elevate your legs, the more you will increase blood circulation.

Leg Lifts

Lie on your back with your hands beneath your buttocks. Keep your buttocks pressed down, and your lower back against the floor. Lift one leg at a time and hold in an elevated pose perpendicular to the floor until you feel the blood begin to flow back up from your feet, calves, and thighs. Repeat with your other leg. Alternately, you can raise both legs and rotate your ankles to further improve leg circulation.

Knee bends with ankle flexion

Lie again on the floor on your back. Slowly pull one knee into your chest, holding onto your leg behind your knee. Now, point and flex your foot several times.

Don’t let your foot flap around loosely, but rather tighten the muscles of the calves and the tendons around your ankle.

PREVENTION

Exercise Regularly

Avoid Wearing tight clothing

Encourage Weight loss

Avoid Prolonged Standing and Sitting

Quit Smoking

Avoid High Heels

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Anterior and Posterior Compartment of Arm (Muscles)

Anterior Compartment of Arm

(1) Biceps Brachii

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Origin

The biceps muscle has two heads

(a) The short head and

Origin at the coracoid process of scapula

(b) The long head

Origin at supraglenoid tubercle of the scapula

Insertion

Inserts at radial tuberosity and bicipital aponeurosis into deep fascia on medial part of forearm

Artery Supply

Brachial artery

Nerve Supply

Musculocutaneous Nerve

Action

Flexion of Elbow

Supination of forearm

Clinical Significance

Biceps tendonitis/tendinosis/tendinopathy

(2) Coracobrachialis

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Origin

Coracoid process of scapula

Insertion

Anteromedial surface of humerus distal to crest of lesser tubercle

Artery Supply

Brachial Artery

Nerve Supply

Musculocutaneous Nerve

Action

Flexion and Adduction of Arm at glenohumeral joint

Clinical Significance

Coracobrachialis Tendon Rupture

(3) Brachialis

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Origin

anterior surface of the humerus, specifically at the distal half of humerus

Insertion

Coronoid Process of ulna and Ulnar Tuberosity

Artery Supply

Radial recurrent artery
Brachial artery

Nerve Supply

Musculocutaneous Nerve
Radial Nerve

Action

Flexion at elbow joint

Clinical Significance

Brachialis muscle injury (rare)

Posterior Compartment of Arm

(1) Triceps Brachii

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Origin

Long head
Infraglenoid tubercle of scapula

Lateral head
Above the radial groove of humerus

Medial head
Below the radial groove of humerus

Insertion

Olecranon process of ulna

Artery Supply

Brachial Artery
Posterior Circumflex Humeral Artery

Nerve Supply

Radial Nerve
Axillary Nerve

Action

Extension of elbow joint antagonist to biceps brachii.
It us also involved in retroversion and adduction of arm.

Clinical Significance

Triceps Strain (common)
Triceps Tendon Rupture

(2) Anconeous

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Origin

Lateral epicondyle of humerus

Insertion

lateral surface of the olecranon process of ulna and the superior proximal part of the posterior ulna

Artery Supply

Brachial Artery
Recurrent Interosseous Artery

Nerve Supply

Radial Nerve

Action

Extension at elbow joint

Clinical Significance

Anconeus Epitrochlearis

Rheumatoid Arthritis

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It is a painful chronic systemic autoimmune disease characterized by inflammatory polyarthritis that affects peripheral joints mainly small joints of hands and feet (metacarpophalangeal joints, interphalangeal joints).

EPIDEMIOLOGY AND CAUSES

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CLINICAL FEATURES AND PATHOPHYSIOLOGY

Joint swelling and pain

RA shows characteristic symmetrical pattern of joint involvement

The proximal interphalangeal joints and metacarpophalangeal joints are often the first to be affected, then wrists, elbows, shoulders, hips, knees, ankles, and metatarsophalangeal joints.

The axial skeleton is largely spared, except for the cervical spine in some cases.

Inability to “wring out a washcloth” or produce a strong grip

Caused by synovial inflammation, pannus, and effusion

Morning stiffness

Typically should last for at least one hour to be characterized as stiffness due to inflammatory arthritis

Stiffness after rest is often called “gelling”

Constitutional Symptoms
Fatigue
Anorexia
Mild weight loss

Deformity

Signs of late disease with irreversible damage in the hands and wrist:

“Swan-Neck Deformity”

Hyperextension of the PIP and flexion of the DIP. Progressive shortening of the tendon maintains DIP flexion and PIP extension.

“Boutonniere Deformity ”

The opposite of swan-neck (flexion of the PIP and extension of the DIP)

Subluxation at the MCP joint with ulnar deviation

Radial deviation of the wrist

Rheumatoid nodules

Occur in 20%; generally those with more severe disease and high-titer RF.

A rheumatoid nodule is a mass of inflammatory tissue with a central focus of necrosis, presumably the consequence of vascular inflammation, surrounded by chronic inflammatory cells.
Occur over extensor surfaces and joints, at sites of chronic mechanical irritation (elbow, toe, and heel), and in the subcutaneous tissues of the fingers.

PHYSICAL EXAMINATION AND DIAGNOSIS

American College of Rheumatology has defined 7 criteria, where a patient has to correspond with at least 4 of these 7 criteria for the diagnose of rheumatoid arthritis.

The first 4 of these criteria are only valid if they persist for at least 6 weeks. These 7 criteria are:

Morning stiffness

Arthritis in 3 or more joints

Arthritis in the joints of the hands (wrist, MCP, PIP)

Symmetrical arthritis

Nodules

Rheumatoid factors

Radiological deviations

Radiogaphic Findings

Soft-tissue swelling

Joint space narrowing from cartilage destruction

Erosion of periarticular cortical bone may occur early in the disease and results from excessive local bone resorption and inadequate bone formation

Subluxation

ACR/EULAR CRITERIA FOR RA

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PHYSIOTHERAPY MANAGEMENT

The therapy goals in most cases are:

Improvement in disease management knowledge

Pain control

Improvement in activities of daily living

Improvement in Joint stiffness and Range of motion

Prevent or limit joint damage

Improve strength

Improve fatigue levels

Improve the quality of life 

Improve aerobic condition

Improve stability and coordination

Physiotherapy Modalities

• Cold/Hot Applications

Cold = for acute phase
Heat = for chronic phase and used before exercise.

• Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain.

Rehabilitative Treatment

Joint Protection Strategies

Rest & Splinting

Orthosis and splinting prevent the development of deformities and support joints

Therapy Gloves

To control and manage hand pain, to maintain or restore the patient’s hand function

Compression Gloves

Used to reduce moderate joint swelling and consequently reduce the pain

Assistive Devices and Adaptive Arrangements like elevated toilet seats to facilitate activities of daily living

Soft tissue Manipulation Therapy

Manipulation and the manual therapy of an articular movement focused on the improvement of function, pain reduction, reduction of disease progression, improve flexibility etc

Therapeutic Exercise

Exercise improves general muscular endurance and strength without detrimental effects on disease activity or pain in rheumatoid arthritis. 

Before beginning an exercise program, it is important to have a global evaluation of the situation, joint inflammation local or systemic, state of the disease, age of the patient and grade of collaboration.

Exercises:

1. ROM exercises

In acute phase

isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day ; load = 40% 1RM.

In chronic phase: isotonic exercises for example: swimming, walking, cycling -> minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the joint will not be loaded during this exercises.

2. Stretching: Has to be avoided in acute cases.

Strengthening: Moderate-intensive exercise therapy where a minimum of 8-10 exercises is necessary for the major muscle groups.

Use light weights important for stabilization of the joint and prevention of traumatic injuries.

3. Aerobic condition exercises: There are two types of exercises to improve the aerobic condition

Intensive exercises and moderate-intensive exercises.

The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate.

The moderate intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of this exercises is to improve the muscle endurance and aerobic capacity.

Stabilizing and coordinating exercises

The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system.

4. Routine daily activities

SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity and range of motion.

A modified Borg scale is used to set the  resistance for the strength exercises based on self perception of effort. The level of resistance is determined by the patient’s s rating of perceived effort using the weaker hand for each strength exercise.

Exercise therapy in patients with RA is used to improve the daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility (range of motion, ROM) and stability and/or coordination.

5. Patient Education

Information about their condition and the different therapies disposed to improve their quality of life. In addition, patients are taught how to protect the joints during routine daily life.

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