Back Pain Articles

The oligoarticular type of juvenile arthritis, which has fewer joints affected, is indicated by four or fewer joints being inflamed with the ankles and knees, the larger joints, being more commonly affected. The children present as feeling well but may exhibit a limp when they walk. If the child appears to only have one hip affected then the diagnosis should be questioned as they are more likely to have a different condition such as Perthes disease. Chronic arthritic problems can lead to weakness and wasting of the main extensor muscles of the knee, with tightness of the hamstrings leading to a flexion contracture of the knee. Asymmetric arthritis just in one leg can produce a leg length discrepancy.

The many joint affected type of disease (polyarticular) is characterised by having at least five joints affected, typically in a symmetrical pattern with the same joints affected on both sides. The child may have a low grade fever and if there are significant limits of joint movement this is associated with weakness of the relevant muscles and decreased normal function. A thorough physical examination of the child is very important for the correct diagnosis of juvenile arthritis as this will indicate where the problems lie and which kind of juvenile arthritis the patient has.

Settling on the diagnosis of juvenile arthritis depends on a joint showing an effusion which is the presence of inflammatory fluid within the joint, along with other symptoms and signs such as warmth, redness, limited range of motion and pain. Some joints may have an effusion which is not apparent such as the hip, but they can still show limited movement of the joint and pain. It may not be possible to establish the diagnosis of juvenile arthritis as the fever and rashes may come on initially without the arthritis at the time, with the arthritis appearing later by several months. Enlargement of lymph nodes and the liver and tenderness of muscles may be evident.

In the polyarticular form of arthritis where many joints are inflamed, it is common for there to be a symmetrical involvement of the weight bearing joints as well as smaller ones of the hand. The joint cartilage may be reduced in thickness with eroded areas and in some joints the formation of a fusion across them. With more chronic changes there can be thickened synovial membranes and joint effusions, subluxations (partial dislocations), joint contractures and stiffness, bony deformity (particularly the fingers) and bony enlargements. The joints can also lose bone mass and suffer narrowing of the joint spaces as the cartilage thins.

A reduction of extension in the neck may not produce any symptoms but it is important to identify this as it can indicate arthritic changes in the cervical spine which can lead to partial dislocation (subluxation) of the upper neck bones, a potentially dangerous situation. The neck bones can also fuse together along the posterior structures. The jaw joints, the tempero-mandibular joints, may also be affected and lead to reduced amount of growth in the lower jaw with inability to open the mouth as wide as normal. There may also be involvement of the eyes in the inflammatory process.

Juvenile arthritis and other complex conditions are best managed by a specialised multidisciplinary team due to the numerous problems which patients have to do with family and patient education and schooling, drug treatments, physiotherapy and occupational therapy. It is rarely if ever successful to give isolated treatments to this patient group. Reviewing patients at regular intervals allows the drug treatments to be fine tuned towards a reduction in the morning stiffness and towards fewer affected joints until no symptomatic joints remain. A typical team to manage these conditions may include a physiotherapist, occupational therapist, social workers, a paediatric rheumatologist and nurse.

Surgery is not routinely indicated for most of these patients although joint injections with steroids may be employed for some. Polyarticular arthritis patients may suffer severe knee and hip arthritis which can be treated with knee and hip replacement once skeletal maturity has been reached and bone growth has stopped. Encouraging patients to be active is important as resting for long periods is not helpful and more active patients do better.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Physiotherapist Croydon visit his website.

The remodelling phase of the healing period occurs over the weeks up to the sixth week after injury and at this point the patient should be tested by the physiotherapist and be able to perform a full strength resisted hamstring contraction without any problems. Isotonic work in prone with ankle weight is the initial approach with lighter weights and higher repetitions to start with, moving on to heavier weights with lower repetitions provided the injury does not complain. Being too adventurous in increasing the weights can lead to re-injury or to the development of a more chronic and troublesome problem.

Once the concentric exercises (movements where the muscle is shortening as it is doing work) have progressed well then patients can start to do an eccentric strengthening programme. Eccentric muscle work occurs while the muscle is lengthening during the activity and while force is being applied to it and by it. Eccentric muscle contraction puts the maximum strain on muscle fibres so slow progress is to be expected as well as to be desirable. With the patient on their front and a weight round the ankle the knee can be bent to ninety degrees (foot pointing up towards the ceiling) and then the leg allowed to straighten in a controlled manner.

Rehabilitation proceeds as long as there are no adverse events until the point that the injured leg can achieve a performance to within ten percent of the uninjured leg, at which point the programme can switch to a more vigorous focus. Stretching of the hamstring continues throughout the whole rehabilitation programme to ensure soft tissue healing occurs in a lengthened position and achieves normal muscle and tendon length. The functional phase of rehabilitation occurs between two weeks up to six months beyond the injury point, dependent on the level of the injury. At this stage the patient will have a normal walking pattern without pain.

A speed walking programme can now be started and when they can manage thirty minutes of this they could be progressed on to small periods of jogging. If there is no adverse reaction and thirty minutes of jogging is achievable then the patient can start to run faster and insert short sprints into the regime. Sprints can become more energetic gradually with sudden stops, turns and re-accelerations providing a gradually closer approximation to real sporting manoeuvres as specific movements related to the relevant sport are added. As therapy proceeds then plyometric exercises can be added to stress the muscular system more profoundly and promote power and speed which will be required.

Plyometric work is characterised by stretching the muscle in the early part of the movement then contracting it concentrically, which often looks like jumping and bounding. Stretching a muscle facilitates its contraction and so allows a stronger effect to be produced as well as stressing the muscle more so it accommodates to increased force. Initially a less stressful exercise can be performed such as skipping (jumping rope) and progression under physio supervision to jumping sideways over benches, up onto higher levels and so on.

The decision allow a return to sporting endeavour can be made any time from about three weeks on to six months or more in very serious injuries. At this stage a physio will check out the condition of the injured part because subtle deficiencies in balance, coordination, strength, tissue length or power can seriously effect performance or likelihood of re-injury. Thorough warming up and regular stretching is recommended for athletes returning to competitive sport although there is little scientific evidence for this advice. A return to sport towards the shorter end of the recovery spectrum is possible is there is a small muscle area damaged or a superficial muscle injury.

In a scientific review of injuries it was found that taking more than a day to be able to achieve painless walking means an athlete will likely need more than three weeks to rehabilitate themselves back to activity. Non-steroidal anti-inflammatory drugs are often prescribed to facilitate the healing process and limit inflammation.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Sheffield Physiotherapists visit his website.

Multiple Sclerosis or MS is a disease of the central nervous system characterised by inflammation and demyelination, the gradual loss of the insulation material around the nerves known as myelin. Sclerosis is the term given to describe the thickened and scarred small lesions which occur in the nerve tracts. The disease is continually active and forms new lesions regularly leading to gradually increasing levels of disability. The most common form of MS is the relapsing and remitting kind, meaning there are periods of worsening followed by at least partial recoveries.

As the neurological lesions can now be identified on MRI scanning this has greatly improved the accuracy and certainty of diagnosing multiple sclerosis. No specific agent which might trigger MS has been isolated but as it gets better with pregnancy and worse afterwards it may be that hormonal factors are involved. A large number of factors have been considered as potentially important such as infections, but infections have only been shown to be present in one out of every four times the disease presents.

There are several different forms of multiple sclerosis which have differing patterns and severities of disease. MS is more common in Caucasian populations and the incidence increases with increasing latitude, in other words how far to the north the individual lives. Genetic inheritance may be important in the risk of getting MS but the environment plays a role somewhere as it is known that moving to a higher risk area before the age of 15 years means you suffer the increased risk of the new area.

In the world overall it is estimated that the number of people suffering from multiple sclerosis is 2.5 million. MS causes significant disability and due to its age profile these are often people with families and work. MS does not cause death directly but is thought to shorten life by about 5 to 7 years due to the likelihood of getting repeated infections secondary to immobility and urinary complications. Northern Europeans are the most commonly affected group, with women suffering 1.6 to 2.1 times as much as men. Hormonal factors are again thought to be important as women outnumber men three to one under fifteen years of age or over fifty.

In men the presenting form of multiple sclerosis tends to be the primary progressive type while female patients more often show the relapsing type. Worsenings or exacerbations of the disease show themselves as newly occurring symptoms of dysfunction in the central nervous system. These symptoms may both be spread out anatomically in the body and across a time period. Development of double vision from involvement of the optic nerve, loss of sensibility in a body part and loss of muscle strength in a limb are all examples of attacks. However, attacks may be absent and the patients may just suffer steady worsening.

The relapsing and remitting type of multiple sclerosis exhibits acute attacks with an improvement again afterwards, however most sufferers in this very common group will eventually become more steadily worse which is termed secondary progressive disease. If affected by the primary progressive type the patient typically undergoes a steady worsening in ability without remissions, with deterioration to complete paralysis. This type of disease responds less well to usual treatments and is more disabling. Relapsing and progressive disease occurs when the disability from attacks is not recovered in remissions.

The symptoms of MS tend to cover a wide range of abilities in any individual patients but there can be a concentration of symptoms involving the visual, mental functioning or balance and coordination systems. It is thought that at some point in the disease MS sufferers reach a point where the disease worsens more continuously with an indication of neurodegeneration rather than just inflammation. However, one of the characteristics of MS is that patients can present with almost any combination of symptoms or with severe changes in one particular neurological system. Severe loss of mental ability may be evident without much evidence of central nervous system lesions.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapists Manchester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The accurate diagnosis of the injury and the degree of its severity is the crucial factor to be decided initially as this indicates how the injury is to be expected to improve and how long it will be until the patient has functionally recovered. The mainstay of treatment is physiotherapy and the physio has to decide the how to progress the treatment according to the level of tissue injury and the time which has elapsed since the event. There is no effective scientific evidence for managing this kind of injury and the physiotherapist will design the rehabilitation programme individually to suit the particular and variable requirements.

The management of hamstring injuries can be divided into three initial phases: the acute, sub acute and remodelling phases, each with a different strategy of treatment and each for a different time since the injury. The acute phase incorporates the first week after injury and the treatment is targeted at reducing the inflammation, pain and swelling associated with a soft tissue injury. The principles of treatment follow the PRICE format: protection; rest; ice; compression; elevation. Protection involves reducing the likelihood of inappropriate stresses being applied to the injured area and for this purpose the knee may be braced in a bent position or the patient taught to use crutches to reduce the weight bearing through the leg.

Rest is protective and important to reduce the stresses through the injured area and with athletes this is often a difficult concept to get across. Ice is very useful as a treatment primarily to reduce pain, applied for up to 20 minutes over the injured area provided the skin can take it. It may also reduce inflammation by limiting the metabolism of the area and so reducing the tendency to attract more blood supply and swelling. Compression is an important treatment and in knee effusions it may be more important than the cooling effects which physios attempt to provide. Elasticated bandages wrapped round the limb can provide compression.

Elevation of the injured area is advised for many injuries and raising the area above heart level drains the limb and prevents tissue fluid build up. It is hard to do this with the situation of the typical injuries to the hamstrings and in these injuries may not be needed. Once the inflammation and pain have receded to some extent the physiotherapist can begin moving the limb passively and giving assisted movements into flexion. Stretching is avoided as this will increase tissue damage. A mostly minor injury should recover quickly but they still need to be managed carefully to avoid a recurrence and ensure good progress.

The usual soft tissue healing time is around six weeks, which applies also to minor strains, so care easing back into activity should be observed by athletes along with the progression they adopt. Rehabilitation should include joint ranges, muscle strengthening, balance work and stretching so that the risk of recurrence is reduced. Up to the three week mark is now the sub-acute time frame and there should be much reduced inflammation and pain by now, giving the physiotherapist the chance to begin range of motion exercises and then move onto muscle strengthening.

Hydrotherapy exercises may be useful in this phase as they allow hamstring exercise without the weight bearing stresses being fully applied to the limb. Patients can take up aerobic training for cardiovascular fitness and upper limb training whilst performing sub-maximal exercises for the injured area. The remodelling phase is indicated as taking the patient forward to the six week point and they should be able to manage isometric contractions at full effort without pain. Now the exercises can be progressed to isotonic (through range), with low weights and higher numbers of repetitions.

The patient starts this process in prone with light ankle weights, progressing to heavier and heavier resistance provided the pain in the injured area is not provoked. The progression of weights should be conservative as too rapid an increase may lead to relapse and a more long term problem. Once the patient has achieved good strengthening with the muscle shortening (concentric contraction) they should be progresses to strengthening with the muscle lengthening (eccentric contraction).

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapy Leeds, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The condition known as thoracic outlet syndrome is not one thing but the name given to a collection of symptoms, all ascribed to problems with compression of blood vessels or nerves as they pass through the anatomical thoracic outlet. This structure is outlined by the first rib, the collar bone or clavicle and the neck scalene muscles, with the neurological and vascular structures passing through it to reach the axilla and travel into the arm. Diagnosis of these related conditions is difficult and there is little clarity or consensus about them.

The signs and symptoms of thoracic outlet syndrome are widely variable and no objective and reliable test has been developed to narrow down the precision of diagnosis for patients with thoracic outlet syndrome. Due to this imprecision it is not clear what the incidence of thoracic outlet syndrome is in the general population although there are more female patients presenting with symptoms, particularly with poor muscle development and posture.

The bundle of blood vessels and nerves which travels down from the neck to the arm has to go through three anatomical, more or less triangular, areas. The bundles can be compressed in any one of the spaces and they are small when the arm is at rest by the side, becoming smaller still when the arm is moved into various positions. These tight positions are used to increase compression during diagnostic testing to give a better idea of which structures are being compressed and which structures might be doing the compressing. Physiotherapists and doctors place the patients’ arms into potentially aggravating positions and ask them to perform repetitive muscle actions such as clenching the fist to increase neurological or vascular demand.

The repetitive movement of the shoulder towards the ends of its ranges makes the onset of thoracic outlet syndrome more likely, increasingly so if shoulder abduction (moving the arm out to the side) and outward rotation are involved at end ranges. A common occurrence is for swimmers to complain of pain during their stroke and this should raise the suspicion of thoracic outlet problems. Repetitive shoulder movements towards the end of the available movement make this more likely to occur in many sports or activities. Symptoms may present as neurological difficulties or as problems connected with blood supply to the arm.

How patients present initially with thoracic outlet syndrome depends on if the compression is mostly neurological, vascular or both combined. Symptoms can be mild and intermittent or severe and continuous and disabling. Typically there tends to be three types of normal presentation involving the blood supply, the nerve supply and the remainder which are non-specific. Direct compression of the main artery or vein is uncommon and more likely in young athletes who indulge in strong activities overhead such as throwing.

If the arterial flow is disrupted the arm can change colour, there can be pain on muscle use due to their not getting enough blood and an overall pain in the hand and the arm. Mild onset is typical as blood can often get round a blockage, but when the block is large patients attend for medical review independently. Thoracic outlet syndrome from neurological compression involves compression of some of the brachial plexus, a nerve crossroads in the neck which supplies the arms. Nerve compression does not usually occur alone but presents with awkwardness holding a ball or a racket and loss of muscle bulk in the small hand muscles.

Neurological compromise may also cause pins and needles or loss of feeling, with some reports of pain but this tends not to be a major issue. Overhead actions with the arm repetitively tend again to be the aggravating factors. The third group is the contentious one, with a large number of patients who complain of pain in the neck, shoulder blade and arm. Often starting after an accident of some type, this kind of pain is not well understood and there is little medical agreement as to whether this is thoracic outlet syndrome or not.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapists London. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Sporting and normal activities expose the shoulder joint frequently to injury due to its very large range of motion and limited stability and strength, requiring accurate treatment to restore it to a fully functional state. The glenohumeral joint is the shoulder joint itself and the acromioclavicular joint lies above the shoulder, rarely making itself apparent except from injury. The most common injuries result from falls of all kinds including from bicycles and skiing and all contact sports. The acromioclavicular joint consists of the acromion (end of the scapula) and the lateral end of the collar bone or clavicle.

The acromioclavicular joint is strengthened and supported by a group of ligaments, injury to which can result in joint sprains up to visible deformity of the joint. Either side of the joint may suffer from a fracture which adds to the complexity of the situation and may cause joint arthritis to develop with time. Medical consultation by athletes for shoulder injuries is most commonly for acromioclavicular joint damage with second place going to shoulder dislocations. It is more likely that patients will have more limited sprains and ligamentous tears rather than joint deformity, all more likely in young men.

The acromioclavicular joint is composed of the lateral end of the collar bone and a part of the shoulder blade called the acromion, surrounded by four minor ligaments and the joint capsule, a fibrous bag. The ligaments prevent the two joint surfaces from moving frontwards or backwards in respect to each other whilst upward and downward stability is maintained by a different ligament group. These latter ligaments attach to the clavicle on the inward side of the acromioclavicular joint and come from part of the scapula. The presentation of the injury will vary depending on which group of ligaments has been damaged to what degree.

Falling onto the shoulder pushes the tip of the shoulder downwards compared to the rest of the shoulder girdle area, potentially injuring the ligaments or causing a fracture as the clavicle remains in its original position. A sprain may result or the ligaments may be completely torn, making the joint unstable and unable to perform its primary function. Sprains of this area are classified as to their severity. A type 1 sprain results from a relatively minor force and results in some spraining of the ligaments but no change in the joint position, which looks normal despite being painful.

A disruption of the ligaments around the acromioclavicular joint itself, not involving the other ligament group, indicates a type 2 sprain. A small prominence of the lateral end of the clavicle may be noticeable as the supporting ligaments have been damaged. If both the major ligament groups are completely ruptured then the surfaces of the joint are no longer in contact and a type 3 sprain is present, showing an easily palpable and visible bony lump at the side of the shoulder. Injuries can be more serious with increased forces causing fractures, disruption of the joints and bony separations.

If a patient complains of pain over the top of the elbow then an acromioclavicular joint injury should be suspected and screened for. A fall directly onto the point of the shoulder is the most common injury mechanism, with the arm usually held close to the body at the time. There can be many other methods of injuring this joint including the very common fall on an outstretched hand. Initial symptoms may not be localised to the acromioclavicular joint itself with a more generalised pain and swelling of the shoulder area, but once a few days have elapsed then it may be more apparent that there is tenderness on pressure over the acromioclavicular joint.

If injured, weight training athletes may find difficulty with exercises which stress the acromioclavicular joint such as bench pressing. Night pain is common as it is difficult to eliminate shoulder stresses during the night and patients may wake when they roll over onto the point of the shoulder. Examination reveals pain over the joint itself which is very localised, and if the injury is more severe there may be obvious deformity of the lateral end of the collar bone, it typically being prominent upwards. Patients will have limited movement in the shoulder and be unwilling to lift the arm beyond horizontal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Manchester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Cystic fibrosis is an inherited condition with a fatal outcome and the most common type of these conditions in populations of Caucasian origin. It is inherited as two recessive genes, one from each partner, although these carriers show no sign of illness. The genetic error affects the exocrine glands and most typically gives chronic respiratory tract infections. A large number of bodily organ systems are involved in this disease but the end of a patient’s life is almost always secondary to severe lung disease.

The genetic abnormality affects the thickness of the body’s mucus, making it stickier which in turn makes it more vulnerable to bacterial infection. Thickened secretions can be present in the respiratory tract which makes them difficult to clear, but they are also present in the pancreas, sweat glands and the digestive tract. Initially the lungs are normal but soon after birth an infection develops at some time and the cycle of infection and inflammation is set up along with a continual presence of specific bacteria in the lungs. Gradually the lung membranes become thickened and less efficient, leading eventually to respiratory failure.

Thickened mucus secretions in the intestinal tract can cause an obstruction of some part of the bowel and the ability to absorb nutrients from food is also reduced, often indicated initially by the baby failing to gain weight normally (”failure to thrive”). If this progresses and adhesions form then the bowel can become obstructed, necessitating removal of part of its length which further reduces nutrient absorption. Pancreatic enzymes are unable to work at optimal efficiency, and if pancreatic insufficiency develops then patients may fail to gain weight and poorly absorb vitamins which are fat soluble such as A, D, E and K.

The incidence of cystic fibrosis makes it the most frequently occurring lethal genetic condition, inherited via a recessive gene trait. In populations of white European origin the typical frequency is one in 3200 births while in populations in Asia this may be one in 90,000 only. 37 years is the typical age of survival with male patients living for a significantly longer period than female patients. Progression of the lung abnormalities goes from bronchitis to bronchiectasis and then on to heart failure with end stage disease of the lungs. The disease is very variable in how it progresses, the age of the patient at presentation, the severity of the symptoms and the manner of disease progression.

Gallbladder inflammatory changes and the presence of gallstones have a higher incidence in patients with cystic fibrosis. Secondary sexual characteristics and the onset of puberty are typically delayed and males are infertile due to absence of a vas deferens, while female patients may have reduced fertility to some degree. Progression of lung disease is worse in patients who come from the lower socioeconomic levels. Overall the severity of lung symptoms is less in male patients than in female patients, with females suffering worse lung prognosis and a lower life expectancy.

Due to the complexity of cystic fibrosis and the involvement of many bodily systems the most effective diagnosis and management of this condition is performed by a multidisciplinary team in a specialist centre. Apart from the initial diagnosis and baseline measurements, followed by the plan of treatment, there are many other parts to the overall management. Education of the patient or the parents is of vital importance as adherence to the treatment regime is so important if the patient is to make the best of their remaining life. Counselling may be employed as patients face the difficulties of managing a lifelong condition. Physiotherapy instruction for airway clearance technique is also vital, with instruction on how to use inhalers and nebulisers.

The complications of respiratory disease may need surgical management to treat such conditions such as collapsed lung or considerable coughing up of blood. Gastrointestinal complications and obstruction may also need to be managed surgically. End stage lung disease can be managed by lung transplant or heart-lung transplant, but transplants may not increase life expectancy although quality of life may be improved. The diet can be essentially normal with an increased energy and fat intake recommended with supplementation of vitamins and minerals. Malabsorption of nutrients and the increased nutrient demand of having chronic inflammation require nutritional supplementation.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Bristol Physiotherapy, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Osteoarthritis is a time related joint degenerative condition, the incidence rising rapidly with age, making it the commonest arthritic condition in the world. It develops in various joints in the human body and in some people it particularly affects the large weight-bearing joints of the hip and the knee. As the joint surfaces deteriorate the joint becomes painful, crunches, loses range of motion and becomes difficult to walk on. When conservative measures are not helpful, such as physiotherapy, analgesics, walking aids and weight loss, then knee replacement is considered.

Total knee replacement is one of the most successful medical technologies with the highest quality of life improvements of any medical intervention, a distinction it shares with total hip replacement. Knee replacement has matured from an experimental procedure of uncertain long-term outcome to a predictable and very common operation with very good results at ten years or more. As western populations age knee replacement is overtaking hip replacement as the most commonly performed joint replacement.

Metal and plastic components are inserted to replace the degenerative joint surfaces of the knee. In knee replacement these consist of four items:

* The metal femoral insert to replace the lower end of the femur which is the top half of the knee.

* The metal tibial insert to replace the tibial surfaces, the lower half of the knee.

* The plastic insert, made of ultra high density polyethylene, is placed between the femoral and tibial inserts.

* The patellar button is also of plastic and placed on the back of the kneecap to replace that surface.

The components are fixed in place using cement which acts as a grouting material rather than sticking anything. Knee replacement surgery causes weakness of the knee muscles, pain, inflammation and joint swelling, all important problems which the physiotherapist needs to treat promptly. Physios in hospitals often use Cryocuffs to provide cold therapy and compression which reduce the knee effusion and the post-operative pain. Analgesia is encouraged regularly and the physio teaches muscle activation of the quadriceps and knee flexion hourly to get the joint moving. Restoring the muscle control of the knee and gaining joint range of movement is the initial goal of the first few day of therapy.

Once the operation has been completed the physiotherapist must treat the consequences of the operation to ensure a successful outcome for the patient. Surgery causes pain, swelling, inflammation and muscle weakness and much of the early physiotherapy is targeted towards this. Initially the physio can use a Cryocuff, a refillable pressure cuff fitted closely to the knee, to reduce the swelling and to provide cold therapy over an extended period, reducing the pain and facilitating muscle action. Taking the painkillers regularly and static quadriceps exercises are encouraged hourly to re-establish muscular knee control and gentle knee flexion exercises to get the knee range of movement going.

Next the physiotherapist assesses the patient for suitability for their first mobilisation, checking the operation note, the patient’s medical observations and the condition of the legs themselves. The operated knee has to have enough stability to safely weight bear, as an epidural can cause profound loss of muscle power and prevent safe mobilisation until the drugs wear off. The patient is mobilised into standing by the physio with an assistant and encouraged to walk a small distance with elbow crutches or a Zimmer frame for more elderly persons. Operative protocol usually encourages normal weight bearing through the new knee as this helps restore normal patterns of muscular activity and improves circulation.

Outpatient physiotherapy aims to restore normal muscle power and function, joint range of motion and regain functional abilities. Initial exercises include knee hangs for full passive extension (very important for normal knee function), inner range quadriceps to restore active extension to full range and knee flexion to increase range. Resisted flexion over the edge of a bed helps the quadriceps relax by reciprocal inhibition and allows increases in flexion range. This can be manually resisted by a physio or performed against a spring or Theraband. Massage to the scar area is also useful to mobilise the scar and free up the tissues.

Further rehabilitation is more likely to take place in the gym, concentrating on functional activities such as moving from sitting to standing and step ups and strengthening work with Theraband and the gymnastic ball. Work on range of motion will continue using resisted exercises and static bicycling and patients can usefully work on proprioception using the wobble board and other balance related activities. Proprioception is the normal ability of a joint to sense its position in space and this is very important for normal activity and safe walking. Normal gait patterns are encouraged and abnormal patterns corrected.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Gloucester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Knee injuries and the management of post-operative knee conditions require physios to apply cold therapy to the joints to control knee effusions and pain. This is difficult to do with traditional methods but the Aircast Cryocuff is a flexible and efficient device to achieve effective cryotherapy and compression.

Knee injuries are very common in sports and vigorous activities and their acute physiotherapy management is very important for a good outcome and a speedy return to normal activities. Typical knee injuries and conditions managed by physiotherapists include meniscal tears (cartilage tears), medial collateral ligament damage, lateral collateral ligament damage, anterior cruciate ligament tears, patellar dislocation, total knee replacement and capsular injury.

The knee is the largest synovial joint in the body and when the joint is damaged it responds by becoming inflamed, increasing the metabolic rate of the tissues and secreting large amounts of synovial fluid into the joint. This can lead to a knee effusion, a large and tight swelling of the knee, at times called “water on the knee”. An effusion can be painful in itself and it inhibits normal muscle function, thereby interfering with muscle action and joint recovery.

Normal methods of applying compression and cooling have several difficulties:

* It is difficult or impossible to provide both at once

* Applying ice to the knee does not provide effective cooling in many cases

* Ice application carries the risk of ice burn by overcooling the skin

* Long periods of cooling are difficult to maintain

* Cooling is difficult to keep up over long periods

* Cooling cannot easily be done whilst mobilizing.

Cooling is always thought to be the main aim, but however as research has shown that management of the acute knee should start with compression instead, pain and inflammation reduction is an important part of the treatment so cold is important too.

The Aircast Cryocuff

The Aircast Cryocuff is a cryotherapy and compression device, designed to be easy to use and to be portable, used in managing post-injury and post-operative inflammation in knees and other joints. The Cryocuff has three parts:

* The Water Bucket. This water/ice reservoir is a plastic cylinder with a lid and guidance markings inside the bucket for the proportions of ice and water to fill for optimal use of the device. The lid is screwed on securely to avoid leakage and the contents can be remixed by simply turning the whole assembly upside down a few times.

* The Hose. The hose from the reservoir to the cuff is insulated and allows rapid clipping and unclipping to and from the cuff.

* The Cuff. This is the business end of the device. It is a wraparound cuff designed to fit the contours of the knee and comes in three sizes.

Application of the Cryocuff by a Physiotherapist

The size of the cuff needed for the patient is measured by the physio 6 inches above the kneecap and then the cuff is fitted snugly to the knee and firmly attached with the Velcro straps. It is important to start with the cuff deflated or the benefits of compression of the Cryocuff will not be forthcoming.

Now the bucket is filled with cubed ice and cold water in the right proportions and the top screwed on firmly to prevent leakage. The hose is clipped to the cuff by pushing the connector into the cuff clip and then the bucket and hose assembly is held up above the knee, allowing the cold water to flow into the cuff by gravity. How high the physiotherapist holds the bucket and for how long has some effect on the tightness of the filled cuff.

The cuff stays cold for an hour or so and the patient can disconnect it from the hose and get on with normal life as able. To change the water the hose is reconnected to the cuff and the bucket put below cuff level to refill the bucket from the cuff, and then the bucket is turned over a few times to remix the water and ice. The process is repeated from the beginning, allowing the compression and cooling to be maintained continuously as the bucket water mixture remains cold enough for 6-8 hours before replenishment.

Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiothrapists in Southampton visit his website.

The wrist-hand complex is a highly complicated tool which allows for the precise use of the hand and its very important role in human function, with the wrist a vital link in this process. The shoulder and scapula allow crude arm positioning, the elbow allows the distance from the body to be varied, the forearm sets the angle at which the wrist will be positioned and the wrist finishes off the last detail of hand positioning. As the joints get closer to the hand the smaller and more precise their movements.

The wrist itself is positioned between the forearm and the hand and consists of eight small bones known as the carpal bones which are arranged in two rows and situated in between the ends of the radius and ulna and the metacarpal bones. The metacarpals run from the furthest row of carpal bones down towards the knuckles to join the finger bones. As the metacarpals are narrow and run almost parallel to each other this gives them the ability to flatten themselves out to make the hand wide or to curl themselves up to aid grasping, a very useful ability.

This tight grouping of carpal bones endows the wrist with a large range of movement of 360 degrees in a conical shape facing forward. They are able to make individual and group movements to improve the precise positioning of the hand, fingers and thumb. Even though the arrangement is a little untidy the two rows of bones do line up with more or less two bones at the end of each metacarpal separating this from the forearm. The large number of in-line joints created with this arrangement allows a high degree of adaptability and precision of movement.

The manoeuvrability of the thumb is one of the most amazing parts of the function of the hand. The “opposable thumb” that humans possess and which apes do not is one of the defining characteristics of precision movement and control. The metacarpal of the thumb on the outside of the hand is not inline with all the others but rotated inwards, having the ability to rotate further inwards to allow the end of the thumb to participate in grasping with one of the fingers. The thumb has a very specialised joint at the junction of the metacarpal and carpal, allowing the specialised movement.

The movements of the carpal bones can be in unison in small amounts as they move together to allow a movement to occur. As the hands move small amplitudes of movement occur between the individual carpal bones and the carpal rows. The metacarpals are able to rotate around their long axes which allows the palm to be curled into a cupped position. As the palm moulds round to assist gripping it also allows the fingers to align so that they can effectively grip at the correct angle. Any loss of the accessory movements of the carpals and metacarpals can reduce the ability of the hand to function adequately.

Using the hands very heavily such as in gripping and holding heavy objects, hauling ropes or operating heavy machinery can adversely affect wrist function. The longitudinal forces which are generated across the wrist are very high as the hand grasping power is applied, compressing the carpal bones between the forearm and the metacarpals. The carpal bones can then suffer a reduction in the accessory movements possible between them. If the wrist is forcibly extended this may dislodge the lunate bone, one of the wrist bones, forwards and cause pain.

The commonest reason for the wrist to be extended forcibly is a FOOSH or a fall on the outstretched hand, which can result in a Colles fracture which involves the last inch of the radius and ulna near the wrist. The fracture, commonest in older females, is the most obvious part of the overall injury which results also in wrist sprain and soft tissue injury. Five to six weeks will be enough to heal the fracture but there may be weakness, pain and difficulty with use in the hand for a longer period, partly related to a upset in the inter carpal movements.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Manchester, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.