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.

• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)
• March 30, 2010 -- Multiple Sclerosis – Part Two (0)

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.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)
• March 30, 2010 -- Multiple Sclerosis – Part Two (0)

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.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)
• March 30, 2010 -- Multiple Sclerosis – Part Two (0)

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.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)
• March 30, 2010 -- Multiple Sclerosis – Part Two (0)

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.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• March 30, 2010 -- Multiple Sclerosis – Part Two (0)

Heat can be an aggravating factor and many patients report they are worse in hot weather, especially if they have to perform physical exertion or even after having a hot shower. The presentation of MS can vary widely with some patients suffering a majority of mental changes, whilst others suffer incoordination, one sided weakness, lower body weakness, depression or symptoms with vision. Symptoms can be worse if the patient has another illness at the same time such as bacterial infections, while trauma and emotional stresses are not thought to have a high level of effect.

Visual disturbance secondary to optic neuritis is a frequent symptom of onset as well as varying degrees of eye pain. The limbs can be the site of frequently reported tingling and numbness with varying levels of muscle weakness and sometimes leg or arm pain problems. Profound mental effects can also be present which can include depression and dementia and inappropriate actions or utterances with lability of emotions. Common urinary symptoms are retention (difficulty in passing water) and incontinence, with frequent disturbance of sexual function.

Magnetic resonance imaging (MRI) scans of the head or the spinal column can be uses to identify the location of sclerotic lesions within the central nervous system. Typical nerve lesions in MS are located close to the ventricles of the brain, small reservoirs for the cerebro-spinal fluid. They are located in the white matter, the parts of the nervous system where the insulated nerve axons are packed together and where there are no, or very few, nerve cell bodies. Even what seem like older lesions can have a surrounding area of inflammation as they advance outwards. Some recent studies suggest that the grey matter (areas of nerve cell bodies) may be involved, with atrophy of the cortex and decline in mental ability.

Treatment of MS is difficult and complex and such patients usually have multifactorial needs and requirements. Medical treatment, psychological counselling, information, rehabilitation access, provision of orthotics and housing issues are all frequent requirements when dealing with patients with this disease. If patients have been on steroids for long periods or are immobile or past the menopause then bone density may need evaluation. Some patients are very dependent and have little or no family support and so present problems with long term housing and care.

Severe tiredness can be an important symptom in MS and can be treated to a degree with medications. Halting the disease’s progress is the overarching aim of medical treatment and this works best in the early disease stages where the condition is most responsive. With increasing disability levels patients suffer highly reduced quality of life and respond less well to drug therapy. Suicide risk is also raised, to a level 7.5 times that of the wider population and this effect is not wholly taken account of by the levels of depression. Drugs which moderate activity of the immune system are employed to retard disease progress and to cut the number of relapses.

Many other drugs are used to suppress attacks but there is no agreement that this has a long term effect on the extent of neural degeneration or levels of disability. Once an MS attack has started there is no particularly effective therapy, although a steroid may improve the time to recovery yet not affect the end result. Surgery is not commonly used in multiple sclerosis but it can be employed to release contractures such as of the hip adductors or to treat severe neuropathic pain by cutting the nerve tracts responsible.

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

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)

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.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)

Hamstring injuries are classified for ease of diagnosis and treatment into various grades of severity. The least serious injury with a number of damaged muscle fibres is a grade 1 injury, rated as a mild muscle strain. More serious involves a larger number of muscle fibres being damaged and a reduction of muscle strength which is obvious on testing and this is a grade 2 injury. In the most serious or grade 3 injury there is a rupture right through the substance of the tendon and muscle. Most injuries are located at the muscle and tendon junction and high up near the buttock, although the biceps femoris has a very long junction, most of its length.

The ischial tuberosity (the bones we sit on or the “bones in the buttock”) is the originating point for most of the hamstring tendons. An avulsion fracture may occur at this point where a sudden, large range of motion occurs without warning and pulls off the tendon from the bony connection, an affliction most commonly seen in people who water ski. Younger people have larger numbers of such injuries as they are more active in sport and participating in risky activities such as contact sports, field sports, sprinting, rugby and football.

The hamstrings start at the ischial tuberosity in the buttock, run down the back of the thigh and insert into varying places on the tibia or fibula. When these muscles are contracting and lengthening at the same time (eccentric contraction) such as in track events and rugby, there can be a high risk of injury. Direct muscle blows can result in contusions to the tissues while water skiers are more prone to avulsion injuries as they fall because they undergo rapid hip flexion with their knees straight. Onset of a hamstring strain is typically sudden and often when the person is moving quickly, with an audible pop in the muscle often reported.

Pain is felt in the back of the thigh immediately and the injury is often either early in the activity (not yet warmed up) or late in the activity where tiredness may be a factor. General movements and functional activities such as stair climbing may be painful provided the injury is not too severe. There may be little to see in the posterior thigh of these patients but testing the ability to bend the knee against resistance may elicit a painful response. If one of the hamstring muscles is ruptured it may contract up into a ball on testing and the examiner will notice the reduced strength.

The likelihood of suffering from an injury to the hamstring is thought to be related to factors such as tiredness, inadequate warm up, flexibility restrictions or if the strength ratio between the hamstrings and the quadriceps is incorrect. Having previously incurred a hamstring injury is enough to raise the risk of having another one. How an injury will be treated depends entirely on its severity with one end of the spectrum seeing the physio progress the patient speedily on to strength work and at the other end of the spectrum some injuries require the intervention of a surgeon.

Physiotherapy for a moderate level injury initially addresses the reduction of local swelling and inflammation and control of the pain which is often significant. The physio will use the PRICE guidelines for treatment: Protection of the injured tissues is vital at first which can include crutch use or braces; Rest is essential to a degree to allow tissue healing to proceed; Ice application for up to 20 minutes reduces pain and inflammation; Compression can be effected by wrapping elasticated bandages around the limb; Elevation is not simple due to the area of the damage and that the patient may prefer a bent knee.

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 Sheffield Physiotherapist visit his website.

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)

The classification can be approached by describing three main subtypes, systemic onset disease where the problems are widespread, polyarticular arthritis where many joints are affected and pauciarticular where only a few joints are involved. The typical disease course is chronic with remission periods inbetween periods of flare ups, the medical treatment being typically aimed at causing remission and maintaining it over time. The biological treatment agents more recently developed have given a greatly increased effectiveness of treatments for arthritic diseases.

The causative factors and how the arthritis develops is not clearly understood, but a trigger such as trauma or infection may start an autoimmune reaction against the joint tissues. This makes the synovial membrane lining the joint enlarge and develops a chronic inflammation, all of these things likely to occur in children who have a genetic susceptibility. Many genes are thought to be responsible for the onset of the disease and how it presents in each individual. There are wide ranges in the incidence of these conditions as the susceptibility to the disease varies along with the different population groups and exposure to environmental influences.

Around half of all sufferers from juvenile chronic arthritis have the oligoarticular or pauciarticular type where a small number of joints are affected, around a third have the polyarticular type with many joints affected and the remainder have the more systemic type. People suffering from juvenile chronic arthritis may develop other autoimmune disorders. Psychological side-effects are common due to the pain and functional problems which occur with this disease, causing depression, anxiety and behaviour problems. The few joint and many joint forms of the disease occur more commonly in girls at a ratio of 3 to 4.5 to one with the systemic type occurring equally in boys and girls.

The polyarticular or many affected joint form of arthritis has two peaks of incidence, one covering one to four years of age and another covering six to twelve years. The fewer joint type, the oligoarticular form, tends to occur in children who are two to four years old. The systemic type has no particular age of incidence. The disease pattern over the first six months determines which pattern the individual patient fits into. If four or fewer joints are affected during this period then the diagnosis is the oligoarticular or fewer joint group. More than five joints are symptomatic during the first six months this indicates the polyarticular or many joint diagnosis. Arthritis, rashes and a fever are the typical onset symptoms of the systemic form.

If a diagnosis of juvenile arthritis of some form is to be made then the patient should have arthritis of some of their joints for at least six weeks. Stiffness in the morning or after periods when the joint has been kept still is a typical complaint. The start of the disease can be very sudden and dramatic or may come on slowly over some time, with common symptoms including stiffness of the joints as mentioned, joint pain in the day, periods of absence from school and a limping gait. Some patients also suffer from inflammatory disease of the bowel. A child may not always report actual pain in a joint but instead they may just allow the joint to go unused and develop atrophy or a joint contracture.

In the systemic form of juvenile arthritis the child suffers from fevers which spike once or twice a day at around the same time, the temperature typically returning back to normal each time. This pattern is different from infections so helps to distinguish what the patient is suffering from. These patients usually show a short lasting rash over the trunk and limbs, joint pain often in the bigger joints and appear to be unwell.

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

• April 7, 2010 -- Juvenile Rheumatoid Arthritis – Part Two (0)
• April 5, 2010 -- Hamstring Injury Physiotherapy Management – Part Two (0)
• April 4, 2010 -- The Nature of Multiple Sclerosis (0)
• April 3, 2010 -- Physiotherapy Management of Hamstring Injuries (0)
• April 3, 2010 -- Thoracic Outlet Syndrome-Part 1 (0)

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.

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