VERTIGO & PHYSIOTHERAPY

INTRODUCTION

 

Vertigo Anatomy

 

Vertigo is a medical condition where a person feels as if they or the objects around them are moving when they are not. Often it feels like a spinning or swaying movement.This may be associated with nausea, vomiting, sweating, or difficulties walking.It is worsened when the head is moved. Actually vertigo is the most common type of dizzines.

CAUSES
The most common diseases that result in vertigo are benign paroxysmal positional vertigo (BPPV), Ménière’s disease, and labyrinthitis.Less common causes include stroke, brain tumors, brain injury, multiple sclerosis, migraines, trauma, and uneven pressures between the middle ears.Physiologic vertigo may occur following being exposed to motion for a prolonged period such as when on a ship or simply following spinning with the eyes closed. Other causes may include toxin exposures such as to carbon monoxide, alcohol, or aspirin.The episodes of vertigo should last less than one minute.
Dizziness affects approximately 20–40% of people at some point in time, while about 7.5–10% have vertigo.It becomes more common with age and affects women two to three to moreoften than men.

CLSSIFICATION
Vertigo is mainly classified into two that is peripheral or central, depending on the location of the dysfunction of the vestibular pathway.Vertigo can also be classified into objective, subjective, and pseudovertigo.
Objective vertigo describes when the person has the sensation that stationary objects are moving.Subjective vertigo refers to when the person feels as if they are moving.The third type is known as pseudovertigo, an intensive sensation of rotation inside the person’s head.

1.Peripheral
Vertigo that is caused by problems with the inner ear or vestibular system(composed of the semicircular canals, the vestibule, and the vestibular nerve is called “peripheral”, “otologic” or “vestibular” vertigo.The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo. People with peripheral vertigo typically present with mild to moderate imbalance, nausea, vomiting, hearing loss, tinnitus, fullness, and pain in the ear.
2.Central
Vertigo that arises from injury to the balance centers of the central nervous system (CNS), often from a lesion in the brainstem or cerebellum,is called “central” vertigo.Central vertigo may have accompanying neurologic deficits (such as slurred speech and double vision), and pathologic nystagmus (which is pure vertical/torsional).Commonlly it can cause disequilibrium which is the sensation of being off balance. The balance disorder associated with central lesions causing vertigo is often so severe that many patients are unable to stand or walk.

RISK FACTOR
Lesions caused by infarctions or hemorrhage, tumors present in the cerebellopontine angle such as a vestibular schwannoma or cerebellar tumors,epilepsy,cervical spine disorders such as cervical spondylosis,degenerative ataxia as well as cerebral dysfunction.Central vertigo may not improve or may do so more slowly than peripheral vertigo.

SIGNS & SYMPTOMS

Vertigo Sign And Symtoms

– Sensation of spinning while stationary,
– Nausea or vomiting,
– Unsteadiness (postural instability),
– Nystagmus,
– Difficulties in walking,
– Motion Sickness
Recurrent episodes in those with vertigo are common and frequently impair the quality of life.Blurred vision, difficulty in speaking, a lowered level of consciousness, and hearing loss may also occur. The signs and symptoms of vertigo can present as a persistent (insidious) onset or an episodic (sudden) onset.

DIAGNOSIS
During an evaluation for vertigo, the health care professional may obtain a full history of the events and symptoms from the patient,which includes medications that have been taken,recent illnesses, and prior medical history.
After that, a physical examination is performed. This often involves a full neurologic exam to evaluate brain function and determine whether the vertigo is due to a central or peripheral cause.
The Dix-Hallpike test is done to try to recreate symptoms of vertigo; this test involves abruptly repositioning the patient’s head and monitoring the symptoms which might then occur.BPPV may be diagnosed with this test.
“Roll test” during which a patient lies flat and the head is rapidly moved from side to side.
If indicated, some cases of vertigo may require an MRI or CT scan of the brain or inner ears to exclude a structural problem like stroke. If hearing loss is suspected, audiometry may be ordered. Hearing loss is not seen with BPPV or other common causes of vertigo. Electronystagmography, or electrical evaluation of vertigo, can help distinguish between peripheral and central vertigo, but is not routinely perform.

MANAGEMENT

 

Care in Vertigo

 

Definitive treatment depends on the underlying cause of vertigo.In many cases, vertigo goes away without any treatment. This is because your brain is able to adapt, at least in part, to the inner ear changes, relying on other mechanisms to maintain balance. But,For some, treatment is needed and may include:
Vitamin D supplementation may be beneficial for patients diagnosed with benign paroxysmal positional vertigo.
. Herbal remedies such as ginger root, ginkgo biloba, and coriander may help reduce vertigo symptoms in some people. This are home remedies, so refer to your doctor before use.

  •  Medicine –
    In some cases, medication may be given to relieve symptoms such as nausea or motion sickness associated with vertigo.
    If vertigo is caused by an infection or inflammation, antibiotics or steroids may reduce swelling and cure infection.
    Commonly refer medications are:
    meclizine hydrochloride (Antivert)
    metoclopramie (Reglan)
    odansetron (Zofran)
    diazepam (Valium)
    prednisone
    For Meniere’s disease, diuretics (water pills) may be prescribed to reduce pressure from fluid buildup. Other than that patient is advised for low-sodium diet.
    In a few cases, surgery may be needed for vertigo.
  • Physiotherapy Management :

 

Vertigo Epley maneuvers

 

1.Epley maneuvers, consist of having the patient sit on the edge of a table and lie down to one side until the vertigo resolves followed by sitting up and lying down on the other side, again until the vertigo ceases. This maneuver is mostly used for BPPV.This is repeated until the vertigo no longer occurs.
2. Vestibular Rehabilitation Therapy is comprised of three main types of exercise: habituation, gaze stabilisation, and balance exercises.
Habituation exercises are used to treat people who experience dizziness as a result of damage to their vestibular system.The exercises aim to reduce the frequency and strength of the dizzy spells over time. This is accomplished by inducing light dizzy spells and gradually increasing the level of exposure, which enables the brain to get used to the stimulus, as well as build its tolerance for dizziness up.
Gaze stabilisation is used for patients who have nystagmus, particularly when they are moving their heads. This not only makes it difficult for people to see their surroundings, but can lead to other issues such as headaches. Gaze stabilisation exercises can help people regain more control over their eyes. One of the most common exercises for gaze stabilisation is having the patient focus their eyes on a stationary object in front of them while moving their head from side to side. This helps to separate the movement of the eyes from the movement of the head. Another exercise is for the patient to keep their head still while following an object, such as a pen, from side to side with their eyes. This helps them to move their eyes without having to move their head as well.Gaze stabilization exercise isnmost commont type of exercise for the treatment of vertigo.
Balancing exercises required will depend on the stimulus that triggers the issue. People may have difficulty balancing when walking outside, inside, on elaborately patterened floors, or around obstacles. Performing tasks while standing or walking can be a major issue for people who have trouble balancing, as can moving through crowds or being surrounded by people.For this patient is advised for straight walking, backward walking and side walking in one line which improves balance and stabilization of the patient during walking and standing.

How long does vertigo last? 

vertigo will usually go away on its own within 24 hours.
Attacks of vertigo due to Meniere’s disease can last from 20 minutes to 24 hours.
For patients with benign paroxysmal positional vertigo, the Epley maneuver can usually stop symptoms within a week.
Vertigo from a stroke, either due to blood vessel blockage or hemorrhage, may leave permanent damage to the brain and cause permanent vertigo symptoms.

PRECAUSIONS

  • prevent injuries from falls.
  • Those with risk factors for stroke should control their high blood pressure and high cholesterol and stop smoking.
  • Avoid substances like caffeine, tobacco, or alcohol.
  • Drink plenty of fluids.

 

 

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CERVICAL RIB

 INTODUCTION

 

Posterior View Cervical Rib
anterior view of cervical  rib

 

 

lateral view of cervical rib

 

A cervical rib in humans is an extra rib which arises from the seventh cervical vertebra. Sometimes known as “neck ribs” their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.2% (1 in 500 people) to 0.5% of the population. People may have a cervical rib on the right, left or both sides.It may be a fully-formed bony rib or just a thin strand of tissue fibres.

Signs & Symptoms

90% cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. and it produces symptoms after the age of 30 years.A patient may present with following symptoms:

 (a) Neurological Symptoms:

  • Pain in your neck and shoulder, which spreads into your arm – this may be constant or come and go. This is commonly seen in thoracic outlet syndrome.
  • Tingling and numbness,temporary loss of feeling in the affected arm and fingers(T1 dermatome). This is  the most common complaint.
  • Wasting of the hand muscle and temporary inability in fine movement of hand like buttoning

 (b) Vascular Symptoms:

subclavian artery compression
  • An aneurysm in the subclavian artery which can affect the blood supply to the fingers leads to small red or black patches on the skin.
  • white colouration in hand
  • There may be present of Raynaud’s phenomenon – a condition that affects the blood supply to the fingers and toes, turning them white.
  • Radial pulse becomes feeble or may even be absent.

(c) Local Symptoms:

  • Sometimes, patient may present with the tenderness in supraclavicular lump which, on palpation very hard and fixed.
  • Swelling in the affected arm but, this is very rare.

Diagnosis:

(1) Generally it is diagnosed by the X-Ray examination to detect cervical rib,

which could be easily palpable.

It is attached to the seventh cervical vertebra.

                                                            Cervical Rib X-Ray

(2) Special test:

    (a)Adson’s Test

Adson’s test

Indications– Evaluation of Cervical Ribs/ Thoracic Outlet Syndrome.
Technique- Patient breathes deeply, Neck extended, Chin turned toward affected side. The examiner lifts the arm away to the side to 90 degrees and performs external rotation of the shoulder, and notes whether the radial pulse disappears. However there are many false positives, as the radial pulse may disappear in normal people as the head of the humerus (upper arm bone) compresses the brachial vessels when the arm is taken beyond 90 degrees. Repeat test with chin to opposite side.
Interpretation Positive test finding suggests interscalene compression, decreased Radial Pulse and/or Distal extremity pain reproduced.

  (b) Foraminal Compression Test/ Spurling’s Test

Spurling’s test

Spurling’s test is an orthopedic test used to diagnose nerve root compression primarily at the cervical level. It should not be used in instances in which vertebral instability is suspected.

   (c) Shoulder Abduction Test

shouldr abduction test

Shoulder Abduction Test is an orthopedic test used to help diagnose a cervical nerve root injury or cervical disc herniation. It is performed by having the patient abduct their shoulder and place their hand on top of their head.  A positive test will involve a decrease in radiculopathy or pain.

Differential Diagnosis:

Patient with cervical rib is to be differtiated from patients presents with radiatiang pain in upper limb and following are the causes:
1)Some of the more common conditions include herniated cervical disk, cervical                     spondylosis, and peripheral neuropathies.
2) Peripheral vascular disease like Raynaud’s disease.
3) Neurological conditions-like syringomyelia, polio, muscular dystrophy, motor neuron        disease.

Treatment

1. medical treatment:
Anti-inflammatory drugs and
analgesics
this two given as a coservative treatment.

2. surgical treatment:
surgery is essential in conditions of severe, progressive vascular and neurological signs and symptoms which are unbearable for the patients. It includes:

  • Removal of extra segment.
  • Dividing the scalene group of muscles.

3. physiothrapy management:
On the basis of symptoms of the patient, the regime of physiotherapy is planned.

  • For pain relief- short wave diathermy is used but it is contraindicated in case of sensory impairments.
  • To improve distal circulation- gripping exercise like ball sqizing, spring stretching.
  • To improve tone, power and endurance-Strengthening exercises of whole arm perticularly small muscles of the arm.
  • For posture Correction -In this, patient is guided to use mirror to see that his shoulders are in level, head is straight, looking forward.
  • Deep Tissue Massage for TOS ( thoracic Outlet Syndrome).
  • Specific exercises- To develop particular muscles groups for specific movements of shoulder girdle like elevation, retraction, and raising the arm overhead as these movements brings spontaneous relief. The important exercises are:

 

  Self resisted exercise

 

 

 

 

 

 

 

1-Self resisted scapular elevation.

2-Self resisted scapular adduction.

3-Endurance training exercise for the shoulder girdle muscles.

4-Progressive resistance exercises for shoulder girdle muscles with weight.

 

GOLFER’S ELBOW

  • INTRODUCTION

Golfer’s elbow, or medial epicondylitis, is tendinosis of the medial epicondyle on the inside of the elbow. It is in some ways similar to tennis elbow, which affects the outside at the lateral epicondyle. The anterior forearm contains several muscles which flexes the digits of the hand, and flexing and pronating the wrist. The tendons of these muscles come together in a common tendinous sheath, which originates from the medial epicondyle of the humerus at the elbow joint. In response to minor injury, or sometimes for no obvious reason at all, this point of insertion becomes inflamed , which is called medial epicondylitis.

muscle tear
muscle tear

 

Anatomy of medial                 epicondyle

 

 

 

 

 

 

 

 

 

CAUSES

The condition is called golfer’s elbow because in making a golf swing this tendon is stressed, especially if a non-overlapping (baseball style) grip is used. But, this condition doesn’t just affect golfers.Any repetitive hand, wrist, or forearm motions can lead to golfer’s elbow. Risky sports include tennis, bowling, and baseball — in fact, it’s sometimes called pitcher’s elbow.
The tendon of the wrist flexor muscles on the inside of the elbow becomes painful and inflamed at their attachment point on the inner elbow because of the overuse of the muscle.
In this condition, pain at the medial epicondyle is aggravated by resisted wrist flexion and pronation, which is used to aid diagnosis.
Epicondylitis is much more common on the lateral side of the elbow (tennis elbow), rather than the medial side.

SIGNS & SYMPTOMS

The main symptoms are –

  • pain
  • tenderness on the medial epicondyle
  • problem in gripping
  • general weakness in the wrist and
  • Inflammation of the flexor tendons.

DIAGNOSIS

The diagnosis of medial epicondylitis is based on local pain at the elbow.Tenderness and pain with palpation on distal and anterior of the medial epicondyle. An increase in pain at the medial epicondyle with resisted isometric flexion, repetitive flexion and pronation of the wrist can also be examined.
In particular the Golfer’s Elbow Test is useful :

In this,the patient should be seated or standing and should have his/her fingers flexed in a fist position.The examiner palpates the medial epicondyle with one hand and grasps the patient’s wrist with his/her other hand.The examiner then passively supinates the forearm and extends the elbow and wrist. A positive test would be a complaint of pain or discomfort along the medial aspect of the elbow in the region of the medial epicondyle.

                                            Golfer’s Elbow Test

 

MANAGEMENT

– Non-specific treatments include:

Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin
Heat or ice therapy.

A counter-force brace or “elbow strap” to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.

-Surgical Management:

When conservative management fails and there is persistent pain after 6 to 12 months and all other pathologies  are considered, surgical treatment must be considered.Surgery for failure of conservative treatment relieves pain,  restored strength and allows a return to the previous level of daily living and sports activity.Following surgical  procedures are prefer:

  1. Minimally invasive method,
  2. Ultrasound-guided removal of scar tissue in the region of the tendon pain
  3. Corticosteroid injections.

-Physiotherapy Management:

  • Rest: Put your golf game or other repetitive activities on hold until the pain is gone. If you return to activity too soon, you may make it worse.
  • For pain relief:

Ultrasound

IFT(inter ferential therapy)

TENS ( Transcutaneous Electrical Nerve Stimalation )

  • Ice: On the affected area. Apply ice packs to your elbow for 15 to 20 minutes at a time, three to four times a day for several days. To protect your skin, wrap the ice packs in a thin towel. It might help to massage the inner elbow with ice for five minutes at a time, two to three times a day.
                  ice pack

     

Use a brace: Your doctor might recommend that you wear a counter force brace on your affected arm, which might reduce tendon and muscle strain.

  •                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

  • Stretching and Stengthening exercise: Your doctor may suggest stretching and strengthening exercises. A type of strengthening (eccentric) that lengthens the tendon of the wrist extensor muscles has been shown to be particularly effective in treating chronic tendon irritation. Exercises are like-

Resisted exercise for elbow flexion and pronation

Strenghtening exercise for wrist flexion with dumbel

Wrist flexor stretching

            

strengthening of wrist flexors

 

 

 

 

 

 

 

 

               rehabilitation exercise

wrist flexor stretching

 

Gradually return to your usual activities. When your pain is gone, practice the arm motions of your sport or activity. Review your golf or tennis swing with an instructor and make adjustments if needed.

COMPARTMENT SYNDROME

DESCRIPTION

Compartment syndrome is a condition in which increased pressure within one of the body’s compartments results in insufficient blood supply to tissue within that space.Compartment syndrome usually results from bleeding or swelling after an injury. There are two main types: acute and chronic.The leg or arm is most commonly involved.
Groups of organs or muscles are organized into areas called compartments. Strong webs of connective tissue called fascia form the walls of these compartments.After an injury, blood or edema may accumulate in the compartment. The tough walls of fascia cannot easily expand, and compartment pressure rises, preventing adequate blood flow to tissues inside the compartment. Severe tissue damage can result, with loss of body function or even death.

CAUSES

Acute compartment syndrome is the most common type of compartment syndrome. Acute compartment syndrome occurs in about 3% of those who have a mid-shaft fracture of the forearm.Compartment syndrome can develop from the fracture itself, due to pressure from bleeding and edema. Or compartment syndrome may occur later, as a result of treatment for the fracture such as surgery and POP.
Acute compartment syndrome can also occur after injuries without bone fractures, including:

  • Crush injuries
  • Burns
  • Overly tight bandaging
  • Prolonged compression of a limb during a period of unconsciousness
  • Surgery to blood vessels of an arm or leg
  • A blood clot in a blood vessel in an arm or leg
  • Extremely vigorous exercise, especially eccentric movements (extension under pressure)
  • vigorous exercise.
    Acute Compartment Syndrome with blister formation

SIGNS & SYMPTOMS

Acute

There are five characteristic signs and symptoms related to acute compartment syndrome: pain, paraesthesia (reduced sensation), pallor, and pulselessness. Pain and paresthesia are the early symptoms of compartment syndrome.

  • Pain – The pain would be disproportionate to the findings of the physical examination, is not relieved by analgesia up to and including morphine. The pain is aggravated by passively stretching the muscle group within the compartment. However, such pain may disappear in the late stages of the compartment syndrome.The role of local anaesthesia in delaying the diagnosis of compartment is still being debated.
  • Paresthesia (altered sensation) – A person may complained of “pins & needles”, numbness, and tingling sensation. This may progress to loss of sensation (anesthesia) if no intervention has been made.
  • Paralysis – Paralysis of the limb is a rare, late finding. It may indicate both nerve or muscular lesion.
  • Pallor and pulselessness – A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures. Absent pulses only occurs when there is arterial injury or during the late stages of the compartment syndrome.
pallor leg
  • Swelling, tightness and bruising.
                               swelling

Chronic

The symptoms of chronic exertional compartment syndrome (CECS) are brought on by exercise and consist of a sensation of extreme tightness in the affected muscles followed by a painful burning sensation if exercise is continued. After exercise is ceased, the pressure in the compartment will decrease within a few minutes, relieving painful symptoms. Symptoms will occur at a certain threshold of exercise which varies from person to person but is rather consistent for a given individual and can range anywhere from 30 seconds of running to about 10–15 minutes of running. CECS most commonly occurs in the lower leg, with the anterior compartment being the most frequently affected compartment.Foot drop is a common symptom of CECS.

DIFFERENTIAL DIAGNOSIS

Patients with exercise-induced lower leg pain, differential diagnosis includes:

  • medial tibial stress syndrome (MTSS)
  • fibular and tibial stress fractures
  • fascial defects
  • nerve entrapment syndromes,
  • vascular claudication
  • lumbar disc herniation.

DIAGNOSIS

Apart from the typical signs and symptoms, measurement of intra-compartmental pressure is also important for diagnosis. A transducer connected to a catheter is inserted 5 cm into the zone of injury.A pressure higher than 30 mmHg of the diastolic pressure in conscious or unconscious person is associated with compartment syndrome; and fasciotomy is indicated. For those with hypotension, a pressure of 20 mmHg higher than the intra-compartmental pressure is associated with compartmental syndrome.

measurement of itra compartment pressure

According to Blackman one of the tools to diagnose compartment syndrome is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.
Less invasive measurement techniques:

  1. Laser Doppler ultrasound
  2. Methoxy isobutyl isonitrile enhanced magnetic resonance imaging (MRI)
  3. Phosphate-nuclear magnetic resonance (NMR) spectroscopy

MANAGEMENT

Medical Management

  • The gold standard treatment is fasciotomy, but most of the reports on its effectiveness are in short follow-up periods.It is recommended that all four compartments (anterior, lateral, deep posterior and superficial posterior) should be decompressed by one lateral incision or anterolateral and posteromedial incisions.Surgery Patients may be able to participate in all common activities a few days post surgery.Treatment should begin with rest, ice, activity modification and if appropriate, nonsteroidal anti-inflammatory drugs.
                                    faciotomy

Physiotherapy Management

  • The only nonoperative treatment that is certain to alleviate the pain of CECS is the cessation of causative activities. Normal physical activities should be modified, pain allowing. Cycling may be substituted for running in patients who wish to maintain their cardiorespiratory fitness, as it is associated with a lower risk of compartment pressure elevation. Massage therapy may provide some benefit to patients with mild symptoms or to those who decline surgical intervention. Overall, however, nonoperative treatment has been generally unsuccessful and symptoms will not disappear without treatment. As alluded to, untreated compartment syndrome can cause ischemia of the muscles and nerves and can eventually lead to irreversible damage like tissue death, muscle necrosis and permanent neurological deficit within the compartment.
  • Aquatic exercises, such as running in water, can maintain/improve mobility and strength without unnecessarily loading the affected compartment. Massage and stretching exercises also have been shown to be effective.
      Aqua Jogging

 

Post-surgical management

Post-surgical therapy for CECS includes:

  • Assisted weight bearing exercise with variation,
  • Early mobilisation is recommended as soon as possible to minimise scarring, which can lead to adhesions and a recurrence of the syndrome.
  • Activity can be upgraded to stationary cycling and swimming after healing of the surgical wounds,
  • Isokinetic muscle strengthening exercises can begin at 3-4 weeks,
  • Running is added into the activity program at 3-6 weeks,
  • Full activity is introduced at approximately 6-12 weeks, with a focus on speed and agility.
Achilles-Tendon Stretching
TIBIALIS ANTERIOR STRETCHING

 

 

 

 

 

 

 

 

 

walking aid

 

            SHOE VARIATION

 

 

 

 

 

 

 

The following are recommendations for a full recovery and to avoid recurrence;

Wearing more appropriate footwear to the terrain
Choosing more appropriate surfaces and terrain for exercise
Pacing your activities
Avoiding certain activities altogether
Mastering strategies for recovery and maintenance of good health (e.g, appropriate rest between sessions)
Modifying the workplace to lower the risk of injury
Postoperative physical therapy is essential for a successful recovery. depending on the nature of the procedure, expected timelines for healing and progress made during rehabilitation. Treatment incorporates strategies to restore range of motion, mobility, strength and function.

 

 

 

 

 

 

 

 

 

 

SUDECK’S DYSTROPHY

DESCRIPTION

Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), is a disorder of a portion of the body, usually the arms or legs, which manifests as pain, swelling, limited range of motion, and changes to the skin and bones. It may initially affect one limb and then spread throughout the body; 35% of affected people report symptoms throughout their whole bodies.There are multiple names for this disease, as well as two subtypes. Type I (also called reflex sympathetic dystrophy) refers to CRPS without evidence of a specific peripheral nerve injury. Type II refers to when there is specific evidence of a nerve injury.

SIGNS & SYMPTOMS

The symptoms are variable and will present themselves differently from patient to patient. The main symptoms are –

  • a generalised burning pain
  • changes in the skin, which may become shiny
  • swelling
  • more perspiration more than usual
  • muscle wastage
  • stiffness in the affected part
  • increased sweating

 

                        wasting
                      Diformity in RS

 

STAGES OF CRPS

Previously it was considered that CRPS had three stages;it is now thought, instead, that such individuals are likely to have one of the three following types of disease progression:

  1. “Stage” one is characterized by severe, burning pain at the site of the injury, muscle spasms, joint stiffness, restricted mobility, rapid hair and nail growth, and vasospasm. The vasospasm is that which causes the changes in the color and temperature of the skin. Some may experience hyperhydrosis (increased sweating). In mild cases this stage lasts a few weeks, in which it can subside spontaneously or respond rapidly to treatment (physical therapy, pain specialist).
  2. “Stage” two is characterized by more intense pain. Swelling spreads, hair growth diminishes, nails become cracked, brittle, grooved and spotty, osteoporosis becomes severe and diffuse, joints thicken, and muscles atrophy.
  3. “Stage” three is characterized by irreversible changes in the skin and bones, while the pain becomes unyielding and may involve the entire limb. There is marked muscle atrophy, severely limited mobility of the affected area, and flexor tendon contractions (contractions of the muscles and tendons that flex the joints). Occasionally the limb is displaced from its normal position, and marked bone softening and thinning is more dispersed.
 Stages of SD

 

CAUSES  

Investigators estimate that 2–5% of those with peripheral nerve injury,and 13-70 percent of those with hemiplegia,will develop CRPS. In addition, some studies have indicated that cigarette smoking was strikingly present in patients and is statistically linked to RSD. This may be involved in its pathology by enhancing sympathetic activity, vasoconstriction, or by some other unknown neurotransmitter-related mechanism. This hypothesis was based on a retrospective analysis of 53 patients with RSD, which showed that 68% of patients and only 37% of controls were smokers. The results are preliminary and are limited by their retrospective nature.7% of people who have CRPS in one limb later develop it in another limb.

PATHOPHYSIOLOGY

Complex regional pain syndrome is a multifactorial disorder with clinical features of neurogenic inflammation (swelling in the central nervous system), nociceptive sensitisation (which causes extreme sensitivity or allodynia), vasomotor dysfunction (blood flow problems which cause swelling and discolouration) and maladaptive neuroplasticity; CRPS is the result of an “inappropriate response to tissue injury”. The “underlying neuronal matrix” of CRPS is seen to involve cognitive and motor as well as nociceptive processing; pinprick stimulation of a CRPS affected limb was painful (mechanical hyperalgesia) and showed a “significantly increased activation” of not just the S1 cortex (contralateral), S2 (bilateral) areas, and insula (bilateral) but also the associative-somatosensory cortices (contralateral), frontal cortices, and parts of the anterior cingulate cortex. In contrast to previous thoughts reflected in the name RSD, it appears that there is reduced Sympathetic Nervous System outflow, at least in the affected region (although there may be sympatho-afferent coupling). Wind-up (the increased sensation of pain with time) and central nervous system (CNS) sensitization are key neurologic processes that appear to be involved in the induction and maintenance of CRPS.

                          The mechanism of RSDS

The pathophysiology of complex regional pain syndrome has not yet been defined; there is conjecture that CRPS, with its variable manifestations, could be the result of multiple pathophysiologies.

DIAGNOSIS

There is no biological test to highlight Sudeck’s disease. The physician makes the diagnosis based primarily on physical findings and history.

  • Temperature measurements: temperature measurement generated by the body surface
  • Measuring the secretion of sweat
  • Radiography, CT, MRI: to highlight a bone decalcification.
  • Blockages friendly: using anesthesia, they can reduce sympathetic activity, this method allows to obtain diagnostic information and a therapeutic action, insofar as Sudeck’s disease depends on the sympathetic system.
  • Scintigraphy in three phases: review specific nuclear medicine
  • The pain and swelling in the limbs may also come from other illnesses, so it is important to eliminate them. (venous thrombosis, lymphedema as accumulation of fluid and lymphatic system disorders, lymph node involvement in cases of breast cancer).
                   X-Ray finding

The International Association for the Study of Pain (IASP) lists the diagnostic criteria for complex regional pain syndrome I (RSDS) as follows:

  1. The presence of an initiating noxious event or a cause of immobilization
  2. Continuing pain, allodynia (perception of pain from a nonpainful stimulus), or hyperalgesia (an exaggerated sense of pain) disproportionate to the inciting event
  3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the area of pain
  4. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

According to the IASP, CRPS II (causalgia) is diagnosed as follows:

  1. The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve
  2. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain
  3. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

TREATMENT

The goal of treatment is the preservation of the normal functionality of the affected body part, that is to say, the mobility of the extremities. Treatment requires patience from the patient and physician. It is very difficult to influence the course of the disease and the psychological burden caused by the pain is very important.

Medical treatment:

Tentative evidence supports the use of bisphosphonates, calcitonin, and ketamine. Doing nerve blocks with guanethidine appears to be harmful. Evidence for sympathetic nerve blocks generally is insufficient to support their use. Intramuscular botulinum injections may benefit people with symptoms localized to one extremity.

  • Ketamine
    Ketamine, a dissociative anesthetic, appears promising as a treatment for complex regional pain syndrome. It may be used in low doses if other treatments have not worked. No benefit on either function or depression, however, has been seen.
  • Bisphosphonate treatment
    Very limited data reviewed showed that bisphosphonates have the potential to reduce pain associated with bone loss in patients with CRPS I.

Surgery

It is required when medication and conservative treatment are failed and mostly used in sever CRPS. Following are the procedures:

  • Spinal cord stimulators
  • Sympathectomy
  • Amputation

Physiotherapy Treatment

It is important that the patient actively participates and takes its responsibilities during treatment.

  • First of all, to rest; possibly splinting
  • Elevation of the affected
  • Cool slightly (NOT ice), carbon dioxide baths costs
  • Manual lymphatic drainage
  • Electrotherapy, TENS (transcutaneous electrical nerve stimulation: inhibition of conduction of pain due to nerve stimulation by electrical current)
  • Massages of connective tissue
  • Mobilization in chronic phase
  • Carefully active movement of affected limb
  • Occupational therapy to maintain mobility
  • Specific training with specialists
  • Learning relaxation techniques
  • Aquatic therapy allows activities to be performed with decreased weight bearing on the lower extremities
  • Mirror therapy
  • Gradual weight bearing
  • Stretching
     support in sd for rest

 

                             treatment

 

 

 

 

 

 

 

 

 

weight lifting exercise

 

Other treatments:

  • Whirlpool bath/ contrast baths
  • Vocational and recreational rehabilitation
  • Psychological therapies: cognitive-behavioural therapy (CBT), operant conditioning (OC), counselling, pain education and relaxation techniques
  • Acupuncture & electroacupuncture
  • Tactile sensory discrimination training
  • Ultrasound therapy
  • Kinesio taping

 

Electrical stimulation
Kinesio Taping
               Ultrasound in RSD

PAINFUL ARCH SYNDROME

INTRODUCTION

Supraspinatus tendinitis or painful arc syndrome occurs in the shoulder. The shoulder joint owes its stability to the ‘rotator cuff’ muscles – which are four small muscles located around the shoulder joint which help with movement, but importantly their tendons stabilise the head of the humerus within the joint capsule.Sometimes, with wear and tear supraspinatus tendinitis results, which is commonly associated with inflammation of the bursa – subacromial bursitis. There may even be little tears in the tendon fibres – partial tears or sometimes even complete tears. It is typically seen in people aged 25-60.

Painful Arc Synddrome, also called shoulde impingement syndrome, subacromial impingement, supraspinatus syndrome, swimmer’s shoulder, and thrower’s shoulder. It is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder.

Tendinitis and partial tears in the supraspinatus tendon causes a ‘painful arc’ since as the person elevates his arm sideways, the tendon begins to impinge under the acromion throught the middle part of the arc, and this is usually relieved as the arm reaches 180 degrees (vertical).

CAUSES

  • Minor tear of supraspinatus muscle
  • Supraspinatus Tendinitis
  • Calsification of supranatus muscle
  • Subacromial buersitis
  • Fracture of greter tuberocity
  • Subacromial spur
  • Tilting of humaral head

 

             Bone Spur

When the arm is raised, the subacromial space (gap between the anterior edge of the acromion and the head of the humerus) narrows, through which the supraspinatus muscle tendon passes Anything causes further narrowing the tendency to impinge the tendon and cause an inflammatory response, resulting in impingement syndrome.

SIGNS & SYMPTOMS

  • The most common symptoms in impingement syndrome are
    pain,
    weakness,
    a loss of movement at the affected shoulder
  • The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder.
  • The onset of the pain may be acute if it is due to an injury or may be insidious if it is due to a gradual process such as an osteoarthritic spur.
  • The pain has been described as dull rather than sharp, and stays for long periods of a time, making it hard to fall asleep at night.
  • Other symptoms can include a grinding or popping sensation during movement of the shoulder.
  • The range of motion at the shoulder may be limited by pain. A painful arc of movement may be present during abduction of the arm from 60° to 120°.

  • Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will ease once the downwards force is removed.

PROGRASSION

The tendinitis results from trauma (e.g. a fall, dog on leash) in around 30% of cases.
5% of cases are bilateral.
The pain will severely limit shoulder movement and may cause secondary muscular neck pains.

DIAGNOSIS

Plain x-rays of the shoulder can be used to detect some joint pathology and variations in the bones, including acromioclavicular arthritis, variations in the acromion, and calcification. However, x-rays do not allow visualization of soft tissue and thus hold a low diagnostic value.

Ultrasonography, arthrography and MRI can be used to detect rotator cuff muscle pathology. MRI is the best imaging test prior to arthroscopic surgery.

The physician may inject lidocaine (usually combined with a steroid) into the bursa, and if there is an improved range of motion and decrease in pain, this is considered a positive “Impingement Test”.

Impingement syndrome can usually be diagnosed by history and physical exam. On physical exam, the physician may twist or elevate the patient’s arm to test for reproducible pain through some special tests.These tests helps localize the pathology to the rotator cuff, which are –

  1. Neer test
  2. Hawkins-Kennedy test
Hawkins-Kennedy Test

However, they are not specific for impingement. Neer sign may also be seen with subacromial bursitis.

TREATMENT

Impingement syndrome is usually treated conservatively, but sometimes it is treated with arthroscopic surgery or open surgery. Conservative treatment includes –

  • Rest : to allow the inflammation to settle
  • Analgesics such as NSAIDs – naprosyn 250mg three times daily with food.
  • Injection of corticosteroid with local anesthetic into the subacromial bursa or the supraspinatus tendon itself will help (though there may be an increase in discomfort in the first 48 hours).
            inajaction
  • Physical therapy

Surgical Treatment

A number of surgical interventions are available, depending on the nature and location of the pathology.

Surgery may be done arthroscopically or as open surgery.

The impinging structures may be removed in surgery, and the subacromial space may be widened by resection of the distal clavicle through acromioplasty – i.e. re-shaping the acromion and excision of osteophytes on the under-surface of the acromioclavicular joint. Damaged rotator cuff muscles can be surgically repaired.

Physiotherapy Management

Physical therapy treatments would typically focus at maintaining range of movement, improving posture, strengthening shoulder muscles, and reduction of pain.Patients who present with SIS will have shoulder pain that is exacerbated with overhead activities. Pain will be the patients’ chief complaint and thus relieving pain will initially be the primary goal of physical therapy. Patients with SIS will present with a painful arc of motion (shown to the right). This arc is from 60-120 degrees of shoulder abduction.

For Pain Relief :

Educating the patient on avoiding this painful ROM with repetitive tasks is key to the initial stages of decreasing pain in the shoulder.

  • Ice pack
  • Joint Mobilisation – grade 1&2 glide
  • SWD
  • Ultrasound
  • IFT

For ROM Improvement :

  • Active assisted movement of shoulder joint for 5-7 days
  • Patient has anterior instability and tightness of the posterior capsule. So, performing stretches into IR will allow patients to regain full ROM into IR.
  • Joint Mobilization with PA grade III/IV
Joint mobilization
  • Functional Activities like waeing clothes by own, doing overhead activities and postural education may be needed.
  • Therapeutic Taping

For Strenghenig of muscle :

  • Resisted exercise for IR, ER, ABDUCTION, SCAPULAR RETRACTION, ELEVATION
  • PNF Techniqes for sholder joint – may provide benefits in more functional patterns.
rom exercise

 

                                                  PNF

 

 

 

 

 

 

 

 

 

 

                      exercise

 

Special Instructions 

Most importantly with patients who are experiencing SIS, avoiding painful activities is the most important instruction. Aggravating the already inflamed, irritated shoulder joint is what must be avoided. Examples of potentially painful positions are:

Instruct the patient to avoid sleeping on the involved shoulder as this will place compressive forces through their shoulder and will exacerbate their pain.
Instruct the patient to avoid repetitive overhead activities outside their pain-free ROM. (i.e. putting groceries away over head, reaching for items in taller closets, hammering nails into the wall above head, lifting children up above their heads).

POPLITEAL CYST

INTRODUCTION

A popliteal cyst, also known as a Baker’s cyst, is a fluid-filled swelling that causes a lump at the back of the knee, leading to tightness and restricted movement. The cyst can be painful when you bend or extend your knee.It is named after the surgeon who first described it, William Morrant Baker (1838–1896). It is not a “true” cyst, as an open communication with the synovial sac is often maintained.

         Baker’s cyst formstion

 

CAUSES

Synovial fluid is a clear liquid that normally circulates through the cavities in your knee joint. Sometimes the knee produces too much of this fluid. The increasing pressure forces the fluid to the back of the knee via a one-way valve, where it creates a bulge. This severe swelling of the knee causes a popliteal cyst to form.

The most common causes of a popliteal cyst are:

  • Damage to the knee’s cartilage (meniscus)
  • Arthritis of the knee
  • Rheumatoid arthritis
  • Other knee conditions that causes joint inflammation

 

SYMPTOMS

You may not feel any pain with a popliteal cyst. In some cases, you may not notice it at all.

  • Mild to severe pain
  • Stiffness
  • Limited range of motion
  • Swelling behind the knee and calf
  • Bruising on the knee and calf
  • Rupturing of the cyst
   Swelling in affected leg

 

DIAGNOSIS

Your doctor will examine your knee and feel the swelling. If the cyst is small, they may compare the affected knee to the healthy one and check your range of motion.A Baker’s cyst is easier to see from behind with the patient standing with knees fully extended. It is most easily palpated (felt) with the knee partially flexed.

Your doctor may recommend noninvasive imaging tests if the cyst rapidly increases in size or causes severe pain or fever. These tests include an MRI or ultrasound. An MRI will enable your doctor to see the cyst clearly and to determine if you have any damage to the cartilage.

Diagnosis is confirmed by ultrasonography.

 

      MRI

 

TREATMENT

A popliteal cyst often doesn’t need treatment and will go away on its own. However, if the swelling becomes large and causes severe pain, your doctor may recommend one of the following treatments.

Knee Compression for rest

 

Fluid draining

Your doctor will insert a needle into the knee joint and may use an ultrasound to help guide the needle to the correct place. They’ll then draw the fluid from the joint.

Physical therapy

  • Avoiding activities such as squatting, kneeling, heavy lifting, climbing, and even running can help prevent pain
  • Regular, gentle exercises may help increase your range of motion and strengthen the muscles around your knee.
          Knee bending exercise
  • Stretching of hamstring and Strengthening of the quadriceps and/or the patellar ligament.
    self stretching of hamstring

 

 

     qudricepes strenghenin

 

  • Crutches may help alleviate the pain.
  • You can also help reduce pain by using a compression wrap or placing ice on the joint.

 

   ice therapy
  • Ultrasound on the back of knee joint

Medication

Your doctor may recommend a corticosteroid medication, such as cortisone. Your doctor will inject this drug into the joint, and the medication will flow back into the cyst. Though it may help relieve the pain, it doesn’t always prevent a popliteal cyst from recurring.

Treating the cause of the cyst is very important to prevent the cyst from returning. As a general rule, if the cyst is left alone, it’ll go away once the underlying cause is treated. Should your doctor determine that you have damage to the cartilage, they may recommend surgery to repair or remove it.

                          surgical treatment

If you have arthritis, the cyst may persist even after your doctor treats the underlying cause. If the cyst causes you pain and limits your range of motion, your doctor might recommend surgery to remove it.

COMPLICATIONS

Complications associated with popliteal cysts. Complications are rare, but they may include:

  • prolonged swelling
  • severe pain
  • complications from related injuries, such as torn cartilage
  • the calf region may become red
  • there may be a sensation of water trickling down the calf

AMPUTATION

INTRODUCTION

Amputation is the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger. It is done by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, wherefetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is or was used as a form of punishment for people who committed crimes. Amputation of the leg — either above or below the knee — is the most common amputation surgery.

 

CAUSES

There are many reasons an amputation may be necessary. The most common is poor circulation because of damage or narrowing of the arteries, called peripheral arterial disease. Without adequate blood flow, the body’s cells cannot get oxygen and nutrients they need from the bloodstream. As a result, the affected tissue begins to die and infection may set in.

Circulatory disorders

Diabetic foot infection or gangrene (the most frequent reason for infection-related amputations)
Sepsis with peripheral necrosis

Neoplasm

Transfemoral amputation due to liposarcoma
Cancerous bone or soft tissue tumors (e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing’s sarcoma, synovial sarcoma)
Melanoma

Trauma

Three fingers from a soldier’s right hand were traumatically amputated during World War I.
Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail.
Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example, a finger that is severed from the blade of a table saw)
Amputation in utero (Amniotic band)

Deformities

Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia)
Extra digits and/or limbs (e.g., polydactyly)

Infection

Bone infection (osteomyelitis)
Diabetes
Frostbite

Athletic performance

Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance. Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance. Rugby union player Jone Tawake also had a finger removed. National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.

Legal punishment

Amputation is used as a legal punishment in a number of countries, among them Saudi Arabia, Yemen, United Arab Emirates, Iran, Sudan, and Islamic regions of Nigeria.

LEVEL OF AMPUTATION

Level of amputation

Upper Limb

  • Forequarter
  • Shoulder Disarticulation SD
  • Transhumberal (Above Elbow AE)
  • Elbos Disarticulation ED
  • Transradial (Below Elbow BE)
  • Hand/ Wrist Disarticulation
  • Transcarpal (Partial Hand PH)

Lower Limb

  • Hemipelvectomy
  • Hip Disarticulation HP
  • Transfemoral TF (Above Knee AK)
  • Knee Disarticulation KD
  • Transtibial TT (Below Knee BK)
  • Ankle Disarticulation
  • Symes
  • Partial Foot PF (Chopart)

 

 

 

PROCEDURE

The first step is ligating the supplying artery and vein, to prevent hemorrhage (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw. Sharp and rough edges of the bone are filed down, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis.

Distal stabilisation of muscles is recommended. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periostium. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles should be attached under similar tension to normal physiological conditions.

Ideal stump

skin flaps: skin should be mobile, sensation intact, no scars
muscles are divided 3 to 5 cm distal to the level of bone resection
nerves are gently pulled and cut cleanly, so that they retract well proximal to the bone level to reduce the complication of neuroma

Location of pulses

  1. Femoral Triangle
  2. Foot pulse (Medial malleolus or dorsum of the foot)
  3. Popliteal (behind the knee)
  4. Femoral (within the femoral triangle)
  5. If a leg has been amputated because of gangrene, the remaining leg is examined for a pulse

The surgeon may choose to close the wound right away by sewing the skin flaps which called as closed amputation. Or the surgeon may leave the site open for several days in case there’s a need to remove additional tissue.

The surgical team then places a sterile dressing on the wound and may place a stocking over the stump to hold drainage tubes or bandages. The doctor may place the limb in traction, in which a device holds it in position, or may use a splint.

SPECIAL INVESTIGATION

 

Doppler ultrasound

X-rays
CT scan
Angiogram (outlines blood vessels)
Doppler ultrasound (occlusion of vessels)
Venogram and arteriogram
Radioactive dye injected into the blood 

MANAGEMENT

Pre-Oparative Management

If the patient has problems with phantom pain (a sense of pain in the amputated limb) or grief over the lost limb, the doctor will prescribe medication and/or counseling, as necessary.

Physiotherapy, beginning with gentle stretching exercises, often begins soon after surgery. Practice with the artificial limb may begin as soon as 10 to 14 days after surgery.

Physiotherapy Management

Burger’s Exercise

Stimulates collateral blood flow in the patient’s leg
It is performed for 20 min.
The leg is elevated until the toes go white, then lowered, then level
Repeat 2-3 times to improve collateral circulation

Burger’s exercise

 

Post-Oparative Management

  • Connective tissue massage
    – Efflurage
    – Rolling
    – It relieves tighteness and loosen the mucles
  • Dynamic stump exercises
Stump exercise

 

 

 

 

 

 

 

 

exercise

 

  • Balance and gait retraining
    – Improve static and dynamic balance
    – Use Parallel bars, walking frame then Crutches (in that order)
    – Therapist stands on the amp side, using a belt around the patient’s waist to support
    – Rest if the patient feels tired
  • Maintain function in the remaining leg and stump to maintain peripheral circulation
  • Maintain respiratory function (important with smokers and those patients under general anaesthesia)

Stump Care

Stump care
  • For hygiene and skin care see handout on amputations
  • A hip flexion Contracture may develop because of elevation to reduce swelling
  • Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs
  • Swelling must be prevented to allow proper attachment of the Prosthesis, and the prevention of Pressure sores
  • The stump sock is put on first, then the prosthesis
  • The prosthesis must be cleaned and maintained (Children who are still growing, grow out of their prostheses)

Mobility Aids

The choice of mobility aids depends on the level of fitness, strength, balance skills of the individual:

  • Walking frame
  • Axillary crutches
  • Elbow crutches
  • Walking stick
Walking Stick
  • For bilateral lower limb amputees a wheelchair is indicated (high energy expenditure during gait with prostheses)
ARTIFICIAL LIMB(Prosthesis)

OSTEOMALACIA

DISCRIPTION

Osteomalacia is the softening of the bones caused by impaired bone metabolism primarily due to inadequate levels of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The impairment of bone metabolism causes inadequate bone mineralization.
Vitamin D and calcium supplements are measures that can be used to prevent and treat osteomalacia. Vitamin D should always be administered in conjunction with calcium supplementation (as the pair work together in the body) since most of the consequences of vitamin D deficiency are a result of impaired mineral ion homeostasis.
Vitamin D also helps maintain calcium and phosphate levels so your bones form properly. It’s made within the skin from exposure to ultraviolet (UV) rays in sunlight. It can also be absorbed from foods like dairy products and fish.

osteomalacia

 

CAUSES

The most common cause of osteomalacia is a deficiency of vitamin D, which is normally derived from sunlight exposure and, to a lesser extent, from the diet. The most specific screening test for vitamin D deficiency in otherwise healthy individuals is a serum 25(OH)D level. Less common causes of osteomalacia can include hereditary deficiencies of vitamin D or phosphate (which would typically be identified in childhood) or malignancy.
The causes of adult osteomalacia are varied, but ultimately result in a vitamin D deficiency:

  • Insufficient nutritional quantities or faulty metabolism of vitamin D or phosphorus
  • Renal tubular acidosis
  • Malnutrition during pregnancy
  • Malabsorption syndrome
  • Hypophosphatemia
  • Chronic kidney failure
  • Tumor-induced osteomalacia (Oncogenic osteomalacia)
  • Long-term anticonvulsant therapy
  • Celiac disease
  • Cadmium poisoning, itai-itai disease

You may also have a problem absorbing vitamin D or breaking down food to release it if you’ve had surgery to remove parts of your stomach or small intestine.
Certain conditions can interfere with the absorption of vitamin D:

Celiac disease can damage the lining of your intestines and prevent the absorption of key nutrients like vitamin D.
Certain types of cancer can interfere with vitamin D processing.
Kidney and liver disorders can affect the metabolism of vitamin D.

SIGNS & SYMPTOMS

  • Diffuse joint and bone pain (especially of spine, pelvis, and legs)
  • Muscle weakness
  • Difficulty walking, often with waddling gait
  • Hypocalcemia
  • Compressed vertebrae and diminished stature
  • Pelvic flattening
  • Weak, soft bones 

  • Easy fracturing
  • Bending of bones
Bow Leg Deformity

 

DIAGNOSIS

Biochemical findings

Biochemical features are similar to those of rickets. The major factor is an abnormally low vitamin D concentration in blood serum. Major typical biochemical findings include:

  • Low serum and urinary calcium
  • Low serum phosphate, except in cases of renal osteodystrophy
  • Elevated serum alkaline phosphatase (due to an increase in compensatory osteoblast activity)
  • Elevated parathyroid hormone (due to low calcium)

Radiographic characteristics

Radiological appearances include:

psedofracture
  • Pseudofractures, also called Looser’s zones.
  • Protrusio acetabuli, a hip joint disorder

DIFFERENTIAL DIAGNOSIS

Fibromyalgia
Rheumatic diseases
Muscular Dystrophy

TREATMENT

Medical Mnagement

If your doctor detects osteomalacia early, you may only need to take oral supplements of vitamin D, calcium, or phosphate.Foods with vitamin D include:

vitamin D foods
  • Cereal
  • Cheese
  • Eggs
  • Fish (tuna, salmon, swordfish, sardines)
  • Liver
  • Milk
  • Orange juice (fortified with vitamin D)
  • Yogurt

 

 

You may also need treatment if you have other underlying conditions that affect vitamin D metabolism. You need treatment for cirrhosis and kidney failure to reduce osteomalacia.ou may need to spend some time outdoors in sunlight so your body can make enough vitamin D in your skin.To treat broken or deformed bones from osteomalacia, your doctor may give you a brace to wear. If the problem is severe, you may need surgery.

Supplimentation Recomendations

Amounts vary depending on cause of deficiency, severity, and physician preference of ramping dosage
Supplement dosages range from 800 to 1000 IU/d of vitamin D
Or less than 2000 IU/d to avoid toxicity for those 1 year and older

Physiotherapy Treatment

There are no direct physical therapy interventions for osteomalacia. Patient will be referred to physical therapy for treatment of impairments that may be a cause of vitamin D deficiency such as decline in muscle strength, decline in physical functioning, or falls prevention. Exercises are like –

  • Muscle strenghening exercise
  • Encourage patient for doing his/her activites by own
  • Teach proper techniqes to prevent falls and fracture
  • Councelling of patient – to prevent/relieve depression, it is rare
  • Ice Therapy for pain relief.

PREVENTION

Prevention of osteomalacia rests on having an adequate intake of vitamin D and calcium. Vitamin D3 Supplementation is often needed due to the scarcity of Vitamin D sources in the modern diet. Treat your underlying conditions like kidney failure properly.Talk to your doctor to create a perfect treatment plan.

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