FIBROUS DYSPLASIA

DISCRIPTION

Fibrous dysplasia is a disorder where normal bone and marrow is replaced with fibrous tissue, resulting in formation of bone that is weak and prone to expansion. As a result, most complications result from fracture, deformity, functional impairment, and pain.

Disease can affect one bone (monostotic) or multiple (polyostotic). Single bone involvement usually occurs in adolescents and young adults. People who have more than one affected bone typically develop symptoms before the age of 10.

   Multiple fibrous dysplasia

Although fibrous dysplasia is a genetic disorder, it’s caused by a gene mutation that’s not passed from parent to child. There’s no cure for the disorder. Treatment, which may include surgery, focuses on relieving pain and repairing or stabilizing bones.

Fibrous dysplasia is a mosaic disease that can involve any part or combination of the craniofacial, axillary, and/or appendicular skeleton. The type and severity of the complications therefore depend on the location and extent of the affected skeleton. The clinical spectrum is very broad, ranging from an isolated, asymptomatic monostotic lesion discovered incidentally, to severe disabling disease involving practically the entire skeleton and leading to loss of vision, hearing, and mobility.

   craniofacial dysplasia

 

PATHOPHYSIOLOGY

Fibrous dysplasia is a mosaic disease resulting from post-zygotic activating mutations of the GNAS locus at 20q13.2-q13.3, which codes for the a subunit of the Gs G-coupled protein receptor. In bone, constitutive Gsa signaling results in impaired differentiation and proliferation of bone marrow stromal cells. Proliferation of these cells causes replacement of normal bone and marrow with fibrous tissue. The bony trabeculae are abnormally thin and irregular, and often likened to Chinese characters (bony spicules on biopsy).

Fibrous dysplasia is not hereditary, and there has never been a case of transmission from parent to child.

CAUSES

Fibrous dysplasia is linked to a gene mutation present in certain cells that produce bone. The mutation results in the production of immature and irregular bone tissue. Most often the irregular bone tissue (lesion) is present at a single site on one bone. Less often multiple bones are affected, and there may be more than one lesion on multiple bones.

A lesion usually stops growing sometime during puberty. However, lesions may grow again during pregnancy.

The gene mutation associated with fibrous dysplasia occurs after conception, in the early stages of fetal development. Therefore, the mutation isn’t inherited from your parents, and you can’t pass it on to your children.

SYMPTOMS

Fibrous dysplasia may cause few or no signs and symptoms, particularly if the condition is mild. More severe fibrous dysplasia may cause:

  • Bone pain, usually a mild to moderate dull ache
  • Swelling
  • Bone deformity
  • Bone fractures, particularly in the arms or legs
  • Curvature of leg bones

Fibrous dysplasia can affect any bone in the body, but the most commonly affected bones include the following:

  • Femur
  • Tibia
  • Humerus
  • Skull
  • Ribs
  • Pelvis

Rarely, fibrous dysplasia may be associated with a syndrome that affects the hormone-producing glands of your endocrine system. These abnormalities may include:

  • Very early puberty
  • Overactive hormone production
  • Light brown spots on the skin

Increased bone pain also may be associated with the normal hormonal changes of the menstrual cycle or pregnancy.

DIGNOSIS

  • X-Ray – Bubbly lytic lesion / Ground glass Imaging tests.
GROUND GLASS APPEARANCE
  • Computerized tomography or magnetic resonance imaging scans may be used to determine how extensively your bones are affected.
   CT Scan
  • Bone scan uses radioactive tracers, which are injected into your bloodstream. The damaged parts of your bones take up more of the tracers, which show up more brightly on the scan.
  • Biopsy uses a hollow needle to remove a small piece of the affected bone for laboratory analysis.

COMPLICATION

Severe fibrous dysplasia can cause:

  1. Bone deformity or fracture – The weakened area of an affected bone can cause the bone to bend. These weakened bones also are more likely to fracture.
 Tibial Bowning(deformity)
  1. Vision and hearing loss – The nerves to your eyes and ears may be surrounded by affected bone. Severe deformity of facial bones can lead to loss of vision and hearing, but it’s a rare complication.
  2. Arthritis – If leg and pelvic bones are deformed, arthritis may form in the joints of those bones.
  3. Cancer – Rarely, an affected area of bone can become cancerous. This rare complication usually only affects people who have had prior radiation therapy.

TREATMENT

Nonsurgical Treatment

  1. Medications
    Bisphosphonates are medications that decrease the activity of cells that dissolve bone. They have recently become available in easy-to-take pill form. These medications have not yet been used extensively in the treatment of fibrous dysplasia; however, early studies have shown effective relief of the pain associated with the disorder.
  2. Bracing
    In some cases, bracing may be used to prevent fracture in weakened bones. However, bracing has not been shown to be effective in preventing progression of deformity.

Surgical Treatment

In patients with fibrous dysplasia, surgery is often necessary to remove a growth or to fix or prevent bone fractures

  1. Curettage – Curettage is a surgical procedure commonly used to treat fibrous dysplasia. In curettage, the tumor is scraped out of the bone.
  2. Bone graft – After curettage, the doctor may fill the cavity with a bone graft to help stabilize the bone.
  3. Internal fixation – Metal rods or plates and screws may be used to fix a fracture or deformity, prevent bone breakage before it occurs, or stabilize the bone.
   TREATMENT OF FD
After surgery

 

Physiotherapy Treatment

  • Weight Bearing exercise like close kinetic chain exercise for affected part
  • Strengthening exercise for surrounding muscles

Post-oprative treatment

  • Councelling to reduce stress
  • Relaxaion exercise like Breathing Exercise
  • Passive ROM Exercise
  • Muscle stregthening exercise
  • Execise for prevetion of arthritis
  • Ice Pack to reduce swelling

Williams Abdominal Exercise

INTRODUCTION

Williams flexion exercises (WFE) — also called Williams lumbar flexion exercises or simply Williams exercises — are a set or system of related physical exercises intended to enhance lumbar flexion, avoid lumbar extension, and strengthen the abdominal and gluteal musculature in an effort to manage low back pain non-surgically. It also stretches the erector spinae, hamstring, and tensor fasciae latae muscles and iliofemoral ligament. The system was first devised in 1937 by Dr. Paul C. Williams, then a Dallas orthopedic surgeon.

HISTORY

The WFEs were developed out of the Regen exercise (also called “squat exercise”), advocated in the 1930s by Eugene M. Regen, a Tennessee orthopedic surgeon, and which consist in squatting and emphasizing the convexity of the lumbar area. Williams first published his own modified exercise program in 1937 for patients with chronic low back pain in response to his clinical observation that the majority of patients who experienced low back pain had degenerative vertebrae secondary to degenerative disk disease. These exercises were initially developed for men under 50 and women under 40 who had exaggerated lumbar lordosis, whose x-ray films showed decreased disc space between lumbar spine segments (L1-S1), and whose symptoms were chronic, but low grade.

RATIONALE

Williams believed that the basic cause of all pain is the stress induced on the inter-vertebral disc by poor posture. He theorized that the lordotic lumbar spine placed inordinate strain on the posterior elements of the inter-vertebral disc and caused its premature dysfunction. He was concerned about the lack of flexion in daily activities in the accumulation of extension forces that hurt the disc.

GOALS OF WILLIAMS FLEXION EXERCISES

The goals of these exercises are to open the intravertebral foramina and stretch the back extensors, hip flexors, and facets; to strengthen the abdominal and gluteal muscles; and to mobilize the lumbosacral junctions. And also reduce pain and provide lower trunk stability.

MECHANISM OF WFE

Williams said: “The exercises outlined will accomplish a proper balance between the flexor and the extensor groups of postural muscles…”. Williams suggested that a posterior pelvic-tilt position was necessary to obtain best results.

Both flexion and extension exercises have been shown to help reduce back pain and has been demonstrated to accomplish the following: a) significantly increase the canal area, b) increase the midsagittal diameter, c) increase the subarticular sagittal diameter, and d) increase all the foraminal dimensions significantly.

PROCEDURE OF WFE

These exercises were performed in the supine position on a floor or other flat surface. There were variations, but the primary maneuver is to grab the legs and pull the knees up to the chest and hold them there for several seconds. The patient then relaxes, drops the legs down and repeats the exercise again. The primary benefit is supposed to be the opening of the intervertebral foramen, the stretching of ligmentous structures, and the distraction of the apophyseal joints.

Seven of the variations of the WFEs are outlined below :

  1. Pelvic tilt – Lie on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor, without pushing down with the legs. Hold for 5 to 10 seconds. Pelvic tilt exercises strengthen muscles that support your low back.

 

            Pelvic Tilt

2. Single Knee to chest – Lie on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.

      single knee chest3. Double knee to chest – Begin as in the previous exercise. After pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly your lower one leg at a time. Knee to chest stretches improve flexibility in your low back.

 

 Double knee chest

4. Partial sit-up – Do the pelvic tilt (exercise 1) and, while holding this position, slowly curl your head and shoulders off the floor. Hold briefly. Return slowly to the starting position. Partial sit-ups strengthen the upper and lower abdominal muscles at the same time.

 

                                                                            Partial sit up

5.Hamstring stretch – Start in long sitting with toes directed toward the ceiling and knees fully extended. Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched over the legs, and eyes focus ahead. The hamstring stretch improves flexibility of the muscles along the back of your thighs.

 

Hamstring stretching

6. Hip Flexor stretch – Place one foot in front of the other with the left (front) knee flexed and the right (back) knee held rigidly straight. Flex forward through the trunk until the left knee contacts the axillary fold (arm pit region). Repeat with right leg forward and left leg back. The hip flexor muscles are located at the front of your hips. These muscles are often tight, particularly if you sit a lot during the day. It improves hip flexibility.

Hip flexor stretching

7. Squat – Stand with both feet parallel, about shoulder’s width apart. Attempting to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet flat on the floor, the subject slowly lowers his body by flexing his knees. The squat exercise strengthens muscles in your hips. Perform this exercise near a sturdy surface if you have difficulty with your balance.

wall sqat

McKenzie Technique

INTODUCTION

Many people spend long periods of time in a seated position. Being seated promotes a flexed spinal posture which, according to back expert and author Stuart McGill, can cause intervertebral discs to bulge outwards resulting in pain and inhibited spinal extension. McKenzie’s exercise series is designed to encourage the displaced disc to move back into its correct position which will alleviate the pain and allow freer spinal movement.

The McKenzie method is a classification system and a classification-based treatment for patients with low back pain. A acronym for the McKenzie method is mechanical diagnosis and therapy (MTD). The McKenzie method was developed in 1981 by Robin McKenzie, a physical therapist from New Zealand.

The aims of the therapy are: reducing pain, centralization of symptoms (symptoms migrating into the middle line of the body) and the complete recovery of pain. The prevention step consists of educating and encouraging the patient to exercise regularly and self-care.

CLASSIFICATION

Posture syndrome

Refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures.

Dysfunction syndrome

Refers to pain which is a result of mechanical deformation of structurally impaired tissues like scar tissue or adhered or adaptively shortened tissue.

Derangement syndrome

Refers to pain which is caused by a disturbance in the normal resting position of the affected joint surfaces.
This syndrome is classified in two groups:

Irreducible derangement

The criteria for derangement are present.
No strategy is capable to produce a permanent change in symptoms.

Reducible derangement

Shows one direction of repeated movement which decreases or centralizes referred symptoms / preferred direction.

Other or non-mechanical syndrome

  • Spinal stenosis
  • Hip disorders
  • Sacroiliac disorders
  • Low back pain in pregnancy
  • Spondylolysis and spondylolisthesis

SIGNIFICANCE

McKenzie’s exercises are designed to reposition any displaced intervertebral discs. This is initially done by using gravity to draw the discs back into the spine and then actively to consolidate the effect of gravity. To facilitate disc movement, you must relax as much as possible when performing the exercises and maintain relaxed and even breathing for the duration of the exercise. McKenzie’s exercises can be categorized as either passive or active and the passive exercises should always be performed first.

STAGES OF EXERCISE

1. Lying Prone

The patient takes place at the treatment table in prone position. The arms have to be parallel with the thorax, with the hands next to the pelvis. The head is turned to one side. This position creates automatically a lordosis of the lumbar spine. Although this position may be painful, the pain does not indicate the procedure is undesirable if it is felt centrally.
Patients with posterior derangement should be careful when arising from the position to standing. It is important that, while arising, the restored lordosis is maintained.
In any kind of derangement it is important to perform the exercise long enough (5-10 minutes) for the fluid to alter its position anteriorly.
For example patients with lumbar kyfosis, it is possible that the patients cannot tolerate the prone position unless they are lying over a few pillows.

 

   prone lying

 

2. Extension in Lying

The patient lies on his abdomen while the hands are placed near the shoulders. The hands are placed with the palms down. Now the patient makes a press-up movement with straight arms. The Pelvis stays near the table while the patient presses the thorax upwards. After this movement the patient returns to his starting position and repeats this exercise 10 times.
The aim of this exercise is to make the lumbar spine relax after the maximum extension, in the relaxation phase.
It is possible that there occurs central low back pain described as a strain pain, but it will gradually wear off.
This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction.

extension on elbow

 

extention on hand

 

 

 

 

 

 

 

3. Standing Lumbar Extension

The patient stands up straight with his feet apart, to remain a stable position. The hands are placed on the lumbar region, in the area of the spina iliaca posterior superior. His hands fixate the pelvis while the patient leans backwards. The patient has to lean backwards as far as possible.
It is used mainly in preventing future back problems once your acute pain has resolved. It can also be used as an alternative to prone press ups if social situations don’t allow you to lie flat on the floor and exercise, but you need to extend your spine to manage your back pain.

extension in standing

4. The Flexion Rotation Exercise for Low Back Pain

To do the exercise, lie on your side (typically on the side with the most pain), and bend your knees. Straighten your bottom leg, and tuck your top foot behind your bottom knee. Slowly reach your upper hand to your shoulder blade, and rotate your spine by moving your top shoulder back and towards the floor. Repeat the exercise for 10 repetitions.
If you have tried the press up with hips off center and the standing side glide exercise and are still having symptoms, you may want to move on to the flexion rotation stretch for low back pain. This stretch can be done to treat back pain on one side or pain that is traveling down your leg.

Self-treatment exercises

Rest position for cold pack
Sphinx-movement
standing back extension
Pelvic side shift

This exercise is called a “mirror exercise” and can be helpful when you have a “blocked” back and you’re leaning to one side because of it. The patient has to lean with his upper body against the wall, while his feet take same distance from the wall. Now the patient has to move his pelvis against the wall and back to the beginning position. This exercise has to be repeated 8-10 times.

Proprioceptive Neuromuscular Facilitation(PNF)

INTRODUCTION

Flexibility is key for athletes and nonathletes alike. It allows you to move freely and comfortably in your daily life, and can also help prevent injury during exercise. One of the best ways to increase your flexibility is by stretching. However, research suggests that not all stretching techniques are created equal. Proprioceptive neuromuscular facilitation (PNF) stretching relies on reflexes to produce deeper stretches that increase flexibility.

Proprioceptive Neuromuscular Facilitation (PNF) is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted.

According to the International PNF Association, PNF stretching was developed by Dr. Herman Kabat in the 1940s as a means to treat neuromuscular conditions including polio and multiple sclerosis.

PNF stretching was originally developed as a form of rehabilitation, and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, it also improves muscular strength.

PRECAUSION

Certain precautions need to be taken when performing PNF stretches as they can put added stress on the targeted muscle group, which can increase the risk of soft tissue injury. To help reduce this risk, it is important to include a conditioning phase before a maximum, or intense effort is used.

Also, before undertaking any form of stretching it is vitally important that a thorough warm up be completed. Warming up prior to stretching does a number of beneficial things, but primarily its purpose is to prepare the body and mind for more strenuous activity. One of the ways it achieves this is by helping to increase the body’s core temperature while also increasing the body’s muscle temperature. This is essential to ensure the maximum benefit is gained from your stretching. Click here for a detailed explanation of how, why and when to perform your warm up.

EFFECT OF PNF

While there are multiple PNF stretching techniques, all of them rely on stretching a muscle to its limit. Doing this triggers the inverse myotatic reflex, a protective reflex that calms the muscle to prevent injury.
“PNF causes the brain to go ‘I don’t want that muscle to tear’ and sends a message to let the muscle relax a little more than it would normally,” says fasciologist Ashley Black.
PNF is a stretching technique utilized to increase ROM and flexibility. PNF increases ROM by increasing the length of the muscle and increasing neuromuscular efficiency.

PNF TECHNIQUES

Revarsal of Antagonists:

A group of techniques that allow for agonist contraction followed by antagonist contraction without pause or relaxation.

  • Dynamic Reversals (Slow Reversals): Utilizes isotonic contractions of first agonists, then antagonists performed against resisitance . Contraction of stronger pattern is selected first with progression to weaker pattern. The limb is moved through full range of motion.
    Indications Impaired strength and coordination between agonist and antagonist, limitations in range of motion, fatigue.
  • Stabilizing Reversals: Utilizes alternating isotonic contractions of first agonists, then antagonists against resistance, allowing only very limited range of motion.
    Indications Impaired strength, stability and balance, coordination.

Rhythmic Stabilization (RS):

Utilizes alternating isometric contractions of first agonists, then antagonists against resistance; no motion is allowed .
Indications Impaired strength and coordination, limitations in ROM; impaired stabilization control and balance.

Repeated Contractions, RC (Repeated stretch):

Repeated isotonic contractions from the lengthened range, induced by quick stretches and enhanced by resistance; performed through the range or part of range at a point of weakness. Technique is repeated (i.e.,three or four stretches) during one pattern or until contraction weakens.
Indications Impaired strength, initiation of movement, fatigue and limitation in active ROM.

Rhythmic Initiation (RI):

Voluntary relaxation followed by passive movements progressing to active assisted and active resisted movements to finally active movements. Verbal commands are used to set the speed and rhythem of the movements. Light tracking is used during the resistive phase to facilitate movement.
Indications Inability to relax, hypertonicity (spasticity, rigidity); difficulty initiating movement; motor planning deficits (apraxia or dyspraxia); motor learning deficits; communication deficits (aphasia).

Hold-relax

One PNF technique that Black says can trigger the reflex is commonly called “hold-relax.” This involves:

Putting a muscle in a stretched position and holding for a few seconds.
Contracting the muscle without moving (also called isometric), such as pushing gently against the stretch without actually moving. This is when the reflex is triggered and there is a “6- to 10-second window of opportunity for a beyond ‘normal’ stretch,” Black says.
Relaxing the stretch, and then stretching again while exhaling. This second stretch should be deeper than the first.

Contract-relax

Another common PNF technique is the contract-relax stretch. It is almost identical to hold-relax, except that instead of contracting the muscle without moving, the muscle is contracted while moving. This is sometimes called isotonic stretching.

For example, in a hamstring stretch, this could mean a trainer provides resistance as an athlete contracts the muscle and pushes the leg down to the floor.

Hold-relax-contract

A third technique, hold-relax-contract, is similar to hold-relax, except that after pushing against the stretch, instead of relaxing into a passive stretch, the athlete actively pushes into the stretch.

For example, in a hamstring stretch, this could mean engaging the muscles to raise the leg further, as the trainer pushes in the same direction.

Regardless of technique, PNF stretching can be used on most muscles in the body, according to Black. Stretches can also be modified so you can do them alone or with a partner.

Rhythmic Rotation

Relaxation is achieved with slow, repeated rotation of a limb at a point where limitation is noticed. As muscles relax the limb is slowly and gently moved into the range. As a new tension is felt, RRo is repeated. The patient can use active movements (voluntary efforts) for RRo or the therapist can perform RRo passively. Voluntary relaxation when possible is important.
Indications Relaxation of excess tension in the muscles (hypertonia) combined with PROM of the range-limiting muscles.

To that end, PNF Techniques have broad applications in treating people with neurologic and musculoskeletal conditions, most frequently in rehabilitating the knee, shoulder, hip and ankle.

PNF PATTERN

UPPER LIMB PTTERN
LOWER LIMB PATTERN

 

 

 

 

 

 

 

  • The PNF exercise patterns involve three components: flexion-extension, abduction-adduction, and internal-external rotation.
  • The patterns mimic a diagonal rotation of the upper extremity, lower extremity, upper trunk, and neck.
  • The pattern activates muscle groups in the lengthened or stretched positions.
  • The upper and lower extremities each have two patterns: D1 and D2 motions targeting flexion and extension.
  • The patterns are used to improve range of motion at the joint as well as introduce resistance training. This will help improve the patients strength.

Upper Extremity
D1 Flexion

  D1 Flexion

Starting Position
Shoulder extended, abducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers extended

Hand Position
Hand placed in patient’s palm so that patient can grip and flex wrist to radial side
hand on the Anterior-medial surface of the patient’s arm just above elbow

Movements to End Position 
Shoulder flexed, adducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers flexed

D1 Extension

D1 extension

Starting Position
Shoulder flexed, adducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers flexed

Hand Position
Hand over dorsal-ulnar aspect of the patient’s hand
hand on he posterior-lateral surface of patient’s arm just above elbow

Movement to Ending Position
Shoulder extended, abducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers extened

D2 Flexion

D2 flexion

Starting Position
Shoulder extended, adducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers flexed

Hand Position
Hand over dorsal-ulnar aspect of the patient’s hand
Hand on anterior-lateral surface of the patient’s arm just above elbow

Movements to End Position
Shoulder flexed, abducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers extended

D2 Extension

D2 extension

Starting Position
Shoulder flexed, abducted, and externally rotated
Forearm supinated
Wrist radially deviated
Fingers extended

Hand Position
Hand placed in the patient’s palm so that the patient can grip and flex wrist to the ulnar side
Hand on posterior-medial surface of the patient’s arm just above elbow

Moving to Ending Position
Shoulder extended, adducted, and internally rotated
Forearm pronated
Wrist ulnarly deviated
Fingers flexed

Lower Extremity
D1 Flexion

D1 Flexion

Starting Position
Hip extended, abducted, and internally rotated
Ankle plantarflexed
Foot everted
Toes flexed

Hand Position
Hand on distal anterior-medial aspect of thigh
Hand on medial aspect of dorsal surface of foot

Movements to Ending Position
Hip flexed, adducted, and externally rotated
Ankle dorsiflexed
Foot inverted
Toes extended

D1 Extension

D1 extension

Starting Position
Hip flexed, adducted, and externally rotated
Ankle dorsiflexed
Foot inverted
Toes extended

Hand Position
Hand on distal posterior-lateral thigh
Hand on lateral aspect of plantar surface of the foot

Movements to Ending Position
Hip extended, abducted, and internally rotated
Ankle plantarflexed
Foot everted
Toes flexed

D2 Flexion

D2 flexion

Starting Position
Hip extended, adducted, and externally rotated
Ankle plantarflexed
Foot inverted
Toes flexed

Hand Position
Hand on distal anterior-lateral thigh
Hand on lateral aspect of dorsal surface of the foot

Movements to Ending Position
Hip flexed, abducted, and internally rotated
Ankle dorsiflexed
Foot everted
Toes Extended

D2 Extension

D2 extension

Starting Position
Hip flexed, abducted, and internally rotated
Ankle dorsiflexed
Foot everted
Toes Entended

Hand Position
Hand on distal posterior-medial thigh (wrapped around posterior aspect of femur)
Hand on medial aspect of plantar surface of the ball of the foot

Movements to Ending Position
Hip extended, adducted, and externally rotated
Ankle Plantarflexed
Foot inverted
Toes flexed

Exercise And Myositis Ossification

DESCRIPTION :

Myositis ossificans (MO) occurs when bone or bone-like tissue grows where it’s not supposed to. It most commonly happens in your muscle after an injury — like when you get hit hard in the thigh during a soccer game or maybe after a car or bicycle accident.Myositis ossificans comprises two syndromes characterized by heterotopic ossification (calcification) of muscle.About 80 percent of the time, these bony growths develop in the muscles of your thigh or upper arm.

CLASSIFICATION

strenghening ex

In the first, and by far most common type, nonhereditary myositis ossificans, calcifications occur at the site of injured muscle, most commonly in the arms or in the quadriceps of the thighs.
The term myositis ossificans traumatica is sometimes used when the condition is due to trauma. Also known as Myositis ossificans circumscripta is another synonym of myositis ossificans traumatica refers to the new extraosseous bone that appears after trauma.
The second condition, myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva) is an inherited affliction, autosomal dominant pattern, in which the ossification can occur without injury, and typically grows in a predictable pattern. Although this disorder can be passed to offspring by those afflicted with FOP, it is also classified as nonhereditary, as it is most often attributed to a spontaneous genetic mutation upon conception.

CAUSES

icing
Ice Pack Applied in Painful Area

Myositis ossificans usually occurs where a person has experienced a single traumatic injury, such as sustaining a hit while playing football or soccer that causes a deep muscle bruise.

It can also happen when there is a repetitive injury to the same area, such as in the thighs of horseback riders.

Sports injuries or accidents usually initiate MO. Adolescents and young adults in their 20s are most likely to develop MO. It’s rare for children age of 10 and under to get the condition. People who have paraplegia are also prone to develope MO, but usually with no evidence of trauma.

SIGNS & SYMPTOMS

Unlike other typical muscle strains or injuries, people with myositis ossificans may notice that their pain worsens with time instead of getting better.
Someone with this condition may also notice changes in the affected muscle, including:

Warmth
Swelling
A lump or bump
Decreased range of motion
Tenderness

DIAGNOSIS

If it has been at least 2–3 weeks since the pain or other symptoms started, the doctor may order some imaging tests to look for evidence of bone growth in the soft tissue.
Your doctor may also order other imaging tests. These may include a diagnostic ultrasound, MRI, CT, or bone scan.

X-ray: It can be difficult to diagnose myositis ossificans in the early stages with just an X-ray. Most X-rays will not show up any abnormalities in the first 2–3 weeks following the injury but will show changes after 3–4 weeks.

Ultrasound: Ultrasounds use sound waves to look at the soft tissues. They are one early diagnostic test that can be used to look for the changes associated with myositis ossificans. Ultrasonography depends on the ability of the person reading the scans, so many doctors do not often recommend it as the first test.

CT scan: Doctors can usually see the early development of bone tissue in soft tissues. However, it is not 100 percent reliable, and if a doctor suspects that someone has myositis ossificans, they may carry out additional testing to make the diagnosis.

Magnetic resonance imaging (MRI): An MRI is a preferred method of looking at soft tissue growths. A doctor may still order additional tests to compare and confirm a diagnosis.

A biopsy of the growth may also be taken and evaluated in a lab.

 

MANAGEMENT :

laser therapy
Physiotherapy Treatment

Rest
Immobilization
Anti-inflammatory drugs
physiotherapy management
surgical debridement

Myositis ossificans usually resolves on its own.You may be able to prevent MO by properly taking care of your injury in the first two weeks. You can reduce inflammation by immobilizing the affected muscle with slight compression, icing, and elevation.

Rest: You don’t have to just lie there, but don’t stress the muscle too much.
Ice: Apply for 15 to 20 minutes at a time.
Compression: Wrap an elastic bandage firmly around your injury to minimize swelling and keep the area stable.
Elevation: Raise your injured limb above the level of your heart to help drain excess fluid from the area.
Non-painful stretching and strengthening: Gently stretch the affected muscle and start doing strengthening exercises when your doctor says it’s OK. Don’t perform any movements to the point of pain.

Medications and orthotics

You can take nonsteroidal anti-inflammatory drugs like ibuprofen (Advil) or naproxen (Aleve) to reduce pain and swelling. Topical treatments like Biofreeze or Tiger Balm can also helps to ease pain.

When your pain and movement allow you to get back to sports, wear some padding or other protection on the injured muscle to prevent additional damage.

Physiotherapy management of myositis ossificans includes

Rest

Icing the injury

Pulsed Ultra sound and phonophoresis

Maintain available range of motion but avoid stretching and massage, until maturation.
Passive range of motion and mobilization: This is when a person or machine moves your body parts for you.
Active range of motion and mobilization: This is when you use your own strength to move your body parts.

Iontophoresis with 2 % acetic acid solution.

Extra corporeal shock wave therapy

Surgical Management

Growth should not be removed in premature stage as it will likely reoccur. The ossification becomes exuberant, infiltrates beyond the original site, and compresses the soft tissues around beyond hope of repair. When after serial x-rays the mass is dense, well delineated, and at a stand still, it may be safely removed. It may be possible to prevent myositis by aspirating the original haematoma.

PREVENTION

While it can be difficult to predict who will get myositis ossificans, it is important to treat every injury promptly using the R.I.C.E. method. This is:

Rest
Ice
Compression
Elevation

An athlete who sustains an injury may need to leave the game or event, especially if there is significant swelling or bruising.

Gentle stretching and range of motion exercises are also essential after an injury; myositis ossificans is more likely to affect a muscle that is not being used.

Doing too much too soon can worsen MO. But not working to recover your range of motion when the doctor says it’s safe may make your pain and stiffness last longer.

Frankele’s Co-Ordination Exercise in Ataxia :

 

FRENKLE ‘S CO-ORDINATION EXERCISE FOR CEREBELLER ATAXIA

CEREBELLUM
Cerebellum And Brain 

Definition of coordination Exercises:

It is the ability to execute smooth, accurate, controlled motor responses (optimal interaction of muscle function).

Coordination is the ability to select the right muscle at the right time with proper intensity to achieve proper action.
Coordinated movement is characterized by appropriate speed, distance, direction, timing and muscular tension.
It is the process that results in activation of motor units of multiple muscles with simultaneous inhibition of all other muscles in order to carry out a desired activity

Importance of the cerebellum in coordination ;

The cerebellum is the primary center in the brain for coordination of movement.

Components of coordinated movement:

Volition: is the ability to initiate,maintain or stop an activity or motion.
Perception:in tact proprioception and subcortical centres to integrate motor impulses and the sensory feedback. When proprioception is affected it is compensated with visual feedback.
Engramformation:is the neurologica lmuscular activity developed in the extrapyramidal system. Research proved that high repetitions of precise performance must be performed in order to develop an engram
.
Types of coordination:

1) Fine motor skills:

Require coordinated movement of small muscles (hands, face).
Examples: include writing, drawing, buttoning a shirt, blowing bubbles

2) Gross motor skills:

Require coordinated movement of large muscles or groups of muscles (trunk, extremities).
Examples: include walking, running, lifting activities.

3)Hand-eye skills:

The ability of the visual system to coordinate visual information. Received and then control or direct the hands in the accomplishment of a task .
Examples : include catching a ball,sewing,computer mouse use.

Causes of coordination impairments , Causes of Ataxia

Degeneration, damage or loss of nerve cells in the cerebellum, which is that part of the brain that controls muscle coordination, causes ataxia. The cerebellum comprises of two small ball-shaped folded tissues present at the base of the brain near the brainstem. Diseases which damage the spinal cord and peripheral nerves which connect the cerebellum to the muscles can also cause ataxia
.
Other causes of ataxia include:

Stroke is a condition where the blood supply to a part of the brain gets severely diminished or interrupted, which deprives the brain tissue of oxygen and other nutrients resulting in death of brain cells.

Trauma or injury to the head, which causes damage to the brain or spinal cord, can cause sudden-onset ataxia (acute cerebellar ataxia).

Chickenpox can result in a complication in the form of Ataxia; although this is not common. Ataxia can appear during the healing stages of the infection and persist for days to weeks and gradually resolve over the time.

Transient ischemic attack (TIA) is caused by a temporary reduction in blood supply to a part of the brain. Majority of the TIAs last only for a few minutes. Some of the symptoms of TIA include ataxia, which is temporary.

Multiple sclerosis is a chronic, potentially debilitating medical condition, which affects the central nervous system.

Cerebral palsy consists of a group of disorders, which occurs as a result of damage to a child’s brain during its early development. It can be before, during or shortly after birth. It affects the ability to coordinate movements of the body.

Paraneoplastic syndromes are rare, degenerative disorders, which are triggered by the response of the immune system to a tumor or neoplasm. This tumor is commonly in the lungs, ovaries, lymph nodes or breast. Patient can experience ataxia many months or years before cancer is actually diagnosed.

Toxic reaction to some medications can also cause ataxia. Medicines, especially barbiturates and certain sedatives, like benzodiazepine, can cause ataxia as a side effect. Other things, which could cause toxic reactions, are heavy metal poisoning, alcohol and drug intoxication and solvent poisoning.

Any type of growth on the brain, either cancerous or noncancerous, can damage cerebellum and cause ataxia.

Deficiency of vitamin E or B-12 can also lead to ataxia.

No specific cause can be found for some adults who develop sporadic ataxia, also known as sporadic degenerative ataxia, which can be of many types, such as multiple system atrophy which is a progressive and degenerative disorder.
s

test UL
Finger to Nose Test

Examples of coordination tests:

1) In the upper limb:

A) Finger-to-nose test

The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose.Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist index finger is held in front of the patient, the patient is asked to touch the tip of the index finger to the therapist index finger.

B) Finger-to-finger test

Both shoulders are abducted to bring both the elbow extended, the patient is asked to bring both the hand toward the midline and approximate the index finger from opposing hand

C) Finger-to-doctor’s finger test

the patient alternately touch the tip of the nose and the tip of the therapist’s finger with the index finger.

D) Adiadokokinesia or dysdiadokokinesia:

The patient asked to do rapidly alternating movement e.g. forearm supination and pronation, hand tapping.

E) Rebound phenomena:

The patient with his elbow fixed, flex it against resistance. When the resistance is suddenly released the patient’s forearm flies upward and may hit his face or shoulder.

F) Buttoning and unbuttoning test.

In any of the previous tests, we may find:

Intention tremors and Decomposition of movements
Dysmetria: in the form of hypermetria or hypometria

2) In the lower limb

A) Heel-to-knee test

heel to shin test
Heel To Knee Test in Lower Limb

B) Walking along a straight line. Foot close to foot:In case of cerebellar lesion, there is deviation of gait

C) Rom-berg test: Ask the patient to stand with heels together. Swaying or loss of balance occurs while his eyes are open or closed.

General principles of coordination exercises involve:

Constant repetition of a few motor activities
Use of sensory cues (tactile, visual,proprioceptive) to enhance motor performance
Increase of speed of the activity over time
Activities are broken down into components that are simple enough to be performed correctly.
Assistance is provided when ever necessary.
The patient there fore should have a short rest after two or three repetitions,to avoid fatigue.
High repetition of precise performance must be performed for the engram to form.
When ever a new movement is trained, various inputs are given, like instruction(auditory), sensory stimulation(touch) ,or positions in which the patient can view the movement (visual stimulation) to enhance motor performance.

Therapeutic exercises used to improve coordination:

Frenkel’s exercises
Proprioceptive Neuromuscular Facilitation
Neurophysiological Basis of Developmental techniques
Sensory Integrative Therapy

FRENKEL’S CO-ORDINATION EXERCISES:

hand eye coordination
Co-ordination Exercise

Frenkel aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.

The process of learning this alternative method of control is similar to that required to learn any new exercise,

the essentials being: Concentration of the attention, Precision and Repetition

The ultimate aim is to establish control of movement so that the patient is able and confident in his ability to carry out these activities which are essential for independence in everyday life.

They are a system of slow repetitious exercises. They increase in difficulty over the time of the program. The patient watches his hand or arm movements (for example) and corrects them as needed.

Although the technique is simple, needs virtually no exercise equipment, and can be done on one’s own, concentration and some degree of perseverance is required. Research has shown that 20,000 to 30,000 repetitions may be required to produce results. A simple calculation will show that this can be achieved by doing 60 repetitions every hour for six weeks in a 16-hour daily waking period. The repetitions will take just a few minutes every hour.

The brain as a whole learns to compensate for motor deficits in the cerebellum (or the spinal cord where applicable). If the ataxia affects say, head movements, the patient can use a mirror or combination of mirrors to watch their own head movements.

History

Best Physiotherapy Exercises for In-Coordination–Frenkel’s Exercises :

Frenkel Exercises are a series of motions of increasing difficulty performed by ataxic patients to facilitate the restoration of coordination. Frenkel’s exercises are used to bring back the rhythmic, smooth and coordinated movements.

 

Dr. H S Frenkel was a physician from Switzerland who aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.

Frenkel Exercises were originally developed in 1889 to treat patients of tabes dorsalis and problems of sensory ataxia owing to loss of proprioception. These exercises have been applied in the treatment of individuals with ataxia, in particular cerebellar ataxia. The exercises are performed in supine, sitting, standing and walking. Each activity is performed slowly with the patient using vision to carefully guide correct movement. These exercises require a high degree of mental concentration and effort. For those patients with the prerequisite abilities, they may be helpful in regaining control of movement through cognitive compensation strategies. Patients with partial sensation can progress to practicing exercises with eyes closed. The main principles of Frenkel exercises are the following:

Concentration or attention
Precision
Repetition

This program consists of a planned series of exercises designed to help patient compensate for the inability to tell where the arms and legs are- in space without looking.

1. Exercises are designed primarily for coordination; they are not intended for strengthening.
2. Commands should be given in an event, slow voice; the exercises should be done to counting.
3. It is important that the area is well lit and that patients are positioned so that they can watch the movement of their legs.
4. Avoid fatigue. Perform each exercise not more than four times. Rest between each exercise.
5. Exercises should be done within normal range of motion to avoid over-stretching of muscles.
6. The ?rst simple exercises should be adequately performed before progressing to more dif?cult patterns.

General Instructions for frenkel exercises

Exercises can be performed with the part supported or unsupported, unilaterally or bilaterally.
They should be practiced as smooth, timed movements, performed at a slow, even tempo by counting out loud.
Consistency of performance is stressed and a specified target can be used to determine range.
Four basic positions are used: lying, sitting, standing and walking.
The exercises progress from postures of greatest stability (lying, sitting) to postures of greatest challenge (standing, walking).
As voluntary control improves, the exercises progress to stopping and starting on command, increasing the range and performing the same exercises with eyes closed.
Concentration and repetition are the keys to success.

Frenkel exercises for lower limb

Exercises for the legs in lying

Flex and extend one leg by the heel sliding down a straight line on the table.
Abduct and adduct hip smoothly with knee bent and heel on the table.
Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table.
Flex and extend hip and knee with heel off the table.
Flex and extend both the legs together with the heel sliding on the table.
Flex one leg while extending the other.
Flex and extend one leg while taking the other leg into abduction and adduction.
Heel of one limb to opposite leg (toes, ankle, shin, patella).
Heel of one limb to opposite knee, sliding down crest of tibia to ankle.

Whether the patient slides the heels or lifts it off the bed he has to touch it to the marks indicated by the patient on the plinth. The patient may also be told to place the heel of one leg on various points of the opposite leg under the guidance of the therapist.
Exercises for the legs in Sitting

One leg is stretched to slide the heel to a position indicated by a mark on the floor.
The alternate leg is lifted to place the heel on the marked point.
From stride sitting posture patient is asked to stand and then sit.
Rise and sit with knees together.
Sitting hip abduction and adduction.

Exercises for the legs in Standing

In stride standing weight is transferred from one foot to other.
Place foot forward and backward on a straight line.
Walk along a winding strip.
Walk between two parallel lines
Walk sideways by placing feet on the marked point.
Walk and turn around
Walk and change direction to avoid obstacles.

 

Frenkel exercises for upper limb :

Similar exercises can be devised for the upper limb wherein the patient may be directed to place the hand on the various points marked on the table or wall board to improve coordination of all the movements in the upper limb.
Some examples of Frankel exercises of upper limb in sitting position

Have patient sit in front of a table and place a number of objects on the table. The patient then touches each object with the right hand and then the left hand.
The patient flexes the right shoulder to 90 degree with elbow and wrist extended. The patient then takes his or her right index finger and touches the tip of his or her nose. This exercise is then repeated with the left hand. The exercise is performed alternating right and left index finger.
The patient taps bilateral hands on bilateral thighs while alternating palmer and dorsal surfaces as fast as possible.

Certain diversional activities such as building with toy bricks or drawing on a black board, buttoning, combing, writing, typing are some of the activities that also improves the coordination.

 

Knee Joint And It’s Importance in India :

KneeJoint
Knee Joint Anatomy

Knee Joint : It’s Important :

The knee joint is one of the strongest and most important joints in the human body. It allows the lower leg to move relative to the thigh while supporting the body’s weight. Movements at the knee joint are essential to many everyday activities, including walking, running, sitting and standing.
The knee, also known as the tibiofemoral joint, is a synovial hinge joint formed between three bones: the femur, tibia, and patella. Two rounded, convex processes (known as condyles) on the distal end of the femur meet two rounded, concave condyles at the proximal end of the tibia.
The patella lies in front of the femur on the anterior surface of the knee with its smooth joint-forming processes on its posterior surface facing the femur.
The joint-forming surfaces of each bone are covered in a thin layer of hyaline cartilage that gives them an extremely smooth surface and protects the underlying bone from damage. Between the femur and tibia is a figure-eight-shaped layer of tough, rubbery fibrocartilage known as the meniscus. The meniscus acts as a shock absorber inside the knee to prevent the collision of the leg bones during strenuous activities such as running and jumping.

KneeJointPain
Knee Joint Pain

As with all synovial joints, a joint capsule surrounds the bones of the knee to provide strength and lubrication. The outer layer of the capsule is made of fibrous connective tissue continuous with the ligaments of the knee to hold the joint in place. Oily synovial fluid is produced by the synovial membrane that lines the joint capsule and fills the hollow space between the bones, lubricating the knee to reduce friction and wear.
Tendons connect the knee bones to the leg muscles that move the knee joint. Ligaments join the knee bones and provide stability to the knee:

The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the tibia sliding forward on the femur).
The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur).
The medial and lateral collateral ligaments prevent the femur from sliding side to side.
Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia.
Numerous bursae, or fluid-filled sacs, help the knee move smoothly

* ANATOMY:-

KneeJoint
Knee Joint View

Bones:-

The femur (thigh bone), tibia (shin bone), and patella (kneecap) make up the bones of the knee. The knee joint keeps these bones in place.

The patella is a small, triangle shaped bone that sits at the front of the knee, within the quadriceps muscle. It is lined with the thickest layer of cartilage in the body because it endures a great deal of force.

Cartilage:-

There are two types of cartilage in the knee:

Meniscus: these are crescent-shaped discs that act as a cushion, or “shock absorber” so that the bones of the knee can move through their range of motion without rubbing directly against each other. The menisci also contain nerves that help improve balance and stability and ensure the correct weight distribution between the femur and tibia.

The knee has two menisci:

medial – on the inner side of the knee, this is largest of the two
lateral – on the outer side of the knee
Articular cartilage: found on the femur, the top of the tibia, and the back of the patella; it is a thin, shiny layer of cartilage. It acts as a shock absorber and helps bones move smoothly over one another.

Ligaments:-

Ligaments are tough and fibrous tissues; they act like strong ropes to connect bones to other bones, preventing too much motion and promoting stability. The knee has four:

ACL (anterior cruciate ligament) – prevents the femur from sliding backward on the tibia, and the tibia from sliding forward on the femur.
PCL (posterior cruciate ligament) – prevents the femur from sliding forward on the tibia, or the tibia from sliding backward on the femur.
MCL (medial collateral ligament) – prevents side to side movement of the femur.
LCL (lateral collateral ligament) – prevents side to side movement of the femur.

Tendons:-

These tough bands of soft tissue provide stability to the joint. They are similar to ligaments, but instead of linking bone to bone, they connect bone to muscle. The largest tendon in the knee is the patellar tendon, which covers the kneecap, runs up the thigh, and attaches to the quadriceps.

Muscles:-

Although they are not technically part of the knee joint, the hamstrings and quadriceps are the muscles that strengthen the leg and help flex the knee.

The quadriceps are four muscles that straighten the knee. The hamstrings are three muscles at the back of the thigh that bend the knee.

The gluteal muscles – gluteus medius and minimus – also known as the glutes are in the buttocks; these are also important in positioning the knee.

Joint capsule:-

The joint capsule is a membrane bag that surrounds the knee joint. It is filled with a liquid called synovial fluid, which lubricates and nourishes the joint.

Bursa:-

There are approximately 14 of these small fluid-filled sacs within the knee joint. They reduce friction between the tissues of the knee and prevent inflammation.

* Knee Conditions:-

(1)Chondromalacia patella (also called patellofemoral syndrome): Irritation of the cartilage on the underside of the kneecap (patella), causing knee pain. This is a common cause of knee pain in young people.
(2)Knee osteoarthritis: Osteoarthritis is the most common form of arthritis, and often affects the knees. Caused by aging and wear and tear of cartilage, osteoarthritis symptoms may include knee pain, stiffness, and swelling.
(3)Knee effusion: Fluid buildup inside the knee, usually from inflammation. Any form of arthritis or injury may cause a knee effusion.
(4)Meniscal tear: Damage to a meniscus, the cartilage that cushions the knee, often occurs with twisting the knee. Large tears may cause the knee to lock.
(5)ACL (anterior cruciate ligament) strain or tear: The ACL is responsible for a large part of the knee’s stability. An ACL tear often leads to the knee “giving out,” and may require surgical repair.
(6)PCL (posterior cruciate ligament) strain or tear: PCL tears can cause pain, swelling, and knee instability. These injuries are less common than ACL tears, and physical therapy (rather than surgery) is usually the best option.
(7)MCL (medial collateral ligament) strain or tear: This injury may cause pain and possible instability to the inner side of the knee.
(8)Patellar subluxation: The kneecap slides abnormally or dislocates along the thigh bone during activity. Knee pain around the kneecap results.
(9)Patellar tendonitis: Inflammation of the tendon connecting the kneecap (patella) to the shin bone. This occurs mostly in athletes from repeated jumping.
(10)Knee bursitis: Pain, swelling, and warmth in any of the bursae of the knee. Bursitis often occurs from overuse or injury.
(11)Baker’s cyst: Collection of fluid in the back of the knee. Baker’s cysts usually develop from a persistent effusion as in conditions such as arthritis.
(12)Rheumatoid arthritis: An autoimmune condition that can cause arthritis in any joint, including the knees. If untreated, rheumatoid arthritis can cause permanent joint damage.
(13)Gout: A form of arthritis caused by buildup of uric acid crystals in a joint. The knees may be affected, causing episodes of severe pain and swelling.
(14)Pseudogout: A form of arthritis similar to gout, caused by calcium pyrophosphate crystals depositing in the knee or other joints.
(15)Septic arthritis: An infection caused by bacteria, a virus, or fungus inside the knee can cause inflammation, pain, swelling, and difficulty moving the knee. Although uncommon, septic arthritis is a serious condition that usually gets worse quickly without treatment.

* Prevention of knee injuries:-
The following tips may help prevent common knee injuries:

Warm up by walking and stretching gently before and after playing sports.
Keep the leg muscles strong by using stairs, riding a stationary bicycle, or working out with weights.
Avoid sudden changes in the intensity of exercise.
Replace worn out shoes. Choose ones that fit properly and provide good traction.
Maintain a healthy weight to avoid added pressure on the knees.
Always wear a seatbelt.
Use knee guards in sports where knees could get injured.
Maintaining strong, flexible leg muscles and seeking prompt medical attention for all knee injuries is essential to assure accurate diagnosis and appropriate treatment of the injury. Additionally, keeping the supporting leg muscles strong and practicing injury prevention will help keep the knee healthy across the lifespan.

* strengthening exercise for knee:-

 

(1)Mini or partial squats with a chair or at a counter (quadriceps):

Holding on to a chair or stable surface, with knees about shoulder width apart and pointing forward, slightly bend hips and knees as if sitting down onto a chair, and then slowly stand back up. Repeat 10 to 12 times.

(2)Standing hamstring curls (hamstrings):

Holding on to the back of a chair or stationary surface, without moving hip, bend knee as far as possible, bringing your heel up towards your buttocks. Do 10 to 12 reps on each leg.

KneeQuadricepsExercise
Knee Quadriceps Muscle Active Exercise

(3)Marching in place (hip flexors and a good balance exercise):

On your own or while holding on to the back of a chair or stationary object, take alternating steps in place, bringing knee up to a comfortable height. Strive for 60 seconds of marching.

(4)Heel raises (calf muscle):

Holding on to back of a chair or stable surface, rise up on toes, lifting heels off ground and then slowly lower back down. Do 10 to 12 reps.

(5)Quad sets:

This simple exercise may be done on the floor with or without a pillow under your knee. Sit with your legs out in front of you and your knees completely straight (lean against a wall or back on your hands). Focus on contracting your quadriceps muscle and holding it as tight as possible for several seconds; relax and repeat 10 times. Repeat several times a day if your knees actively ache.

(6)Straight leg raises:

In the same starting position as the quad sets, sit with your right leg (do one at a time) straight in front of you with your toes pulled towards the knee. (If this is too difficult you may also do these lying on your back to start.) Keep your left leg bent with your foot on the floor. Contract your quads on your right leg, lift your foot about 12 inches off the ground and hold it up for 5 seconds; slowly lower it back down and repeat 10 times. Switch legs.

(7)Wall slides with ball squeeze:

Stand with your back against the wall and your feet shoulder width apart. Hold a small (soccer ball size) inflated ball between your knees. Slowly slide down the wall by bending your knees and lowering yourself (knees should form a right angle with quads parallel to the floor and shins perpendicular to the floor). Hold 5 to 10 seconds and slowly return to starting position. Repeat 10 or more times.

(8)Clams:

Lie on your side with your hip and knee bent to approximately a 90-degree angle, with feet together. While keeping your ankles together, raise your top knee up about 12 inches from the other in a clamshell type motion. Repeat 10 to 25 times and switch sides.

(9)Glute bridges:

Lie on your back with both knees bent at about a 90-degree angle with your feet on the floor. Tighten your buttocks as you lift your bottom off the floor as high as you can without arching your back; shoulders, hips and knees should align. Hold this position as you extend one leg up while keeping knees aligned; hold 3 to 5 seconds and lower. Repeat on the opposite side. Perform 10 to 25 reps per side.

Include one or more of these exercises along with or instead of your usual leg routine two to three times a week for stronger legs and healthier, pain-free knees.

* famous surgery for knee joint :-
(1)Arthroscopy:-

In a knee arthroscopy, a surgeon will look inside the knee joint, repair torn ligaments and remove damaged parts. Two or three very small incisions are made on the front of the knee. A fiber optic camera is inserted through one incision. A surgical instrument is inserted through the other incision.

The surgeon can then examine and repair the knee. Knee scopes are most often performed for meniscal tears (torn cartilage). A degenerative tear can be debrided (cleaned up) during the arthroscopy. A traumatic sports-related tear can be debrided or repaired via arthroplasty.

Because of the minimal soft tissue damage resulting from from an arthroscopy, recovery is relatively quick. It is a relatively easy surgery and most patients go home immediately after the scope. Patients will typically be able to resume normal activity and return to work within two or three weeks. The knee will be swollen for less than a week.

(2)Osteotomy:-

Knee osteotomy is a surgical procedure in which the surgeon removes or adds a wedge of bone to the top of your tibia (shinbone) or the bottom of your femur (thighbone). This provides a less worn area of articular cartilage to the weight bearing part of the joint.

Osteotomy is typically recommended for those with arthritis damage in just one area of the knee. Arthritis on just one side of the knee can cause the knee to bow inward (valgus deformity) or outward (varus deformity). This can be corrected by the removal or addition of a wedge of bone. (Traumatic injury or even birth defects can also cause misalignment for which osteotomy is an appropriate surgical intervention.)

Many patients who undergo knee osteotomy will eventually need a total knee replacement. The osteotomy will buy them a varying amount of time before the need for total joint replacement becomes necessary.

* importance of knee joint :-
We need our knees to run, walk, squat. With research suggesting our bones are weaker than those of Westerners, here’s a quiz to test how well you are caring for your ‘hinges’
Walking, running, climbing, dancing — the knees bear the brunt of every move we make throughout our lives. The main hinge between the ground and the body, knees bring together the femur (thigh bone), tibia (shin bone), fibula (next to tibia) and kneecap, and work as wheels that keep you going.

We use knee joint daily But We Do Not Take Care Of This Joint That’s Why Osteoarthritis is more commmon in india , Here we give basic detail of knee joint and exercise of knee joint, common knee surgeries and Overview and Related Muscle Detail

 

Oral SubMucous Fibrosis And Exercise :

ORAL SUB MUCOUS FIBROSIS :

DEFINATION:

SMF2
Patient With SMF

Oral submucous fibrosis is characterized as the unending, tricky ailment influencing the oral pit and here and there pharynx, albeit at times went before or potentially connected with vesicle arrangement and is constantly connected with juxtaepithelial fiery response took after by fibro versatile changes in the lamina propria with epithelial decay prompting firmness of oral pit prompting trismus and powerlessness to eat.

Oral submucous fibrosis is an interminable crippling and an all around perceived possibly threatening condition related with areca nut biting, an element of betel quid and is pervasive in South Asian populace. Pathogenesis isn’t yet settled however is accepted to be because of multifactorial causes; consequently the treatment of oral submucous fibrosis proposes a noteworthy test for oral doctors.

ETIOLOGY AND PATHOPHYSIOLOGY:

The pathogenesis of the illness isn’t entrenched, however the reason for OSF is accepted to be multifactorial.

Various variables may trigger the infection procedure by causing a juxtaepithelial fiery response in the oral mucosa. Components incorporate are areca nut biting, ingestion of chilies, hereditary and immunologic procedures, wholesome inadequacies and different variables.

Areca Nut (Betel Nut) Chewing:

The areca nut segment of betel quid assumes a noteworthy part in the pathogenesis of OSF 15. Betel nut is much of the time utilized as a psychotropic and antihelminthic operator and utilized as an after feast digestant which is taken to ease stomach inconvenience.

Smoking and liquor utilization alone, propensities basic to areca nut chewers, have been found to have no impact in the advancement of OSF. The most grounded confirm in regards to the etiology of OSF is with the propensity for areca nut biting.

Areca nut shape might be accessible in thefollowing structure:

Supari + Tobacco

Supari + Pan+ Tobacco

Supari + Pan + Pan masala

Skillet Parag/Pan masala

Supari + Pan + Lime

Supari-Roasted/Raw Areca nut

Part of areca nut in pathogenesis of OSF:

Arecoline, a dynamic alkaloid found in betel nuts. Animates fibroblasts to build creation of collagen by 150%.

To lift the mRNA and protein articulation of cystatin C, a nonglycosylated fundamental protein reliably up-directed the assortment of fibrotic illnesses, in a measurement subordinate way in people with OSF.

Areca nuts have likewise been appeared to have a high copper substance, and biting areca nuts for 5-30 minutes altogether increments solvent copper levels in oral liquids. This expanded level of solvent copper underpins the speculation as a starting element in people with OSF.

Healthful Deficiencies:

Press insufficiency frailty, vitamin B complex inadequacy and lack of healthy sustenance are advancing variables that unsettle the repair of the excited oral mucosa, prompting damaged recuperating and resultant scarring.

The resultant atrophic oral mucosa is more defenseless to the impacts of chilies and betel nuts. Mucosal changes like those in vitamin B and iron insufficiency are found in oral sub mucosal fibrosis.

Chillies:

The part of chillies ingestion in the pathogenesis of OSF is disputable.

A touchiness response to chilies is accepted to add to OSF.

Hereditary and Immunologic Processes:

A hereditary segment is thought to be engaged with OSF Patients with expanded recurrence of HLA-A10, HLA-B7, and HLA-DR3.

ExerciseinSMF
Measurement Of Mouth Opening

Phases OF OSF:

Stage 1:

Stomatitis incorporates erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation, and mucosal petechia.

Stage 2:

Fibrosis happens in cracked vesicles and ulcers when they mend, which is the sign of this stage.

Early sores show whitening of the oral mucosa.

More established sores incorporate vertical and round unmistakable sinewy groups in the buccal mucosa and around the mouth opening or lips, bringing about a mottled, marble like appearance of the mucosa in view of the vertical, thick, stringy groups running in a whitening mucosa. Particular discoveries incorporate the accompanying:

Decrease of the mouth opening (trismus).

Solid and little tongue.

Whitened and rough floor of the mouth.

Fibrotic and depigmented gingiva.

Rubbery delicate sense of taste with diminished portability.

Whitened and atrophic tonsils.

Contracted budlike uvula.

Sinking of the cheeks, not comparable with age or nutritious status.

Stage 3:

Screech of OSF are as per the following:

Leukoplakia is precancerous and is found in over 25% of people with OSF.

Discourse and hearing deficiencies may happen in view of inclusion of the tongue and the eustachian tubes.

Manifestations:

Xerostomia.

Intermittent ulceration.

Torment in the ear or deafness.

Nasal pitch of voice.

Confinement of the development of the delicate sense of taste.

Diminishing and hardening of the lips.

Pigmentation of the oral mucosa.

Dryness of the mouth and consuming sensation.

Diminished mouth opening and tongue bulge.

CAUSES:

Immunological ailments.

Outrageous climatic conditions.

Delayed insufficiency to iron and vitamins in the eating regimen.

DIFFERENTIAL DIAGNOSIS:

Oral appearances of scleroderma

Oral appearances of Plummer Vinson disorder (Iron lack Anemia).

Examination:

Finish Hemogram

Toludine blue test

Biopsy :- Incisional biopsy

Immunofluorescent test:

a) Direct b) Indirect

Administration AND PREVENTION:

The treatment of patients with OSF relies upon the level of clinical contribution. On the off chance that the malady is identified at a beginning period, suspension of the propensity is adequate. Most patients with OSMF give moderateto-serious arranging. Direct to-serious arranging of OSF is irreversible. Medicinal treatment is symptomatic and gone for enhancing mouth developments.

Not to devour areca nut and other incessant aggravation, for example, hot and zesty sustenance including chiles.

Guidance green verdant vegetables.

Organization of Vit. A, B complex and high protein consume less calories.

Organization of Antoxid OD for 6 – two months.

Organization of Lycored OD for 6 two months.

Keeping up legitimate oral cleanliness.

Supplementing the eating regimen with nourishments rich in vitamins A, B complex, and C and iron.

Swearing off hot liquids like tea, espresso.

Swearing off liquor.

Utilizing a dental specialist to round off sharp teeth and concentrate third molars.

SURGICAL MANAGEMENT:

Surgical treatment is shown in patients with extreme conditions. These incorporate:-

Basic extraction of the stringy groups: Excision can bring about contracture of the tissue and intensification of the condition.

Split-thickness skin joining following respective temporalis myotomy or coronoidectomy: Trismus related with OSF might be because of changes in the temporalis ligament auxiliary to OSF; subsequently, skin unions may assuage.

Nasolabial folds and lingual pedicle folds: Surgery performed just in patients with OSF in whom the tongue isn’t included.

PHYSIOTHERAPY MANAGEMENT:

smf3
Exercise In Oral Sub Mucous Fibrosis

Muscle extending practices for the mouth might be useful to anticipate advance restrictions of mouth opening strong mouth opening has been attempted with mouth choke and non-cyclic surgical screw.

Diathermy: Microwave diathermy appear to be better than short wave, in light of the fact that specific warming of juxtaepitheliel connective tissue is conceivable it acts by physio fibrinolysis of groups.

Ultrasound: Ultra sound selectivity bring the temperature up in some all around aggregated territories. Ultrasound turns out to be an effective profound warming methodology.

Trigeminal Neuralgia : Overview

Presentation :-

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Trigeminal Nerve

Trigeminal neuralgia is a ceaseless torment condition that influences the trigeminal nerve, which conveys sensation from your face to your mind. In the event that you have trigeminal neuralgia, even mellow incitement of your face —, for example, from brushing your teeth or putting on cosmetics — may trigger a jar of unbearable agony.

You may at first experience short, mellow assaults. Yet, trigeminal neuralgia can advance and cause longer, more-visit episodes of burning agony. Trigeminal neuralgia influences ladies more frequently than men, and it will probably happen in individuals who are more established than 50.

On account of the assortment of treatment alternatives accessible, having trigeminal neuralgia doesn’t really mean you’re bound to an existence of agony. Specialists for the most part can adequately oversee trigeminal neuralgia with drugs, infusions or surgey

Manifestation:-

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Trigeminal Neuralgia

Representation indicating branches of the trigeminal nerve

Trigeminal neuralgia manifestations may incorporate at least one of these examples:

(1)Episodes of serious, shooting or Tabbing torment that may feel like an electric stun

(2)Spontaneous assaults of torment or assaults activated by things, for example, touching the face, biting, talking or brushing teeth

Episodes of torment enduring from a couple of moments to a few minutes

(3)Episodes of a few assaults enduring days, weeks, months or longer — a few people have periods when they encounter no torment

Consistent hurting, consuming feeling that may happen before it advances into the fit like torment of trigeminal neuralgia

(4)Pain in territories provided by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less frequently the eye and brow

Torment influencing one side of the face at any given moment, however may once in a while influence the two sides of the face

(5)Pain centered in one spot or spread in a more extensive example

Causes:-

In trigeminal neuralgia, likewise called tic douloureux, the trigeminal nerve’s capacity is upset. For the most part, the issue is contact between an ordinary vein — for this situation, a supply route or a vein — and the trigeminal nerve at the base of your mind. This contact puts weight on the nerve and makes it glitch.

Trigeminal neuralgia can happen because of maturing, or it can be identified with different sclerosis or a comparable issue that harms the myelin sheath securing certain nerves. Trigeminal neuralgia can likewise be caused by a tumor packing the trigeminal nerve.

A few people may encounter trigeminal neuralgia because of a mind sore or different anomalies. In different cases, surgical wounds, stroke or facial injury might be in charge of trigeminal neuralgia.

Treatment:-

PhysiotherapyTrigeminal
Treatment In Trigeminal Neuralgia

The principal line of treatment is prescription.

The medication of decision is carbamazepine (Tegretol™), which disposes of or gets worthy torment help 69 percent of patients.

Baclofen (Lioresal™) is the second medication of decision and might be more viable if utilized with low-dosage carbamazepine.

Different medicines that might be compelling incorporate pimozide, phenytoin (Dilantin™), capsaicin, clonazepam (Klonopin™) and amitriptyline (Elavil™).

Surgical methods:-

(1)Percutaneous trigeminal radiofrequency rhizotomy

This method specifically decimates torment causing nerve strands while safeguarding touch filaments.

Lesioning methods incorporate radiofrequency thermocoagulation, glycerol infusion and mechanical injury. They are utilized for patients who are poor contender for real surgery.

Confusions can incorporate shortcoming in biting, facial deadness, changes in tearing or salivation and, less frequently, corneal ulcers, serious throbbing torment (anesthesia dolorosa) or meningitis.

(2)Microvascular decompression of the trigeminal nerve

This surgical system includes microsurgery to move the vessel, causing pressure far from the trigeminal nerve.

Help is frequently extensive; however the rate of facial deadness is considerably less than in particular rhizotomy and anesthesia dolorosa does not happen.

The methodology is best for patients more youthful than 65 with no critical medicinal or surgical hazard factors.

Conceivable intricacies incorporate asceptic meningitis, with head and neck solidness; major neurological issues, including deafness and facial nerve brokenness; mellow tactile misfortune; cranial nerve paralysis, causing twofold vision, facial shortcoming, hearing misfortune; and, on extremely uncommon events, postoperative draining and demise.

Microvascular decompression brings finish help to 75 percent to 80 percent of patients. The repeat rate is 5 percent to 17 percent.

Physiotherapy Management:-

*The points of physiotherapy administration:-

To diminish torment and practical impediment, and to enhance personal satisfaction.

Medicines incorporate the utilization of electro-physical specialist to ease torment amid intense beginning.

Manual treatment, practice treatment for Temporomandibular Joint (TMJ) also

as self-knead for facial muscles can likewise reestablish patients’ capacities.

Transcutaneous electrical nerve incitement (TENS) as of now is one of the

most regularly utilized types of electroanalgesia

Interferential Therapy(IFT)

Interferential treatment (IFT) is another electro-physical methodology generally utilized

for torment administration in clinical circumstances. IFT is the utilization of substituting

medium recurrence current (4,000 Hz) with abundancy adjusted at low

recurrence (0– 250 Hz). A few hypothetical physiological instruments, for example,

the door control hypothesis, expanded course, slipping agony concealment,

square of nerve conduction, and fake treatment have been proposed in the writing to

bolster the pain relieving impacts of IFT diminishing torment for patients with trigeminal neuralgia by having them gotten

fifteen sessions of IFT with treatment span of thirty minutes. The force of

the motivation shifted by patient’s resistance. The outcomes recommended that

IFT could be considered as one of the electro-physical modalities in lessening

torment for trigeminal neuralgia.

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