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.
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.
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:
A lump or bump
Decreased range of motion
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.
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
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
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.
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:
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.
FRENKLE ‘S CO-ORDINATION EXERCISE FOR CEREBELLER ATAXIA
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.
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.
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
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 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.
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
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.