Sunday, 18 February 2018

ORAL SUB MUCOUSAL FIBROSIS : Physiotherapy Exercise :

Oral submucous fibrosis is defined as the chronic, insidious disease affecting the oral cavity and sometimes pharynx, although occasionally preceded and/or associated with vesicle formation and is always associated with juxtaepithelial inflammatory reaction followed by fibro elastic changes in the lamina propria with epithelial atrophy leading to stiffness of oral cavity leading to trismus and inability to eat.

Uable To open Mouth -SMF

    Oral submucous fibrosis is a chronic debilitating and a well recognised potentially malignant condition associated with areca nut chewing, an ingredient of betel quid and is prevalent in South Asian population. Pathogenesis is not yet established but is believed to be due to multifactorial causes; hence the treatment of oral submucous fibrosis postulates a major challenge for oral physicians.


The pathogenesis of the disease is not well established, but the cause of OSF is believed to be multifactorial.
    A number of factors may trigger the disease process by causing a juxtaepithelial inflammatory reaction in the oral mucosa. Factors include are areca nut chewing, ingestion of chilies, genetic and immunologic processes, nutritional deficiencies and other factors.
    Areca Nut (Betel Nut) Chewing:
    The areca nut component of betel quid plays a major role in the pathogenesis of OSF 15. Betel nut is frequently used as a psychotropic and antihelminthic agent and used as an after meal digestant which is taken to ease abdominal discomfort.
    Smoking and alcohol consumption alone, habits common to areca nut chewers, have been found to have no effect in the development of OSF. The strongest evidence regarding the etiology of OSF is with the habit of areca nut chewing.
    Areca nut form may be available in thefollowing form:
    Supari + Tobacco
    Supari + Pan+ Tobacco
    Supari + Pan + Pan masala
    Pan Parag / Pan masala
    Supari + Pan + Lime
    Supari- Roasted / Raw Areca nut
    Role of areca nut in pathogenesis of OSF:
    Arecoline, an active alkaloid found in betel nuts. Stimulates fibroblasts to increase production of collagen by 150%.
    To elevate the mRNA and protein expression of cystatin C, a nonglycosylated basic protein consistently up-regulated the variety of fibrotic diseases, in a dose-dependent manner in persons with OSF.
    Areca nuts have also been shown to have a high copper content, and chewing areca nuts for 5-30 minutes significantly increases soluble copper levels in oral fluids. This increased level of soluble copper supports the hypothesis as an initiating factor in individuals with OSF.
    Nutritional Deficiencies:
    Iron deficiency anemia, vitamin B complex deficiency and malnutrition are promoting factors that derange the repair of the inflamed oral mucosa, leading to defective healing and resultant scarring.
    The resultant atrophic oral mucosa is more susceptible to the effects of chilies and betel nuts. Mucosal changes similar to those in vitamin B and iron deficiency are seen in oral sub mucosal fibrosis.
    The role of chillies ingestion in the pathogenesis of OSF is controversial.
    A hypersensitivity reaction to chilies is believed to contribute to OSF.
    Genetic and Immunologic Processes:

    A genetic component is assumed to be involved in OSF Patients with increased frequency of HLA-A10, HLA-B7, and HLA-DR3.

Mouth Opening Device With Patient


    Stage 1:
    Stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation, and mucosal petechia.
    Stage 2:
    Fibrosis occurs in ruptured vesicles and ulcers when they heal, which is the hallmark of this stage.
    Early lesions demonstrate blanching of the oral mucosa.
    Older lesions include vertical and circular palpable fibrous bands in the buccal mucosa and around the mouth opening or lips, resulting in a mottled, marble like appearance of the mucosa because of the vertical, thick, fibrous bands running in a blanching mucosa. Specific findings include the following:
    Reduction of the mouth opening (trismus).
    Stiff and small tongue.
    Blanched and leathery floor of the mouth.
    Fibrotic and depigmented gingiva.
    Rubbery soft palate with decreased mobility.
    Blanched and atrophic tonsils.
    Shrunken budlike uvula.
    Sinking of the cheeks, not commensurate with age or nutritional status.
    Stage 3:
    Squeal of OSF are as follows:
    Leukoplakia is precancerous and is found in more than 25% of individuals with OSF.

    Speech and hearing deficits may occur because of involvement of the tongue and the eustachian tubes.


  • Xerostomia.
  • Recurrent ulceration.
  • Pain in the ear or deafness.
  • Nasal intonation of voice.
  • Restriction of the movement of the soft palate.
  • Thinning and stiffening of the lips.
  • Pigmentation of the oral mucosa.
  • Dryness of the mouth and burning sensation.
  • Decreased mouth opening and tongue protrusion.


  •   Immunological diseases.
  •   Extreme climatic conditions.
  •   Prolonged deficiency to iron and vitamins in the diet.


    Oral manifestations of scleroderma
    Oral manifestations of Plummer Vinson syndrome (Iron deficiency Anemia).


  Complete Hemogram
  Toludine blue test
  Biopsy :- Incisional biopsy
  Immunofluorescent test:
    a)  Direct   b) Indirect


The treatment of patients with OSF depends on the degree of clinical involvement. If the disease is detected at a very early stage, cessation of the habit is sufficient. Most patients with OSMF present with moderateto- severe staging. Moderate-to-severe staging of OSF is irreversible. Medical treatment is symptomatic and aimed at improving mouth movements.
    Not to consume areca nut & other chronic irritant such as hot and spicy food including chiles.
    Advice green leafy vegetables.
    Administration of Vit. A, B complex & high protein diet.
    Administration of Antoxid OD for 6 – 8 weeks.
    Administration of Lycored OD for 6-8 weeks.
    Maintaining proper oral hygiene.
    Supplementing the diet with foods rich in vitamins A, B complex, and C and iron.
    Forgoing hot fluids like tea, coffee.
    Forgoing alcohol.
    Employing a dental surgeon to round off sharp teeth and extract third molars.


Surgical treatment is indicated in patients with severe conditions. These include:-
    Simple excision of the fibrous bands: Excision can result in contracture of the tissue and exacerbation of the condition.
    Split-thickness skin grafting following bilateral temporalis myotomy or coronoidectomy: Trismus associated with OSF may be due to changes in the temporalis tendon secondary to OSF; therefore, skin grafts may relieve.
    Nasolabial flaps and lingual pedicle flaps: Surgery performed only in patients with OSF in whom the tongue is not involved.

Mouth Opening Exercise in SMF

Mouth Opening Exercise With Spoon And Device at regular Interval Like 3 Time a day.

Muscle stretching exercises for the mouth may be helpful to prevent further limitations of mouth opening forceful mouth opening has been tried with mouth gag and acyclic surgical screw.
Diathermy: Microwave diathermy seem superior to short wave, because selective heating of juxtaepitheliel connective tissue is possible it acts by physio fibrinolysis of bands.
Ultrasound: Ultra sound selectivity raise the temperature in some well accumulated areas. Ultrasound proves to be an efficient deep heating modality.

Sunday, 28 January 2018

Bicipital Tendinitis: And Physiotherapy Exercise :

Bicipital Tendinitis 
Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle.

Overview :

Biceps tendinosis is caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process. 
Inflam-mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis. 
Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff tears or SLAP (superior labrum anterior to posterior) lesions. Patients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior shoulder. Repetitive overhead motion of the arm initiates or exacerbates the symptoms. The most common isolated clinical finding in biceps tendinitis is bicipital groove point tenderness with the arm in 10 degrees of internal rotation. Local anesthetic injections into the biceps tendon sheath may be therapeutic and diagnostic. Ultrasonography is preferred for visualizing the overall tendon, whereas magnetic resonance imaging or computed tomography arthrography is preferred for visualizing the
 intraarticular tendon and related pathology. Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticosteroid injections into the biceps tendon sheath. Surgery should be considered if conservative measures fail after three months, or if there is severe damage to the biceps tendon.

Anatomy and Physiology:

Bicipital Tendinitis Anatomy 

The long head of the biceps tendon rises from the supraglenoid tubercle and the superior glenoid labrum. 
The proximal portion of the long head of the biceps tendon is extrasynovial but intra-articular.
5 The tendon travels obliquely inside the shoulder joint, across the humeral head anteriorly, and exits the joint within the bicipital groove of the humeral head beneath the transverse humeral ligament.
 The bicipital groove is defined by the greater tuberosity (lateral) and the lesser tuberosity (medial). The biceps tendon is contained in the rotator interval, a triangular area between the subscapularis and supraspinatus tendons at the shoulder (Figure 1). The rotator interval is responsible for keeping the biceps tendon in its correct location.6–8 Because the rotator interval is usually indistinguishable from the rotator cuff and capsule, lesions of the biceps tendon are usually accompanied by lesions of the rotator cuff

SLAP lesions are often present in patients with biceps tendinitis and tendinosis. The anterosuperior labrum and superior labrum are more likely to tear than the inferior portion of the labrum because they are not attached as tightly to the glenoid.9–13 Additionally, certain conditions that affect the glenohumeral joint may also involve the biceps tendon because it is intra-articular. These may include rheumatologic (e.g., rheumatoid arthritis, lupus), infectious, or other types of reactive or inflammatory conditions.


Bicipital Tendinitis 

Patients with biceps tendinitis often complain of a deep, throbbing ache in the anterior shoulder. The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in a radial distribution. 
This makes it difficult to distinguish from pain that is secondary to impingement or tendinitis of the rotator cuff, or cervical disk disease. Pain from biceps tendinitis usually worsens at night, especially if the patient sleeps on the affected shoulder.
Repetitive overhead arm motion, pulling, or lifting may also initiate or exacerbate the pain.9 The pain is most noticeable in the follow-through of a throwing motion.3 Instability of the tendon may present as a palpable or audible snap when range of motion of the arm is tested.

Rupture of the biceps tendon is one of the most common musculotendinous tears. If the biceps has ruptured, patients will describe an audible, painful popping, followed by relief of symptoms. The anterior shoulder may be bruised, with a bulge visible above the elbow as the muscle retracts distally from the rupture point. Risk factors of biceps rupture include a history of rotator cuff tear, recurrent tendinitis, contralateral biceps tendon rupture, rheumatoid arthritis, age older than 40 years, and poor conditioning.9 If a patient has a feeling of popping, catching, or locking in the shoulder, a SLAP lesion may be present. This usually occurs after trauma, such as a direct blow to the shoulder, a fall on an outstretched arm, or repetitive overhead motion in athletes.

The most common finding of biceps tendon injury is bicipital groove point tenderness.


Many provocative tests (i.e., Yergason, Neer, Hawkins, and Speed tests) have been developed to isolate pathology of the biceps tendonhowever, because these tests create impingement underneath the coracoacromial arch, it is difficult to rule out concomitant rotator cuff lesions. 
The Yergason test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance18 (Figure 2). The test is considered positive if pain is referred to the bicipital groove. 

The Neer test involves internal rotation of the arm while in the forward flexed position16 (Figure 3). If the patient experiences pain, it is a positive sign of impingement syndrome.

During the Hawkins test, the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position19 (Figure 4). With the arm supported, the humerus is rotated internally. The test is positive if bicipital groove pain is present.

Speed test, the patient tries to flex the shoulder against resistance with the elbow extended and the forearm supinated9,20 (Figure 5). A positive test is pain radiating to the bicipital groove. If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinitis or tendinosis.

Advantages and Disadvantages of Radiologic Imaging Studies in the Evaluation of Biceps Tendinitis


Arthrography (used with MRI or CT to visualize the joint capsule and glenoid labrum)
CT arthrography shows biceps tendon subluxations, ruptures, dislocations, and SLAP lesion
MRI arthrography is preferable for diagnosing biceps lesions and SLAP lesions14 because the agreement between MRI and arthroscopy for biceps lesions is only 37 percent and 60 percent for rotator cuff lesions
Filling of the biceps tendon sheath is unreliable
Sharp images of the tendon may be lost

Ionizing radiation
Bicipital groove view radiography
Shows the width and medial wall angle of the bicipital groove, spurs in the groove, and supertubercular bone spur or ridge
Does not show possible intra-articular disorders of the labrum (soft tissue injuries)

Excellent evaluation of the superior labral complex and biceps tendon
Partial tears of the biceps tendon are more difficult to detect than complete ruptures

Treatment :


Biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs).


Bicipital Tendinitis And Exercise

Ice, rest from overhead activity, or physical therapy.14 Rehabilitation of an athlete's shoulder involves four phases:

rest; stretching exercises of the scapula, rotator cuff, and posterior capsule; 
The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position.

Taping Over Biceps Give Great Relief From Pain And Allow Smooth Movement.

Tapping in Bicipital Tendinitis

Strengthening and a progressively difficult throwing program.
The patient may begin exercises after the shoulder is pain-free.

Strenthening Exercise Of Biceps Muscle

Monday, 22 January 2018


Profound vein thrombosis (DVT) happens when a blood coagulation (thrombus) frames in at least one of the profound veins in your body,


as a rule in your legs. Profound vein thrombosis can cause leg torment or swelling, yet in addition can happen without any side effects.

Profound vein thrombosis can be intense on the grounds that blood coagulations in your veins can loosen up, go through your circulatory system and cabin in your lungs, blocking blood stream (pneumonic embolism).

Deep Vein Thrombosis 

Lower-appendage profound venous thrombosis (DVT) influences between 1% to 2% of hospitalized patients. These thrombi upset the vascular uprightness of the lower appendages and are the wellspring of emboli that

slaughter around 200,000 patients every year in the United States. The reasons for thrombosis incorporate vessel divider harm, stasis or low stream, and hypercoagulability. These components support cluster arrangement by disturbing the adjust of the contradicting coagulative and fibrinolytic frameworks.


Profound vein thrombosis signs and indications can include:

Swelling in the influenced leg. Once in a while, there's swelling in the two legs.

Torment in your leg. The torment regularly begins in your calf and can have a craving for cramping or soreness.

Red or stained skin on the leg.

A sentiment warmth in the influenced leg.

Profound vein thrombosis can happen without recognizable side effects.

The notice signs and side effects of an aspiratory embolism include:

Sudden shortness of breath

Chest agony or distress that compounds when you take a full breath or when you hack

Feeling woozy or mixed up, or blacking out

Fast heartbeat

Hacking up blood


The blood coagulations of profound vein thrombosis can be caused by anything that keeps your blood from coursing or thickening ordinarily, for example, damage to a vein, surgery, certain solutions and restricted development.

Hazard factors

Numerous elements can build your danger of growing profound vein thrombosis (DVT). The more you have, the more prominent your danger of DVT. Hazard factors include:

Acquiring a blood-thickening issue. A few people acquire a turmoil that influences their blood to cluster all the more effortlessly. This condition without anyone else won't not cause blood clusters unless joined with at least one other hazard factors.

Drawn out bed rest, for example, amid a long clinic stay, or loss of motion. At the point when your legs stay still for long stretches, your lower leg muscles don't contract to enable blood to course, which can build the danger of blood clusters.

Damage or surgery. Damage to your veins or surgery can build the danger of blood clusters.

Pregnancy. Pregnancy builds the weight in the veins in your pelvis and legs. Ladies with an acquired thickening issue are particularly in danger. The danger of blood clumps from pregnancy can proceed for up to a month and a half after you have your child.

Anti-conception medication pills (oral contraceptives) or hormone substitution treatment. Both can expand your blood's capacity to clump.

Being overweight or fat. Being overweight expands the weight in the veins in your pelvis and legs.

Smoking. Smoking influences blood thickening and flow, which can build your danger of DVT.

Growth. A few types of disease increment substances in your blood that reason your blood to clump. A few types of disease treatment additionally increment the danger of blood clusters.

Heart disappointment. This expands your danger of DVT and pneumonic embolism. Since individuals with heart disappointment have restricted heart and lung work, the side effects caused by even a little aspiratory embolism are more observable.

Incendiary inside illness. Gut ailments, for example, Crohn's sickness or ulcerative colitis, increment the danger of DVT.

An individual or family history of profound vein thrombosis or pneumonic embolism. In the event that you or somebody in your family has had either of these, you may be at more serious danger of building up a DVT.

Age. Being more established than 60 expands your danger of DVT, however it can happen at any age.

Sitting for drawn out stretches of time, for example, when driving or flying. At the point when your legs stay still for quite a long time, your lower leg muscles don't contract, which regularly enables blood to circle. Blood clumps can shape in the calves of your legs if your lower leg muscles don't move for long stretches.


Pneumonic embolism

Pneumonic embolism

A genuine confusion related with profound vein thrombosis is aspiratory embolism.

Pneumonic embolism

A pneumonic embolism happens when a vein in your lung ends up noticeably hindered by a blood coagulation (thrombus) that movements to your lung from another piece of your body, for the most part your leg.

An aspiratory embolism can be dangerous. It's vital to look for signs and manifestations of a pneumonic embolism and look for medicinal consideration in the event that they happen. Signs and side effects of a pneumonic embolism include:

Sudden shortness of breath

Chest torment or distress that intensifies when you take a full breath or when you hack

Feeling bleary eyed or unsteady, or swooning

Fast heartbeat

Hacking up blood

Postphlebitic disorder

A typical complexity that can happen after profound vein thrombosis is known as postphlebitic disorder, additionally called postthrombotic disorder. Harm to your veins from the blood coagulation diminishes blood stream in the influenced regions, which can cause:

Determined swelling of your legs (edema)

Leg torment

Skin staining

Skin wounds


Measures to avoid profound vein thrombosis include:

Abstain from sitting still. In the event that you have had surgery or have been on bed rest for different reasons, endeavor to move at the earliest opportunity. In case you're sitting for some time, don't fold your legs, which can hamper blood stream. In case you're voyaging a long separation via auto, stop each hour or thereabouts and stroll around.

In case you're on a plane, stand or walk every so often. In the event that you can't do that, activity your lower legs. Take a stab at raising and bringing down your foot rear areas while keeping your toes on the floor, at that point raising your toes with your rear areas are on the floor.

Roll out way of life improvements. Get more fit and quit smoking.

Exercise. Customary exercise brings down your danger of blood clumps, which is particularly essential for individuals who sit a ton or travel much of the time.


To analyze profound vein thrombosis, your specialist will get some information about your side effects. You'll additionally have a physical exam so your specialist can check for regions of swelling, delicacy or staining on your skin. Contingent upon the fact that you are so prone to have a blood coagulation, your specialist may recommend tests, including:

Ultrasound. A wandlike gadget (transducer) set over the piece of your body where there's a coagulation sends sound waves into the region. As the sound waves go through your tissue and reflect back, a PC changes the waves into a moving picture on a video screen. A coagulation may be noticeable in the picture.

Some of the time a progression of ultrasounds are done more than a few days to decide if a blood coagulation is developing or to check for another one.

Blood test. All individuals who create serious profound vein thrombosis have a hoisted blood level of a substance called D dimer.

Venography. A color is infused into an expansive vein in your foot or lower leg. A X-beam makes a picture of the veins in your legs and feet, to search for clusters. Be that as it may, less intrusive strategies for finding, for example, ultrasound, can as a rule affirm the determination.

CT or MRI checks. Either can give visual pictures of your veins and may appear in the event that you have a coagulation. Here and there these sweeps performed for different reasons uncover a coagulation.

Treatment : 

Bolster leggings

Stockings in DVT

Bolster tights

Profound vein thrombosis (DVT) treatment is gone for keeping the coagulation from getting greater and keeping it from loosening up and causing an aspiratory embolism. At that point the objective progresses toward becoming lessening your odds of profound vein thrombosis happening once more.

Profound vein thrombosis treatment alternatives include:

Blood thinners. Profound vein thrombosis is most regularly treated with anticoagulants, likewise called blood thinners. These medications, which can be infused or taken as pills, diminish your blood's capacity to cluster. They don't separate existing blood clumps, however they can keep clusters from getting greater and decrease your danger of growing more clumps.

The injectable prescriptions can be given as a shot under the skin or by infusion into your arm vein (intravenous).

Heparin is regularly given intravenously. Other comparative blood thinners, for example, enoxaparin (Lovenox), dalteparin (Fragmin) or fondaparinux (Arixtra), are infused under the skin.

You may get an injectable blood more slender for a couple of days, after which pills, for example, warfarin (Coumadin, Jantoven) or dabigatran (Pradaxa) are begun. When warfarin has diminished your blood, the injectable blood thinners are ceased.

Other blood thinners can be given in pill shape without the requirement for an injectable blood more slender. These incorporate rivaroxaban (Xarelto), apixaban (Eliquis) or edoxaban (Savaysa).

You may need to take blood more slender pills for three months or more. It's essential to take them precisely as your specialist educates in light of the fact that taking excessively or too little can cause genuine reactions.

On the off chance that you take warfarin, you'll require occasional blood tests to check to what extent it takes your blood to cluster. Pregnant ladies shouldn't take certain blood-diminishing meds.

Cluster busters. On the off chance that you have a more genuine kind of profound vein thrombosis or aspiratory embolism, or if different meds aren't working, your specialist may endorse drugs that separate coagulations immediately, called cluster busters or thrombolytics.

These medications are either given through an IV line to separate blood clumps or through a catheter put straightforwardly into the coagulation. These medications can cause genuine dying, so they're for the most part held for extreme instances of blood clumps.

Channels. In the event that you can't take drugs to thin your blood, you may have a channel embedded into an extensive vein — the vena cava — in your guts. A vena cava channel keeps clusters that loosen up from hotel in your lungs.

Pressure leggings. To assist counteract swelling related with profound vein thrombosis, these are worn on your legs from your feet to about the level of your knees.

Monday, 1 January 2018

Torticollis And Physiotherapy Treatment Overview :


Torticolis is a condition ( Also Called ‘wryneck’) in which the baby’s head is tilted One Side. The head often rotates towards one shoulder and tilts away to the opposite side. The term ‘congenital’ is also sometime used when describing From Birth torticollis. This means that it is present at or shortly after birth. Babies treated early with physiotherapy programmes usually Give Good Result to treatment.

Torticollis is a symptom related to turning or bending of the neck one side . Many different causes are possible. In newborns, torticollis usually results from injury during labor and delivery or the infant’s position in the womb. Less often, it is caused by birth defects. In older children, torticollis may result from injuries to the neck muscles, common infections, or other causes.
Painful spasms of the neck muscles may occur.
Other symptoms may be present, depending on the cause. For example, there may be a tender lymph node (gland) if the cause is infection.


  • Congenital torticolis.
  • Acquired torticolis.
Acquired torticolis


The normal physiologic range of rotation of the atlas on the axis is 25-53 degrees to either side. The transverse ligament is the primary stabilizer of the atlantoaxial joint and prevents excessive anterior motion of the atlas on the axis. It extends behind the dens, between the medial portions of the lateral masses of C1. The paired alar ligaments act as secondary stabilizers to prevent anterior shift. The alar ligaments extend from the lateral aspect of the dens tip to the medial aspect of the occipital condyles, with a lower portion attaching to the medial aspect of the lateral masses of C1.
The sternocleidomastoid muscle has a sternal and clavicular head. The sternal head is directed from the manubrium sterni superiorly, laterally and posteriorly and the clavicular from the medial third of the clavicle vertically upward. It runs to the mastoid process. It enables an ipsilateral lateral flexion and a contralateral rotation. The muscle extends the upper part of the cervical spine and flexes the lower part.


Muscular in more than 80% of the cases. Types muscular torticollis
          - Fibromatosis colli: torticollis with palpable mass in the SCM;
          - Tightness of the SCM without an apparent mass;
Postural torticollis with neither mass or tightness.
Birth trauma: facet dislocation, tears in the sternocleidomastoid muscle
Congenital anomalies of the craniovertebral junction: occipitoatlantal fusion or Klippel-Feil syndrome.
Sternocleidomastoid tumour.
Ocular abnormalities.
Intrauterine mechanical factors


Congenital Torticollis 

Sitting or sleeping in an unusual position without adequate neck support.
Poor posture when looking at a computer screen.
Carrying heavy unbalanced loads (for example, a briefcase or shopping bag).
Allowing certain muscles of the neck to be exposed to cold (sleeping in a draught).


SternocleidoMustoid Muscle 

The twisting of your neck (torticollis) occurs when your muscles supporting the neck on one side are painful.
The pain is usually on one side of your neck and stiffness of the muscles in that area twists the neck to one side. You may find it very difficult when you try to straighten your neck, due to pain. Occasionally, the pain is in the middle of your neck.

The pain may spread to the back of your head or to your shoulder. The muscles of your affected side may be tender. Pressure on certain areas may trigger a 'spasm' of these muscles. Movement of your neck is restricted, particularly on one side.


A thorough neurologic examination should be performed, and anteroposterior and lateral radiographs of the cervical spine should be obtained. A CT scan or MRI of the head and neck is necessary for any patient with persistent neck pain or with neurologic signs and symptoms.


Pain killer are often helpful. such as,
Paracetamol at strength is often sufficient.
Anti inflammatory painkillers.
A stronger pain killer such codeine.
A muscle relaxant such as diazepam.

Other treatments such as:
A good posture.
A firm supporting pillow.
Heat pack.


Exercise In Sternocleidomustoid Muscle

  • Positioning.
  • Gentle range of motion exercises for neck.
  • Stretching of sternocleido mastoid muscle.
  • Strnengthening exercises.
  • Activities to encourage active head movement.
  • Visual tracking.
  • Lateral head tilt.
  • Therapy ball exercises.
  • Side sitting exercises.
  • Hands and knees.
  • Kneeling to standing.
  • Assisted rolling.
  • Proped sidelying.

Torticollis treatment at home for babies:

The best method of torticollis treatment is to encourage your baby to turn his or her head in both directions. This will help to loosen tense neck muscles and tighten the loose ones. Here are some exercises to try:
When your baby wants to eat, offer the bottle or your breast in a way that encourages your baby to turn away from the favored side. (Use your child's desire to eat to encourage him or her along!)
When putting your baby down to sleep, position him or her to face the wall. Since babies prefer to look out onto the room, your baby will actively turn away from the wall and this will stretch the tightened muscles of the neck. 
During play, draw your baby's attention with toys and sounds to make him or her turn in both directions.

Friday, 1 December 2017

Parkinsonism Disease And Exercise :

Parkinsonism Disease And Physiotherapy Treatment : 

Parkinsonism Disease 

Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability.
Parkinsonism is any condition that causes a combination of the movement abnormalities seen in Parkinson's disease — such as tremor, slow movement, impaired speech or muscle stiffness — especially resulting from the loss of dopamine-containing nerve cells (neurons).

Parkinsonism disease (PD) is a degenerative, progressive disorder that affects nerve cells in deep parts of the brain called the basal ganglia and the substantia nigra. Nerve cells in the substantia nigra produce the neurotransmitter dopamine and are responsible for relaying messages that plan and control body movement. For reasons not yet understood, the dopamine-producing nerve cells of the substantia nigra begin to die off in some individuals. When 80 percent of dopamine is lost, PD symptoms such as tremor, slowness of movement, stiffness, and balance problems occur.
Body movement is controlled by a complex chain of decisions involving inter-connected groups of nerve cells called ganglia. Information comes to a central area of the brain called the striatum, which works with the substantia nigra to send impulses back and forth from the spinal cord to the brain. The basal ganglia and cerebellum are responsible for ensuring that movement is carried out in a smooth, fluid manner.


Stages Of Parkinsonism Disease

1st STAGE  - A Person usually has mild symptoms, such as tremors or shaking in a limb.Change such as poor posture, loss of balance,and abnormal facial expressions.

2nd STAGE  - Symptoms affect both limbs and both sides of the body. The person has usually has problem walking or balancing, and the inability to complete physical tasks becomes more apparent.

3rd STAGE  - Symptoms can be severe and include the inability to walk straight or stand. there is a noticeable slowing of physical movements.

4th STAGE  - The ability to walk is often limited .

5th STAGE - The Person is often unable to take care of herself and may not be able to stand or walk .she may need constant one on one nursing care.


Brain injury
Diffuse Lewy body disease (a type of dementia)
Multiple system atrophy
Progressive supranuclear palsy
Wilson disease

Other causes of secondary parkinsonism include:

Brain damage caused by anesthesia drugs (such as during surgery)
Carbon monoxide poisoning
Certain medicines used to treat mental disorders or nausea
Mercury poisoning and other chemical poisonings
Overdoses of narcotics
MPTP (a contaminant in some street drugs) 


Symptoms of Parkinson's disease differ from person to person. They also change as the disease progresses.
Symptoms typically begin appearing between the ages of 50 and 60. They develop slowly and often go unnoticed by family, friends, and even the person who has them.
The most common one is tremor.
Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson's disease is a tremor of your hand when it is relaxed (at rest).
Slowed movement (bradykinesia). Over time, Parkinson's disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move.
Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can limit your range of motion and cause you pain.
Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease.
Loss of automatic movements. In Parkinson's disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.
Speech changes. You may have speech problems as a result of Parkinson's disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than with the usual inflections.
Writing changes. It may become hard to write, and your writing may appear small.

Stepping Examination Of Parkinson's Disease


Computed tomography (CT) scans of people with PD usually appear normal.
MRI has become more accurate in diagnosis of the disease over time, specifically through iron-sensitive T2* and SWI sequences at a magnetic field strength of at least 3T, both of which can demonstrate absence of the characteristic 'swallow tail' imaging pattern in the dorsolateral substantia nigra.


Balancing Exercise

Carbidopa-levodopa infusion. 
Dopamine agonists. 
MAO-B inhibitors.
Catechol-O-methyltransferase (COMT) inhibitors. 


Treatment In Parkinsonism Disease


    Maintain and improve levels of function and independence, which will help to improve a person’s quality of life
    Use exercise and movement strategies to improve mobility
    Correct and improve abnormal movement patterns and posture, where possible
    Maximise muscle strength and joint flexibility
    Correct and improve posture and balance, and minimise risks of falls
    Maintain a good breathing pattern and effective cough
    Educate the person with Parkinson’s and their carer or family members
    Enhance the effects of drug therapy

Gait Training In Parkinson Disease

Visual cueing – a focus point to step over and initiate gait; strips of tape on the floor to initiate or continue walking through areas that cause slowing or freezing
Auditory cueing – counting 1-2-3 to initiate walking; stepping to the beat of a metronome or specific music at a specified cadence to continue the rhythm of a walk
Attention – Thinking about taking a big step; making a wider arc turn
Proprioceptive cueing – rocking from side to side ready to initiate a step; taking one step backwards as a cue ready to then walk forwards.

Gait Training 2 In Parkinson's Disease

Related Post :

Wednesday, 22 November 2017

Hallux Valgus Deformity And Physiotherapy :

Hallux Valgus Deformity

Hallux valgus is a progressive foot deformity in which the first metatarso-phalangeal (MTP) joint is affected and is often accompanied with significant functional disability and foot pain.


Hallux Valgus in Lower Limb Foot 

Bunions are a widespread foot ailment that can be caused by a number of factors including genetics 
Excess weight gain,
Activity level, and
Ill-fitting shoes. 
Other less common causes of bunions include trauma to the
MTP joint (sprains, fractures, and nerve injuries), 
Neuromuscular disorders,
Limb-length discrepancies.
Some studies report that bunions tend to occur ten times more frequently in women than in men, primarily as the result of wearing narrow, pointy, tight fitting, and/or high-heeled shoes over a significant period of time. Repetitive stresses to the foot can also cause bunions.


Hallux Valgus 

Your big toe points toward your second toe, or your second toe overlaps your big toe
A prominent bump on the inside of the MTP or big toe joint
Pain on the inside of your foot at the big toe joint when wearing any kind of shoe
Pain each time the big toe flexes when walking
Redness, swelling , or thickening of the skin on the inside of the big toe joint


Radiographic exmatination show the angle formed between longitudinal bisection of the 1st Metatarsal and proximal phalanx.
A big toe position with an angle of up to 10° is still considered normal.
A minor hallux valgus defect is 16-20°.
A moderate hallux valgus deformity has a deviation of 16-40°.
A severe hallux valgus deformity has a deviation of over 40°.
Magnetic resonance imaging (MRI) will detect cartilage damage, trapped soft tissue and bone damage.


Exercise In Hallux Valgus

Adjusted footwear with wider and deeper tip
Increase extension of MTP joint
Relieve weight-bearing stresses (orthosis)
Sesamoid Mobilization:The physical therapist performs grade III joint mobilizations on the medial and lateral sesamoid of the affected first MPJ. One thumb is placed on the proximal aspect of the sesamoid and is used to apply a force from proximal to distal that causes the sesamoid to reach the end range of motion (distal glides). These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ should be allowed during the technique.

Splinting In Hallux Valgus 

Strengthening of peroneus longus

Electrotherapy Modalities - Ultrasound, ice, Electrical stimulation, MTJ mobilizations and exercises. This is more effective than physical therapy alone. The combination will result in a increase in ROM of the MTP joint, strength and function, and also a decrease in pain . 
Pain is the main reason that patients seek treatment for a bunion. Inflammation is best eased using ice therapy, techniques (e.g. soft tissue massage, acupuncture, unloading taping techniques) or exercises that unload the inflamed structures. Anti-inflammatory medications may help. Orthotics can also be used to offload the bunion. 

For Restoring the Normal Joint Of Motion -
Physiotherapy Exercise In Hallux Valgus

  • Joint mobilisation (abduction and flexion) and alignment techniques (between the first and the second metatarsal)
  • Massage
  • Muscle and joint stretches
  • Taping
  • Bunion splint or orthotics
  • bunion stretch and soft tissue release.
Tapping Technique In Hallux Valgus

For Strenghting Of Muscles -

Towel curls The patient spreads out a small towel on the floor, curling his/her toes around it and pulling the towel towards them. 
The ends of the band are either held by an assistant or secured against an immovable object (e.g. a table leg). The patient then dorsiflexes the ankle, pulling "towards their nose," working against the resistance of the band. 

Saturday, 18 November 2017

Tennis Elbow And Physiotherapy Treatment :


Tennis Elbow 

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse.
Tennis elbow is an inflammation of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.
There are many treatment options for tennis elbow. In most cases, treatment involves a team approach. Primary doctors, physical therapists, and, in some cases, surgeons work together to provide the most effective care.


Anatomy Of Muscle And Joint

Elbow joint is a joint made up of three bones: upper arm bone (humerus) and the two bones in forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.
Muscles, ligaments, and tendons hold the elbow joint together.
Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of forearm. Forearm muscles extend wrist and fingers. Forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).


  • Overuse.
  • Activities.
  • Age.
  • Unknown.


  • Phase 0: No pain or soreness. 
  • Phase 1: Soreness after activity, usually gone in twenty-four hours.
  • Phase 2: Mild stiffness and soreness before activity which disappears with warm-up. No pain during activity, but mild soreness after activity that disappears within 24 hours. 
  • Phase 3: Mild/moderate stiffness and soreness plus mild pain during activity which does not alter activity.
  • Phase 4: Pain during activity which alters activity.
  • Phase 5: Constant pain even at rest.


  • Diffuse achiness.
  • Morning stiffness.
  • Occasional night pain.
  • Dropping of objects/ weak grip strength.
  • Pain with palpation of lateral epicondyle.
  • Pain with active or resisted extension.
  • Pain with grasping objects with the effected hand.
  • Pain or tenderness on the outer side of the elbow.
  • Pain when you straighten or raise your wrist and hand.
  • Pain made worse by lifting a heavy object.
  • Pain when you make a fist, grip an object, shake hands, or turn door handles.
  • Pain that shoots from the elbow down into the forearm or up into the upper arm.


  • Weak muscles.
  • Overuse- playing or working with excessive and repetitive forceful gripping.
  • Gripping while extending or twisting of the wrist.
  • Racquets/ tools that are too heavy or unbalanced.
  • Improper equipment- incorrect grip size, strings too tight.
  • poor playing technique- too much wrist action, jerky strokes, poor ball contact.




Examination Of Patient

Cozen's test:

Resistive Tennis Elbow Test:The patient sits with the examiner stabilizing the involved elbow while palpating the lateral epicondyle With a closed fist, the patient pronates and radially deviates the forearm and extends the wrist against the examiner’s resistance”. A positive result would be if there is pain along the lateral epicondyle or objective muscle weakness.


Tapping Technique In Tennis Elbow

Medication: Anti-inflammatory medication helps to reduce pain.
Steroid Inection:  Steroids, such as cortisone, are very effective anti-inflammatory medicines.
Rest: You may have temporarily stop the aggravating activity. A period of rest is most important to allow the injury a chance to heal. You will make the condition worse by continuing the activity that cause the injury, especially if you experience pain. Avoid heavy liftting or carrying opening doors or repeatedly shaking hands.
Ice: Apply cold to your elbow three times a day for 20 to 30 minutes at a time in the early painful stage and for 20 minutes after active use of arm. Protect skin by putting a towel between elbow and the ice bag.
Brace: A counter force brace which is and elastic strap that is worn 1-2 inches below the elbow. This type of brace gives compression to the forearm muscle and helps lessen the force that the muscle transmits to the tendon.
Interferential current.
Cold pack.
Laser therapy.

Physiotherapy Exercises:
Exercise Of Grip Muscle 

  • Resisted wrist extension.
  • Resisted wrist flexion.
  • Resisted forearm supination and pronation.
  • Wrist flexor stretch.
  • Wrist extensor stretch.
  • Finger extension.
  • Hand squuze.
Strenthening Exercise Using Weight 

Wrist range of motion: Bend your wrist forward and backward as far as you can. Repeat 10 times. Do 3 sets.
Forearm range of motion: With your elbow at your side and bent 90 degrees, bring your palm facing up and hold for 5 seconds then slowly turn your palm facing down and hold for 5 seconds. Repeat 10 times. Do 3 sets. Make sure you keep your elbow bent at 90 degrees throughout this exercise.
Elbow range of motion: Gently bring your palm up toward your shoulder and bend your elbow as far as you can. Then straighten your elbow out as far as you can. Repeat 10 times. Do 3 sets
Forearm pronation and supination: Hold a soup can or hammer handle in your hand, with your elbow bent 90 degrees. Slowly rotate your hand with palm upward and then palm down. Repeat 10 times. Do 3 sets.
Wrist extension: Stand up and hold a broom handle in both hands. With your arms at shoulder level, elbows straight and palms down, roll the broom handle backward in your hand as if you are reeling something in using the broom handle. Repeat for 1 minute and then rest. Do 3 sets.
Wrist strenghening.
(1) Wrist flexion: Holding a soup can or hammer handle with your palm up, slowly bend your wrist up. Slowly lower the weight and return to the starting position. Repeat 10 times. Do 3 sets. Gradually increase the weight of the can you are holding.
(2) Wrist extension: Holding a soup can or hammer handle with your palm down, gently bend your wrist up. Slowly lower the weight and return to the starting position. Repeat 10 times. Do 3 sets. Gradually increase the weight of the can you are holding.
(3) Wrist radial deviation: Hold your wrist in the sideways position with your thumb up. Holding a can of soup or . hammer handle, gently bend your wrist up with your thumb reaching towards the ceiling. Slowly lower to the starting position. Do not move your forearm throughout this exercise. Repeat 10 times. Do 3 sets.
Elbow rehabilitation program:
A gradual progression of the exercises is extremely important. Although they may seem easy at first you must follow the enclosed steps closely to prevent an increase or re-aggravation of your symptoms. Before beginning the strengthening exercises you should warm-up your body to a light sweat. Try 3 to 5 minutes of brisk walking, cycling, jogging etc. Do exercises only once a day: more is not better and can re-aggravate your symptoms. Wear the Count’R-Force brace if advised by your therapist or if you experience pain while performing the exercises. Do each exercise at its own rate. You will achieve higher weights faster on some exercises than others. Do each exercise properly and slowly do not work through peavierain.

Stage 1 Exercises:

Keep your elbow bent to 90 degrees. If this is  painful lean forward and bend your elbow even more. Your forearm should be well supported on your thigh or a table.
Begin with no weight, doing 10 to 15 repetitions for each exercise.
Slowly progress the repetitions in sets of 10, every few days as your elbow allows until you are comfortably doing 3 sets of 10 repetitions for 2 consecutive days without increasing your symptoms.
Increase to a one-pound weight (a small can of soup works well). Go back to 10 to 15 repetitions for each exercise.
Slowly work up to 3 sets of 10 repetitions again.
Increase to a two-pound weight and again cut back to 10 to 15 repetitions.
Slowly progress to  3 sets of 10 repetitions.
Continue this gradual progression until you are using a three-pound weight for 3 sets of 10 repetitions without increasing your symptoms.
Progress to next stage as able.

Stage 2 Exercises:

Rubber band and squeeze exercises:
Begin with your elbow bent at your side and progress by performing the exercises with your arm straight out in front of you as able. You should do these two exercises several times a day, every day. It is a good idea to have a ball and rubber band in convenient places like in your car, at your desk, or by the television. Be careful not to overdo these exercises as they can increase your pain.
Ice after exercises.