Thursday, 7 June 2018

VERTIGO And Physiotherapy Treatment :


                                                  Vertigo Anatomy

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


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


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

Vertigo that is caused by problems with the inner ear or vestibular system(composed of the semicircular canals, the vestibule, and the vestibular nerve is called "peripheral", "otologic" or "vestibular" vertigo.The most common cause is benign paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo. People with peripheral vertigo typically present with mild to moderate imbalance, nausea, vomiting, hearing loss, tinnitus, fullness, and pain in the ear.

Vertigo that arises from injury to the balance centers of the central nervous system (CNS), often from a lesion in the brainstem or cerebellum,is called "central" vertigo.Central vertigo may have accompanying neurologic deficits (such as slurred speech and double vision), and pathologic nystagmus (which is pure vertical/torsional).Commonlly it can cause disequilibrium which is the sensation of being off balance. The balance disorder associated with central lesions causing vertigo is often so severe that many patients are unable to stand or walk.


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

Vertigo Sign

                  Vertigo Sign And Symtoms

- Sensation of spinning while stationary,
- Nausea or vomiting,
- Unsteadiness (postural instability),
- Nystagmus,
- Difficulties in walking,
- Motion Sickness

Recurrent episodes in those with vertigo are common and frequently impair the quality of life.Blurred vision, difficulty in speaking, a lowered level of consciousness, and hearing loss may also occur. The signs and symptoms of vertigo can present as a persistent (insidious) onset or an episodic (sudden) onset.


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


                            Care in Vertigo

Definitive treatment depends on the underlying cause of vertigo.In many cases, vertigo goes away without any treatment. This is because your brain is able to adapt, at least in part, to the inner ear changes, relying on other mechanisms to maintain balance. But,For some, treatment is needed and may include:

  • Vitamin D supplementation may be beneficial for patients diagnosed with benign paroxysmal positional vertigo.
  •  Herbal remedies such as ginger root, ginkgo biloba, and coriander may help reduce vertigo symptoms in some people. This are home remedies, so refer to your doctor before use.

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

                                       Vertigo Epley maneuvers

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

How long does vertigo last? 

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

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


Cervical Rib  

             Anterior view                                                                                         Lateral View       

                                                                        Posterior View

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

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

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

                subclavian artery compression
  • An aneurysm in the subclavian artery which can affect the blood supply to the fingers leads to small red or black patches on the skin.
                                  white colouration in hand
  • There may be present of Raynaud's phenomenon – a condition that affects the blood supply to the fingers and toes, turning them white.
  • Radial pulse becomes feeble or may even be absent.
(c) Local Symptoms:
  • Sometimes, patient may present with the tenderness in supraclavicular lump which, on palpation very hard and fixed.
  • Swelling in the affected arm but, this is very rare.

(1) Generally it is diagnosed by the X-Ray examination to detect cervical rib, which could be easily palpable.
it is attached to the seventh cervical vertebra.

                                                                                               Cervical Rib X-Ray

(2) Special test:

    (a)Adson's Test

                              Adson's test

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

  (b) Foraminal Compression Test/ Spurling's Test

                                  Spurling's test

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

   (c) Shoulder Abduction Test

                                   shouldr abduction test

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

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


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

2. surgical treatment:
surgery is essential in conditions of severe, progressive vascular and neurological signs and symptoms which are        unbearable for the patients. It includes:
  • Removal of extra segment.
  • Dividing the scalene group of muscles.
3. physiothrapy management:
On the basis of symptoms of the patient, the regime of physiotherapy is planned.
  • For pain relief- short wave diathermy is used but it is contraindicated in case of sensory impairments.
  • To improve distal circulation- gripping exercise like ball sqizing, spring stretching.
  • To improve tone, power and endurance-Strengthening exercises of whole arm perticularly small muscles of the arm.
  • For posture Correction -In this, patient is guided to use mirror to see that his shoulders are in level, head is straight, looking forward
  • Specific exercises- To develop particular muscles groups for specific movements of shoulder girdle like elevation, retraction, and raising the arm overhead as these movements brings spontaneous relief. The important exercises are:

                                    Self resisted exercise


1-Self resisted scapular elevation.
2-Self resisted scapular adduction.
3-Endurance training exercise for the shoulder girdle muscles.
4-Progressive resistance exercises for shoulder girdle muscles with weight.
  • Deep Tissue Massage for TOS ( thoracic Outlet Syndrome).

Wednesday, 6 June 2018


Compartment syndrome is a condition in which increased pressure within one of the body's compartments results in insufficient blood supply to tissue within that space.Compartment syndrome usually results from bleeding or swelling after an injury. There are two main types: acute and chronic.The leg or arm is most commonly involved.

Groups of organs or muscles are organized into areas called compartments. Strong webs of connective tissue called fascia form the walls of these compartments.

After an injury, blood or edema may accumulate in the compartment. The tough walls of fascia cannot easily expand, and compartment pressure rises, preventing adequate blood flow to tissues inside the compartment. Severe tissue damage can result, with loss of body function or even death.

Acute compartment syndrome is the most common type of compartment syndrome. Acute compartment syndrome occurs in about 3% of those who have a mid-shaft fracture of the forearm.

Compartment syndrome can develop from the fracture itself, due to pressure from bleeding and edema. Or compartment syndrome may occur later, as a result of treatment for the fracture such as surgery and POP.

Acute compartment syndrome can also occur after injuries without bone fractures, including:
  • Crush injuries
  • Burns
  • Overly tight bandaging
  • Prolonged compression of a limb during a period of unconsciousness
  • Surgery to blood vessels of an arm or leg
  • A blood clot in a blood vessel in an arm or leg
  • Extremely vigorous exercise, especially eccentric movements (extension under pressure)
  • vigorous exercise.
                  Acute Compartment Syndrome with blister formation


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

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

Patients with exercise-induced lower leg pain, differential diagnosis includes:
  • medial tibial stress syndrome (MTSS)
  • fibular and tibial stress fractures
  • fascial defects
  • nerve entrapment syndromes,
  • vascular claudication
  • lumbar disc herniation.

Apart from the typical signs and symptoms, measurement of intra-compartmental pressure is also important for diagnosis. A transducer connected to a catheter is inserted 5 cm into the zone of injury.

A pressure higher than 30 mmHg of the diastolic pressure in conscious or unconscious person is associated with compartment syndrome; and fasciotomy is indicated. For those with hypotension, a pressure of 20 mmHg higher than the intra-compartmental pressure is associated with compartmental syndrome.

                  measurement of itra compartment pressure

According to Blackman one of the tools to diagnose compartment syndrome is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.
Less invasive measurement techniques:
  1. Laser Doppler ultrasound
  2. Methoxy isobutyl isonitrile enhanced magnetic resonance imaging (MRI)
  3. Phosphate-nuclear magnetic resonance (NMR) spectroscopy

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

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

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

                   Achilles-Tendon Stretching

                    Tibialis Anterior Stretching

                                  walking aid

                        SHOE VARIATION

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

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


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

The symptoms are variable and will present themselves differently from patient to patient. The main symptoms are -
  • a generalised burning pain
  • changes in the skin, which may become shiny
  • swelling
  • more perspiration more than usual
  • muscle wastage
  • stiffness in the affected part
  • increased sweating

                      Diformity in RS

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

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

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

                       The mechanism of RSDS

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

There is no biological test to highlight Sudeck’s disease. The physician makes the diagnosis based primarily on physical findings and history.
  • Temperature measurements: temperature measurement generated by the body surface
  • Measuring the secretion of sweat
  • Radiography, CT, MRI: to highlight a bone decalcification.
  • Blockages friendly: using anesthesia, they can reduce sympathetic activity, this method allows to obtain diagnostic information and a therapeutic action, insofar as Sudeck’s disease depends on the sympathetic system.
  • Scintigraphy in three phases: review specific nuclear medicine
  • The pain and swelling in the limbs may also come from other illnesses, so it is important to eliminate them. (venous thrombosis, lymphedema as accumulation of fluid and lymphatic system disorders, lymph node involvement in cases of breast cancer).

                       X-Ray finding

The International Association for the Study of Pain (IASP) lists the diagnostic criteria for complex regional pain syndrome I (RSDS) as follows:
  1. The presence of an initiating noxious event or a cause of immobilization
  2. Continuing pain, allodynia (perception of pain from a nonpainful stimulus), or hyperalgesia (an exaggerated sense of pain) disproportionate to the inciting event
  3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the area of pain
  4. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.
According to the IASP, CRPS II (causalgia) is diagnosed as follows:
  1. The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve
  2. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain
  3. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

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

Medical treatment:
Tentative evidence supports the use of bisphosphonates, calcitonin, and ketamine. Doing nerve blocks with guanethidine appears to be harmful. Evidence for sympathetic nerve blocks generally is insufficient to support their use. Intramuscular botulinum injections may benefit people with symptoms localized to one extremity.
  • Ketamine
    Ketamine, a dissociative anesthetic, appears promising as a treatment for complex regional pain syndrome. It may be used in low doses if other treatments have not worked. No benefit on either function or depression, however, has been seen.
  • Bisphosphonate treatment
    Very limited data reviewed showed that bisphosphonates have the potential to reduce pain associated with bone loss in patients with CRPS I.
It is required when medication and conservative treatment are failed and mostly used in sever CRPS. Following are the procedures:
  • Spinal cord stimulators
  • Sympathectomy
  • Amputation
Physiotherapy Treatment
It is important that the patient actively participates and takes its responsibilities during treatment.
  • First of all, to rest; possibly splinting
  • Elevation of the affected
  • Cool slightly (NOT ice), carbon dioxide baths costs
  • Manual lymphatic drainage
  • Electrotherapy, TENS (transcutaneous electrical nerve stimulation: inhibition of conduction of pain due to nerve stimulation by electrical current)
  • Massages of connective tissue
  • Mobilization in chronic phase
  • Carefully active movement of affected limb
  • Occupational therapy to maintain mobility
  • Specific training with specialists
  • Learning relaxation techniques
  • Aquatic therapy allows activities to be performed with decreased weight bearing on the lower extremities
  • Mirror therapy
  • Gradual weight bearing
  • Stretching

                                                  support in sd for rest


                        weight lifting exercise

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

                         Electrical stimulation

                                                            Kinesio Taping

                                Ultrasound in RSD

Myositis Ossificans

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.

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

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.

                                                           Egg like ossificstion

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.

  • 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.

                     Elevation of affected limb

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
Icing the injury
Pulsed Ultra sound and phonophoresis

              laser therapy

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.

               Strenghening exercise

                          Taping for MO

Iontophoresis with 2 % acetic acid solution.
Extra corporeal shock wave therapy

           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.

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.
Over Exercise And Painful Exercise May Lead To Myositis Ossificans Too Many Time , So Avoiding Painful Exercise And Over Exercise And Take Enough Rest is Too Important in Physiotherapy Treatment.

Painful Arc Syndrome

Supraspinatus tendinitis or painful arc syndrome occurs in the shoulder. The shoulder joint owes its stability to the ‘rotator cuff’ muscles – which are four small muscles located around the shoulder joint which help with movement, but importantly their tendons stabilise the head of the humerus within the joint capsule.Sometimes, with wear and tear supraspinatus tendinitis results, which is commonly associated with inflammation of the bursa – subacromial bursitis. There may even be little tears in the tendon fibres – partial tears or sometimes even complete tears. It is typically seen in people aged 25-60.
Painful Arc Synddrome, also called shoulde impingement syndrome, subacromial impingement, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder. It is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder.
Tendinitis and partial tears in the supraspinatus tendon causes a ‘painful arc’ since as the person elevates his arm sideways, the tendon begins to impinge under the acromion throught the middle part of the arc, and this is usually relieved as the arm reaches 180 degrees (vertical).

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

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

  • The most common symptoms in impingement syndrome are
    a loss of movement at the affected shoulder
  • The pain is often worsened by shoulder overhead movement and may occur at night, especially if the patient is lying on the affected shoulder.
  • The onset of the pain may be acute if it is due to an injury or may be insidious if it is due to a gradual process such as an osteoarthritic spur.
  • The pain has been described as dull rather than sharp, and stays for long periods of a time, making it hard to fall asleep at night.
  • Other symptoms can include a grinding or popping sensation during movement of the shoulder.
  • The range of motion at the shoulder may be limited by pain. A painful arc of movement may be present during abduction of the arm from 60° to 120°.
  • Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will ease once the downwards force is removed.
The tendinitis results from trauma (e.g. a fall, dog on leash) in around 30% of cases.
5% of cases are bilateral.
The pain will severely limit shoulder movement and may cause secondary muscular neck pains.

Plain x-rays of the shoulder can be used to detect some joint pathology and variations in the bones, including acromioclavicular arthritis, variations in the acromion, and calcification. However, x-rays do not allow visualization of soft tissue and thus hold a low diagnostic value.
Ultrasonography, arthrography and MRI can be used to detect rotator cuff muscle pathology. MRI is the best imaging test prior to arthroscopic surgery.
The physician may inject lidocaine (usually combined with a steroid) into the bursa, and if there is an improved range of motion and decrease in pain, this is considered a positive "Impingement Test".
Impingement syndrome can usually be diagnosed by history and physical exam. On physical exam, the physician may twist or elevate the patient's arm to test for reproducible pain through some special tests.These tests helps localize the pathology to the rotator cuff, which are -
  1. Neer test
  2. Hawkins-Kennedy test
                Hawkins-Kennedy Test

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

Impingement syndrome is usually treated conservatively, but sometimes it is treated with arthroscopic surgery or open surgery. Conservative treatment includes -
  • Rest : to allow the inflammation to settle
  • Analgesics such as NSAIDs – naprosyn 250mg three times daily with food.
  • Injection of corticosteroid with local anesthetic into the subacromial bursa or the supraspinatus tendon itself will help (though there may be an increase in discomfort in the first 48 hours).
  • Physiotherapy


Surgical Treatment
A number of surgical interventions are available, depending on the nature and location of the pathology.
Surgery may be done arthroscopically or as open surgery.
The impinging structures may be removed in surgery, and the subacromial space may be widened by resection of the distal clavicle through acromioplasty – i.e. re-shaping the acromion and excision of osteophytes on the under-surface of the acromioclavicular joint. Damaged rotator cuff muscles can be surgically repaired.

Physiotherapy Treatment

Physical therapy treatments would typically focus at maintaining range of movement, improving posture, strengthening shoulder muscles, and reduction of pain.Patients who present with SIS will have shoulder pain that is exacerbated with overhead activities. Pain will be the patients' chief complaint and thus relieving pain will initially be the primary goal of physical therapy. Patients with SIS will present with a painful arc of motion (shown to the right). This arc is from 60-120 degrees of shoulder abduction.
For Pain Relief :
Educating the patient on avoiding this painful ROM with repetitive tasks is key to the initial stages of decreasing pain in the shoulder.
  • Ice pack
  • Joint Mobilisation - grade 1&2 glide
  • SWD
  • Ultrasound
  • IFT
For ROM Improvement :
  • Active assisted movement of shoulder joint for 5-7 days
  • Patient has anterior instability and tightness of the posterior capsule. So, performing stretches into IR will allow patients to regain full ROM into IR.
  • Joint Mobilization with PA grade III/IV
         Joint mobilization
  • Functional Activities like waeing clothes by own, doing overhead activities and postural education may be needed.
  • Therapeutic Taping
For Strenghenig of muscle :
  • PNF Techniqes for sholder joint - may provide benefits in more functional patterns.

      rom exercise



Special Instructions 
Most importantly with patients who are experiencing SIS, avoiding painful activities is the most important instruction. Aggravating the already inflamed, irritated shoulder joint is what must be avoided. Examples of potentially painful positions are:
Instruct the patient to avoid sleeping on the involved shoulder as this will place compressive forces through their shoulder and will exacerbate their pain.
Instruct the patient to avoid repetitive overhead activities outside their pain-free ROM. (i.e. putting groceries away over head, reaching for items in taller closets, hammering nails into the wall above head, lifting children up above their heads).