Shoulder impingement syndrome and Physical Therapy

Shoulder impingement results from the compression of the rotator cuff muscles under the coracoacromial arch.
Inflammation and pain occurs and is aggravated by the shoulder and arm movements.Pain is felt on antero lateral aspect of shoulder radiating down to mid arm at times.
It can be confirmed with Hawkins-Kennedy impingement test and Neer's impingement test.

ETIOLOGY of shoulder impingement syndrome is multifactorial-

1. Acute trauma: fall on to the shoulder or direct blow on the shoulder.

2. Chronic injury from:
a) Repeated overhead activity like throwing, lifting and catching.
b) Improper postural habits leading to muscle imbalances between deltoid and infraspinatus, teres minor, subscapularis or between supraspinatus and gravity. As a result one group of muscles become tight and other gets stretched and become weak.Loss of rotator cuff strength causes superior migration of humerus resulting in impingement.

3.Outlet impingement due to subacromial osteophytes, hooked or beaked acromion shape, thickened or calcified coracoacromial ligament.


TREATMENT GOALS

1-Decrease the inflammation

*Cryotherapy-Use ice packs for a maximum of 15 minutes, 3 times a day
*Anti inflammatory medication
*Relative rest-Avoiding aggravating and loading activities like overhead reaching and lifting heavy weights in order to prevent further injury to the rotator cuff.

2-Improve posture and shoulder ROM

*Gentle stretching exercises and ROM
-Downward and backward pulling of both the arms with the hands clasped behind the back
-Scapular retraction exercises
-Codman pendular exercises
-Horizontal adduction stretch
-Triceps stretching
-Corner stretch-to stretch the front of the shoulder and the pectorals muscles by pushing against a wall in the corner of the room.
-Biceps stretch

* Sit with back fully supported and work with shoulders being close to the body.

3-Strengthen the rotator cuff muscles and scapular stabilizers.

*Bilateral shoulder extension exercises in prone or standing position.
*Resisted shoulder external and internal rotation in the gravity eliminated plane.
*Supraspinatus strenthening by resisting shoulder abduction in empty can position of the hand.
*Bilateral shoulder abduction in prone
*Supine press
*Biceps curls

Physical Therapy and Parkinson's disease

Parkinson's disease is a chronic progressive neurological disorder resulting from deficiency of dopamine in the brain.It manifest with the triad of-
1. Rigidity or stiffness in the body
2. Bradykinesia or slowness of the movements
3. Resting tremors and postural instability.

Other manifestations include- Intellectual impairment in form of dementia, communication problems due to dysarthria and hypophonia, dysphagia and silorrhea, muscuoskeletal problems due to disuse and inactivity and festinating gait pattern.

Physical therapy management of Parkinson's disease include-

1.Increasing activity levels-Increase overall mobility, do some stretching exercises to elongate muscles and involve patient in a regular walking program.

2.Decreasing rigidity and bradykinesia-Incorporate PNF patterns(specially D2F for upper extremity and D1E for lower extremity) with emphasis on trunk rotation patterns and rhythmic initiation technique.Relaxation exercises in form of gentle rocking can be used to reduce muscle tension.Deep breathing exercises can also be used.Daily stretching and ROM exercises are important.

3.Improving gait pattern-Emphasize high stepping, broad based gait with arm swing and contralateral trunk rotation.Toe wedge can be used to counteract festination.

4.Improving balance-Weight shifts in standing,stepping movements forward and backward, walking and marching in place can be helpful.

5.Improve strength-Focus on lower extremity strengthening in order to improve gait and posture.Trunk extension exercises are also important.

6.Walking aids in form of canes can be used to improve gait and balance

EXERCISES FOR FLAT FOOT

Flat foot / Pes planus

Flat foot/Pes planus is a condition where the arch or instep of the foot collapses and comes in contact with the ground.

The Exercises for the treatment of Flat Feet are-

1. Toe clawing: The toes of the foot are flexed fully; hold in that position and then release again…extend them fully. Repeat this 10-15 times, thrice a day to develop intrinsic muscles of the foot.
2. Toe spreading-The toes are pulled away from each other and then towards one-another
3. Rising the inner border of the foot-The foot is slightly inverted (the internal arch is raised), but the sole is not turned upwards. The height of the arch is increased, whilst the toes are still gripping the ground.
4. Foot-closing-Making fist with foot, relax and then repeat it again.
5. Active foot rolling. The patient tries to draw an 'O' with his/her big toe in sitting position. For the right foot clockwise; for the left foot anti-clockwise.
6. Picking up small logs (of different sizes) through foot, releasing them and then picking up again.
7. Standing on the outer borders of the foot, hold it for 10 seconds, relax and then repeat it again.
8. Toe flexion and extension while sanding on the edge of the stairs with toes of the stairs.
9. Walk on a straight line
10. Walking on the lateral border of the foot
11. Curved foot walking: It involves walking with the foot in arched position and touching the heel and the toe on the ground with the center in arched position. This will help the foot developing the arch. 
12. Heel walking: It involves walking on the heels with the whole body weight on the heels.
13. Toe walking: It involves walking on the toes to strengthen the intrinsic muscles of the foot.

 

 

VESTIBULAR REHABILITATION

Physical therapy for dizziness and imbalance is called as vestibular rehabilitation, or more generally, balance rehabilitation.

Symptoms of vestibular dysfunction include but are not limited to imbalance, nausea, dizziness, true vertigo, and blurry vision, and poor depth perception, loss of balance when walking, falling, confusion, and disorientation.

Vestibular rehabilitation therapy (VRT) has been a highly effective modality for disorders of the vestibular or central balance system. It includes combined specific head and body movements with eye exercises. If the exercises are correctly performed, muscle tension, headaches, and fatigue will diminish, and symptoms of dizziness, vertigo, and nausea will decrease.Most VRT exercises involve head movement, and head movements are essential in stimulating and retraining the vestibular system.

Goals of VRT (Vestibular Rehabilitation Therapy)

• Improve balance
• Minimize falls
• Decrease subjective sensations of dizziness
• Improve stability during locomotion
• Reduce overdependence on visual and somatosensory inputs
• Improve neuromuscular coordination
• Decrease anxiety and somatization due to vestibular disorientation

These conditions can benefit from Vestibular Rehabilitation Therapy:

• BPPV (Benign Paroxysmal Positional Vertigo)
• Bilateral & Unilateral dysfunctions
• Otolith Dysfunction
• Vestibular Labyrinthitis
• Acoustic Neuroma or vestibular neuritis.
• Ototoxicity
• Meniere’s Syndrome
• Neurologic Disorders (stroke, brain injury, multiple sclerosis)

VOR stimulation exercises

Gaze stabilization is the ability to hold the visual world steady while the head and/or body are moving. The vestibulo-ocular reflex (VOR) helps to provide gaze stability when the head moves.

Balance exercises

Static balance activities used for training include Romberg position and standing on one leg. Exercises are made more challenging and incorporate the use of the vestibular system as patients improve by altering the surface they stand on (e.g.: foam, trampoline, tilt board), performing activities with eyes closed and lastly incorporating head motions while maintaining balance.

Dynamic balance is trained by performance of activities including ambulation with head turns, full body turns and marching in place. Dynamic activities are made more challenging as the patient improves by altering the surface (e.g.: balance beam, treadmill), and performance with eyes open and eyes closed.

Cawthorne Cooksey Exercises

1. In bed or sitting

Eye movements -- at first slow, then quickly -up and down, from side to side and diagonally. Focusing on finger moving from 3 feet to 1 foot away from face

Head movements at first slow, then quick, first with eyes open and later with eyes closed -bending forward and backward and turning from side to side, tilting from side to side and moving diagonally.

2. Sitting

Eye movements and head movements as above

Shoulder shrugging and circling

Bending forward and picking up objects from the ground

3. Standing

Eye, head and shoulder movements as above.

Changing from sitting to standing position with eyes open and closed.

Throwing a small ball from hand to hand above eye level

Throwing a ball from hand to hand under knees

Changing from sitting to standing and turning to one side and then to another.

4. Moving about

Walk across room with eyes open and then closed

Walk up and down slope with eyes open and then closed

Walk up and down steps with eyes open and then closed

Sit up and lie down in bed

Sit down in a chair, then stand up

Recover balance when pushed in a specific direction.

Throw and catch a ball

Engage in any game involving stooping or stretching and aiming, such as bowling, volleyball, or shuffleboard.

LOW BACK PAIN

Low Back pain is a musculoskeletal problem encountered by most of the adults at some time in their life. It’s a most common medical problem. There can be variety of causes of low back pain ranging from minor ligamentous sprain to spinal tumour or fracture.
Etiology of low back pain can be categorized as follows-
1. Mechanical Low Backache
• Ligamentous Sprain
• Muscle Strain
2. Degenerative
• Lumbar Spondylosis
• Disc prolapse / slip disc
• Spondylolisthesis
• Spinal stenosis
3. Inflammatory
• Ankylosing spondylitis
• Rheumatoid arthritis
• Osteomyelitis
4. Neoplastic
• Tumors
5. Metabolic
• Osteoporosis
• Osteomalacia
The diagnosis of Low back pain is based on medical history, physical examination including range of motion of back and hip, tests of neurological involvement, muscle strength testing and diagnostic tests like X ray and MRI.
The treatment options depend on the nature of the pain, whether acute or chronic and cause of the pain and accordingly may vary from conservative to surgical. Our focus here is on conservative treatment which includes-
• Analgesics and anti-inflammatory drugs/NSAIDS
• Muscle relaxants
• Various electrotherapeutic modalities like SWD (short wave diathermy), MWD (microwave diathermy), Ultrasound, IFT (interferential therapy), TENS (transcutaneous electrical nerve stimulation).
• Moist heat- Hot packs.
• Lumbar corsets.
• Spinal manipulation
• Exercises to strengthen stretch and condition the back muscles- It is generally recommended in chronic cases. Usually exercise is not performed in acute cases of low back pain. Commonly performed exercises include-
Spinal extension exercises, pelvic tilts, abdominal curls, back rotation exercises.

PRENATAL EXERCISES

Regular exercise (at least three times per week) during pregnancy is extremely beneficial as exercise leads to potentially easier pregnancy and labour, improves cardiovascular fitness, decrease risk of gestational diabetes and promotes faster recovery from labour. It also helps in prevention of low back pain during pregnancy and weight gain. It also counteracts the post partum depression.
But certain precautions are to be taken care of while doing exercise in pregnancy like-

1. Avoid any vigorous exercise in hot and humid weather or during a period of febrile illness.
2. Avoid jerky, bouncy motions.
3. Exercise should be done on a wooden floor or tightly carpeted surface to reduce shock and provide a sure footing.
4. Exercise should include a five minute warm up period of muscle warm up and should follow a cool down period at the end of exercise session.
5. Maintain adequate hydration levels during exercise.
6. Ensure proper body mechanics of posture and lifting.
7. After first trimester of pregnancy, avoid exercise in supine or back lying position.
8. Women with a history of sedentary lifestyle should begin with low intensity exercises and progress gradually.
   
   RECOMMENDED EXERCISES
   
   · Leg sliding exercises.
   · Pelvic tilts
   Postural exercises
   · Stretching at various joints of the body.
   · Modified upper and lower limb strengthening exercises.
   Pelvic floor exercises
   · Kegel exercises
   · Pelvic clock exercises
   Breathing exercises
   · Diaphragmatic and abdominal breathing.
   
   Before starting any exercise program it’s important to get permission from your doctor to rule out any CONTRAINDICATIONS
   
   WARNIG SIGNS to stop exercise-
   · Shortness of breath
   · Dizziness
   · Headache
   · Calf swelling
   · Chest pain
   · Bleeding/Amniotic fluid leakage.
   · Unusual abdominal, back or pubic pain