The examination by a physiotherapist often begins before the patient has started to remove their clothes by assessing the patient’s posture. Slumped or rounded shoulders and a protracted neck posture put the shoulder blade and neck muscles on a stretch and may contribute to bringing on symptoms. Neck active movements will be tested and the physio will make note of any loss of motion. The physio may place the neck in a combined stressful position involving downward forces to see if this will elicit symptoms, with shoulder range of movement also recorded.

Examination of the nerves and the blood supply to the arm will normally be performed, with the greatest effects on the nerves and muscles supplied by the lower roots of the brachial plexus. If the veins are being compressed in the vascular type of syndrome then patients turn up with swelling and blueness of the arm. If the arteries are the vessels suffering compression then the arm can be pale, cool and without a pulse or with a very weak one. The blood pressure in the affected arm may be reduced by more than 20mmHg compared to the normal arm.

In the case of thoracic outlet syndrome due to neurological compression the finding are often of weakness and wasting of the small muscles of the hand. There may also be reduced sensation in the areas supplied by the ulnar nerve, which again reflects the fact that the lower nerves of the brachial plexus are most often involved. The last type of this syndrome, that of non-specific thoracic outlet syndrome, has widespread but less precisely located pain, with less precise and clear examination findings, making the diagnosis unreliable at best.

The potentially large numbers of structures in the neck and arm region which could elicit thoracic outlet syndrome has spawned an equally large number of testing procedures in an attempt to reproduce the symptoms. This has lead to a high incidence of false positive and false negative results. In false positive results the test returns a positive result for whatever problem is being tested but the problem is not actually present. In false negatives the test indicates there is no problem present when there is.

Physiotherapists can perform Roos stress test, whereby the patient is asked to maintain their arms in a position of “hands up” while they close and open their hands repetitively. The test is positive if it brings on the usual symptoms complained of or if the arms feel tired and heavy. The structures which cause thoracic outlet syndrome can be of bony or soft tissue origin. The compression or obstructive problems can be caused by a bony structure such as a neck rib or a bony growth on the clavicle or ribs. Soft tissue compressive forces can be due to a fibrous band or oversize muscles.

Trauma to the neck and mechanical stressors may combine with any abnormalities in neck anatomy such as cervical ribs to increase the likelihood of developing thoracic outlet syndrome. Obstruction of the blood supply is an emergency and should be speedily assessed and surgically decompressed with repair to the arteries or veins. Most people with this syndrome are however treated conservatively with anti-inflammatory drugs, transcutaneous electrical nerve stimulation (TENS) and assessment and mobilisation or exercise prescription by a physiotherapist.

Surgical management continues to be an option in patients whose pain does not settle but the mainstay of treatment remains conservative measures. Physiotherapy review takes in any abnormal muscle balance around the area and any postural abnormality in the thorax, shoulders and neck. If one posture is held for long periods or repeatedly returned to then this may cause dysfunction of neck structures.

Abnormalities of posture can elevate local tension or compressive forces and cause chronic compression of the nerves in the area. Maintenance of muscles in a shortened position can cause them to shorten permanently and then react with pain when they are put on a stretch. The idea of muscle imbalance implies that some muscles are stretched by the person’s function and become weaker whilst others become shorter in consequence and so stronger, perpetuating abnormal function. Management of these conditions starts with patient education as understanding is vital if they are to make long term postural changes.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

categories: Back pain,injury management,sciatica,Piriformis Syndrome,pain management,sciatica,back injury,back pain relief,Frozen Shoulder,Alternative medicine,physiotherapists,physiotherapy,Health,physical fitness

In the raising up on tiptoe manoeuvre we should observe that as the calf muscle exerts its power to raise the body weight over the metatarsal heads, the heel should adopt a slight inward slant. If the tibialis posterior tendon is not functioning well this inward movement of the heel does not happen and patients may find the action difficult, painful or not possible. The physiotherapist will next check the foot up on the bed and palpate around the insertion of the tendon for pain, tenderness and swelling. Then the foot will be held in an inwards and foot down position and the patient asked to hold it there as the physio applies resistance to test the muscle power.

Palpation of the length of the tendon during the muscle power testing is performed to check its integrity, followed by measuring the dorsiflexion of the ankle with a straight knee which is usually at least twenty degrees. Longer term flat foot can mean this is limited as the foot has been in a slight downward and outward position for long enough to develop a contracture, a tightening up of the soft tissues. The forefoot may also be subject to the development of an abnormal posture over time and should be reviewed. If the patient has pain, some deformity, problems with gait and managing footwear then treatment may be appropriate.

If the flat foot is painless and the person can walk well then normal shoes with or without insoles will suffice. Conservative management of posterior tibial tendon dysfunction involves resting, immobilisation, anti-inflammatories, physiotherapy and bracing or orthotics. This might be sufficient especially in elderly people as they do not put large forces through the area and may be less suitable for operative intervention. The initial stage of this condition presents primarily with pain, with acute inflammation of the tendon managed in plaster of Paris cast for a few weeks, which can be a weight bearing cast if walking is comfortable.

After the acute inflammatory stage has settled down then orthotics can be employed to support the foot posture and physiotherapy started to increase the ranges of motion of tight joints and increase muscle strength. An AFO or ankle foot orthosis can be used to control the hindfoot posture more strongly as the condition worsens towards a painful but flexible foot deformity. As the deformity increases in rigidity then braces which reach to the knee or above and are individually casted may be necessary. These methods are useful for less active or older individuals who do not demand so much of their feet, leaving surgical management in case of failure.

Surgical treatment of the early acute stage of tendon dysfunction involves opening up the sheath of the tendon to release pressure, a cleaning up of any irregularities in the tendon (debridement) and repairs of tears in the tendon. A below knee cast is used for three weeks after operation and this sort of intervention is thought to prevent the condition from worsening with time. Once the dysfunction becomes more severe the surgical options are many and the choice of which to employ not universally agreed upon and it is difficult to get a very good surgical result.

A ruptured tendon can be trimmed and an end-to-end repair performed, or if avulsed from its bony attachment this can be re-attached to the navicular bone. In more complex surgical procedures the tendons of other local muscles can be used as reinforcements to the posterior tibial muscle tendon, so restoring some of its function. The bony anatomy can also be reshaped by performing an osteotomy and realigning the joint relationships, such an operation on the calcaneum or heel bone aimed at restoring alignment, reducing forces through the plantar and spring ligaments and permitting the soft tissues to endure less stress.

The end result from successful surgery should be the creation of a non-painful foot which can adapt flat to the ground and wear normal footwear. Foot surgery can result in an over correction or an under correction of normal foot posture, with close attention needed to correctly restore the various joint relationships. In the initial phases surgery is aimed at preventing the move towards a tendon rupture.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapists in Coventry. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

After neck injury or generalised pain problems, the disturbances in sensory aspects may occur in the arms and legs even though there are no symptoms in these areas. Local hyperalgesia in the neck, an increased pain response to normally painful stimuli, may be due to the local nerve systems being abnormally sensitised to incoming stimuli. But these more widespread reactions can be indicative of altered processing in the central nervous system. Locally increased pain reactions in the neck can be present in whiplash and general neck pain sufferers but the more widespread sensory upsets may help distinguish whiplash from less severe neck problems.

Patients suffering from whiplash associated disorder report increased levels of disability and neck pain and have more widespread pain on manual examination. There are typical changes which occur in the processes by which pain is processed in the central nervous system which are shared by both whiplash patients and those with nerve root lesions in the cervical spine. A pain condition called allodynia may also present, which is a pain reaction defined by being a painful response to a normally non-painful stimulus. Allodynia also gives a clue that central nervous systems are involved in the process.

The abnormalities in sensory mechanisms which have been found in chronic whiplash patients have been shown to be present just after the time of injury. All whiplash sufferers, irrespective of their severity, develop some hyperalgesia to local mechanical stimuli but in milder injuries and good recovery this settles over two or three months. Those with higher pain and chronic symptoms have persistent hyperalgesia symptoms which may not change from the early period. It is known that musculoskeletal pain patients can have their pain thresholds altered by the presence of anxiety or other psychological distress.

Psychological distress is commonly present in patients who have whiplash associated disorder and if a patient has higher levels of pain and disability they are also likely to have elevated amounts of mental distress. The increased pain sensitivity that patients exhibit is not thought to be the result of psychological distress but the underlying pain reaction mechanisms in the central nervous system might be responsible for both the hyperalgesia and the psychological distress. Along with these findings, cold hyperalgesia (an increased pain reaction to cold) and abnormalities of circulatory function can occur.

As an overreaction to cold is part of the typical symptoms of injury to the peripheral nerves of the body this may indicate that nerve injury is present in some cases of whiplash injury. This cold overreaction is also found in neck nerve root injury, reinforcing the idea that the same underlying nerve abnormalities are found in both this condition and whiplash. In investigations of acute whiplash patients a significant percentage of neuropathic pain symptoms such as cold overreaction, burning neck pain and sudden bursts of electric shock pains have been found.

The jump from investigating the abnormalities in sensory abilities to the application of effective physiotherapy programmes is a large one. Physiotherapy or other manual therapy techniques can help to reduce hyperalgesia caused by local neck structure damage in the absence of other more severe abnormalities of the sensory systems. Prescribing an exercise routine can also have some effect in improvement of local coordination of muscles and reducing the tendency of nerves to overreact.

The presence of the allodynia, the overreaction to cold and the wider spread sensitivity to mechanical inputs means that the treatment needs to be approached with much greater care. It is very easy to stir up the symptoms in this condition and this merely increases the abnormal nerve processing. Manual and manipulative techniques must be applied with care and if this is done then there is some expectation that physiotherapy can be of some use in the management of this kind of disorder.

However if the patients do exhibit neuropathic symptoms such as overreaction to cold stimuli then the therapeutic approach is much less clear, with much higher levels of pain and disability reported. With about 30 percent of patients being helped by drug therapy, the role of physiotherapy in these cases has not been established.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in bradford visit his website.

categories: Back pain,injury management,sciatica,Piriformis Syndrome,pain management,sciatica,back injury,back pain relief,Frozen Shoulder,Alternative medicine,physiotherapists,physiotherapy,Health,physical fitness