COMMON PROBLEMS OF THE SPINE, PELVIS and THORACIC CAGE
COMMON PROBLEMS OF THE SPINE, PELVIS and THORACIC CAGE ( rib cage ) in Bhutan
( including non-ortho diagnoses which may present as an orthopedic problem or have ortho issues also )
Notes of Kim Byrd-Rider 2014, not to be used for medical diagnoses
Unspecified pain of a certain area of the spine (although the pt may come with a diagnosis from the doctor, most often the exact diagnosis is not known ). Read further under Disc Herniation, Facet Joint problems, Spondylosis below.
Disc herniation – most often seen in the lower cervical spine and the lower lumbar spine
1Herniated Disk
Also called: Bulging disk, Compressed disk, Herniated intervertebral disk, Herniated nucleus pulposus, Prolapsed disk, Ruptured disk, Slipped disk
Your backbone, or spine, is made up of 26 bones called vertebrae. In between them are soft disks filled with a jelly-like substance. These disks cushion the vertebrae and keep them in place. A herniated disk is a disk that slips out of place or ruptures**. If it presses on a nerve, it can cause back pain or sciatica.
Symptoms include:
Back pain that spreads to the buttocks and legs, when the herniated disk is in your lower back
Neck pain that spreads to the shoulders and upper arms, when the herniated disk is in your upper back
Tingling or numbness
Muscle spasms or weakness
With treatment, most people recover. It can take a long time. Treatments include rest, pain and anti-inflammatory medicines, physical therapy and sometimes surgery. Losing weight can help, too.
** Comment : A herniated disc is NOT a disc that slips out of place. It is a problem where some of the softer, jelly-like inside may protrudes out through the harder outside of the disc
2Bulging and herniated disks
A bulging disk is one in which the tough outer layer of the disk bulges into the spinal canal. A herniated disk is one in which the disk has cracked and some of the soft inner part has leaked out.
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Facet joint problems – this can be in any part of the spine although it may occur more frequently in the areas of the spine where there is a peak of the kyphosis or lordosis curves.
3Facet joint disease
Definition
The Facet joints are the joint structures that connect the vertebrae to one another. The facet joint is like any other joint in your body – they have cartilage that line the joint, (this allows the bone to glide smoothly over one another) and a capsule surrounding the joint. The function of the facet joint is to provide support, stability, and mobility to the vertebrae (spine). Facet Disease occurs when there is degeneration of the facet joint.
There are two facet joints between each vertebrae. They are located on each side of the vertebrae. Facet disease can occur at any level of the spine, but are most common in the lumbar region. There are a number of terms that are used to diagnose facet problems:
Facet Arthritis
Facet Joint Syndrome
Facet Disease
Facet Hypertrophy
Degenerative Facet Joints
In general, all of the terms mean pretty much the same thing – arthritis or degeneration of the facet joint.
Causes
Facet Disease is caused by the cartilage in the joints. This type of injury to the spine can be attributed to arthritis of the spine, work, over-use or an accident.
Risk Factors
Primary risk factors: Idiopathic = unknown cause, and getting growing old ( = “wear and tear” )
Secondary risk factors: Trauma; in this case a physical injury, osteonecrosis or temporary or permanent loss of the blood supply to an area of bone, inflammatory arthritis. Other risk factors: Heredity, gender, diet, obesity, age, physical activity.
Symptoms
Symptoms related to facet joint problems are usually localized to the area of the facet joint. This can occur in the cervical (neck), thoracic (mid-back) and lumbar (lower back).
When the facets are affected in the lumbar region, a person can experience lower back pain that can go to the buttocks and upper thigh area. If the area affected is cervical, then pain can occur in the back of the neck and radiate to the top of the shoulders, and can radiate around the neck.
Diagnosis
Mechanical pain is defined as a damaged specific part of the spine, such as an intervertebral disc, a ligament or a joint that is damaged and not working correctly. Most people suffering from back pain suffer from mechanical pain. Significant lower back pain is rarely caused by facet disease alone because most patients who suffer from facet disease will often have other conditions contributing to their symptoms. Spinal arthritis, degenerative disc disease and often spinal stenosis will often be the contributing factors to facet disease.
Treatment
Since there are a lot of causes of back and neck pain, it is important that when evaluating and treating a patient that the correct diagnosis is made. Pain related to facet disease can be easily diagnosed. This is accomplished by either a thorough physical exam or a diagnostic facet injection, a numbing medication injected into the facet joint. If your pain is caused from the facet joint, then the pain should resolve immediately. If you still have pain after the injection, then your pain may be caused by something else such as Spinal Stenosis or a herniated/bulging disc, which may require a different procedure to correct.
Prevention
When considering conservative methods of treatment for the pain and symptoms being caused by facet disease there are several options. Initially the treatment of the facet disease will involve the patient avoiding the movements and motions such as lifting, extension of the lumbar spine or repetitive twisting that are causing the joints to be painful. Strengthening and stretching exercises aimed at improving the strength and endurance of muscles in the lumbar spine region along with a course of anti-inflammatory medications is often the initial approach.
The inflammation caused by facet disease can be relieved through injections reducing the pain and discomfort that the patient is feeling. Pain may recur after several months making this not often a permanent solution for combating the symptoms of facet disease.
Comment: physiotherapy treatment including exercises, mobilization, activities modification / posture instruction are usually very helpful for patients with facet joint problems.
Combination of the two above - The 3 joints have to work together so therefore a combined problem is most often the case. The problem can, however, be predominantly one or the other.
4Postural problems resulting in pain
Poor posture is the posture that results from certain muscles tightening up or shortening while others lengthen and become weak which often occurs as a result of one’s daily activities. There are different factors which can impact on posture and they include occupational activities and biomechanical factors such as force and repetition. Risk factors for poor posture also include psychosocial factors such as job stress and strain. Workers who have higher job stress are more likely to develop neck and shoulder symptoms.
Who is at risk
Studies have shown that drivers of trucks and public transport vehicles are at a greater risk of lower back and neck pain syndromes as well as other musculoskeletal disorders than clerical workers, partly because of their poor sitting posture and lack of breaks. Clerical workers who use a computer for extended periods are at greater risk of upper extremity and neck pain, especially on the side where the mouse is used. Further studies have implicated poor sitting posture in the development and perpetuation of neck pain syndromes. Sitting for long periods without interruption with poor posture has been shown to cause postural backache.
Poor posture can result in spinal and joint dysfunction as a result of muscle changes. Poor posture can result in short term but more likely long term pain or damage.
Types of poor posture
Poor posture can present in several ways:
It can present with rounded and elevated shoulders and a pushed-forward head position. This position places stress on the spine between the top of the neck and skull and the base of the neck and upper shoulders. There is a reduction in the stability of the shoulder blades resulting in changes to the movement pattern of the upper extremities.
It can present with a forward tilting of the hips, an increase in the curve of the lumbar spine, and a protruding stomach. This position places stress over both the hip joints and lower back.
What Poor Posture Looks Like
Poor posture is the result of musculoskeletal distortion in the neck, and lower and upper back. Most people think of poor posture as simply slumping over, but that is not necessarily the case. Due to the variety of body types, incorrect posture differs from person to person. One person’s proper posture can be incorrect posture for someone else and vice versa. Nevertheless, there are ways to determine poor posture. Some of the classic signs of poor posture include having a pot belly, rounded shoulders, and a jutted out neck and chin. Pot bellies result when the lower back experiences an exaggerated curve, thus pushing the internal organs, in the abdominal region of the body, toward the anterior of the body. Rounded shoulders and postural neck problems result from the excessive anterior curve of the cervical and thoracic spine.
Risks
There are numerous risks associated with poor posture. Poor posture can impede the ability of the lungs to expand.[1] Posture, when correct, helps to increases one’s ability to breathe, and allows muscles to work at optimum capacity. When slumped over, the lungs have less room to contract and inflate, therefore, decreasing its capacity to obtain the maximum amount of oxygen needed.
Poor posture is also a main risk factor in many injuries. Many athletic injuries are the result of poor posture. For example, the Journal of Athletic Training; May 2009 Supplement, states that “many overhead athletes suffer from shoulder pain due to poor posture”. Poor posture injuries can be found everywhere.
Comments: Treatment includes activity modification/posture instructions, body mechanics instruction, exercises to improve mobility and strength etc.
5Scoliosis
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What is scoliosis ?
CLICK TO ENLARGE
Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown.
Most cases of scoliosis are mild, but some children develop spine deformities that continue to get more severe as they grow. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly.
Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.
6STRUCTURAL VERSUS FUNCTIONAL SCOLIOSIS
Functional scoliosis
Functional scoliosis is a curvature due to a problem that does not involve the spine, such as having legs that are different lengths or muscle spasms caused by pain. These can cause a child to lean to the side, creating the appearance of scoliosis.
The curvature, however, is flexible and will go away if the problem that causes the child to lean to the side goes away or if the child canges position such as from standing to lying down. .
Structural scoliosis
In structural scoliosis, the spine curvature is not flexible and does not go away with a change in position.
There is no evidence that functional scoliosis will lead to structural scoliosis.
In about two out of every 10 cases, children with structural scoliosis also have one of these conditions:
Born with vertebrae that do not develop normally (congenital scoliosis )
An underlying problem in the brain or spinal cordCerebral palsy, such as a cyst or a tumor.
A problem with nerves or muscles, such as cerebral palsy or muscular dystrophy (MD)
Scoliosis in Children
Between one and three of every 100 children have a measurable curve in their spines (more than 10 degrees of tilt on an X-ray) that does not have a known cause (idiopathic scoliosis). But only about two of every 1000 children ever gets a curve that is large enough to need treatment.
Equal numbers of boys and girls have the smaller curves that need no treatment. Girls are seven times as likely as boys to have the larger curves in their backbones.
A term for a group of brain injuries that can occur while a fetus is in the womb, at birth or shortly after a baby is born.
Cerebral palsy
A term for a group of brain injuries that can occur while a fetus is in the womb, at birth or shortly after a baby is born.
Leg length difference ( also called leg length discrepancy ) – this will result in some type of functional scoliosis. Also see above under scoliosis.
7A limb length difference may simply be a mild variation between the two sides of the body. This is not unusual in the general population. For example, one study reported that 32 percent of 600 military recruits had a 1/5 inch to a 3/5 inch ( = about less than 2 cm ) difference between the lengths of their legs. This is a normal variation. Greater differences may need treatment because a significant difference can affect a patient's well-being and quality of life.
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Cause
There are many causes of limb length discrepancy. Some include:
Previous Injury to a Bone in the Leg
A broken leg bone may lead to a limb length discrepancy if it heals in a shortened position. This is more likely if the bone was broken in many pieces. It also is more likely if skin and muscle tissue around the bone were severely injured and exposed, as in an open fracture.
Broken bones in children sometimes grow faster for several years after healing, causing the injured bone to become longer. A break in a child's bone through the growth center near the end of the bone may cause slower growth, resulting in a shorter leg.
Bone Infection
Bone infections that occur in children while they are growing may cause a significant limb length discrepancy. This is especially true if the infection happens in infancy. Inflammation of joints during growth may cause unequal leg length. One example is juvenile arthritis.
Bone Diseases (Dysplasias)
Bone diseases may cause limb length discrepancy, as well.
Other Causes
Other causes include inflammation (arthritis) and neurologic conditions
Sometimes the cause of limb length discrepancy is unknown, particularly in cases involving underdevelopment of the inner or outer side of the leg, or partial overgrowth of one side of the body.
Piriformis syndrome
8What is piriformis syndrome?
Piriformis syndrome is a relatively uncommon cause of buttock pain and sciatica. The piriformis muscle is responsible for rotating and stabilizing the hip joint. The sciatic nerve passes directly beneath or occasionally through the piriformis muscle. Due to this anatomic relationship, the sciatic nerve can be compressed due to tightness in the piriformis muscle or following a piriformis strain. When this occurs the condition is known as piriformis syndrome.
Causes of piriformis syndrome
Piriformis syndrome typically occurs due to tightness of the piriformis muscle. This may occur following piriformis injury, overuse of the piriformis, injury to the lumbar spine or due to repetitive strain or trauma. Piriformis syndrome is more common in sports or activities requiring repeated use of the piriformis muscle. These activities may include: running (especially changing direction), sprinting, jumping, squatting or lunging.
Signs and symptoms of piriformis syndrome
Patients with this condition typically experience a pain or ache that is felt deep within the buttock. Pain may also radiate into the back of the thigh, calf, ankle or foot. Patients with piriformis syndrome typically experience an increase in pain when placing the piriformis muscle on stretch (i.e. taking your knee towards your opposite shoulder – see below) or during forceful piriformis muscle contraction (e.g. when running and changing directions). Other activities that may aggravate symptoms include: sitting, climbing stairs, squatting and lunging. In addition, patients may also have reduced hip range of movement and experience tenderness in the piriformis muscle on firm palpation.
Diagnosis of piriformis syndrome
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose piriformis syndrome. Occasionally, further investigations such as an MRI scan or Ultrasound may be required, to assist diagnosis.
Prognosis of piriformis syndrome
With early diagnosis and appropriate management, most patients with this condition can usually recover in days to weeks. In severe or chronic cases of piriformis syndrome, recovery may take significantly longer.
Contributing factors to the development of piriformis syndrome
There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:
muscle tightness (particularly the piriformis and adductor muscles)
joint stiffness (particularly the hip, lower back, sacroiliac joints or pelvic joints)
muscle weakness (particularly the piriformis and gluteals)
lower back injury
poor posture
excessive or inappropriate training
poor biomechanics
inadequate warm up
poor pelvic or core stability
muscle imbalances
Physiotherapy for piriformis syndrome
Physiotherapy for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:
soft tissue massage
electrotherapy (e.g. ultrasound)
stretches
dry needling
muscle energy techniques
joint mobilization
neural mobilization
ice or heat treatment
education
biomechanical correction
progressive exercises to improve strength, flexibility and core stability
activity modification advice
technique correction
devising and monitoring a return to sport or activity plan
Exercises for piriformis syndrome
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.
As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Initial Exercise - Piriformis Stretch Supine
Begin lying on your back (figure 2). Using your hands, take your knee towards your opposite shoulder until you feel a stretch in the buttocks or front of your hip. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercises is pain free.
Figure 2 – Piriformis Stretch (right leg)
9Pudental nerve problems ( pudental neuralgia ) from
Alcock’s Canal or the Pudental Canal travels along the lower obturator internus muscle and pelvic bone. Note the potential for intense compression of the canal by bicycle riding. Many new bicycle seat designs have a depression in the center to reduce perineum pressure. However, this only increases pressure elsewhere, resulting in an even higher chance of injury. Please don't be fooled by such fancy seat designs.
10Overview of Symptoms: The main symptom of pudendal neuralgia (PN) and pudendal nerve entrapment (PNE) is pain in one or more of the areas innervated by the pudendal nerve or one of its branches. These areas include the rectum, anus, urethra, perineum, and genital area.
In women this includes the clitoris, mons pubis, vulva, lower 1/3 of the vagina, and labia.
In men this includes the penis and scrotum. But often pain is referred to nearby areas in the pelvis.
The symptoms can start suddenly or develop slowly over time.
Typically pain gets worse as the day progresses and is worse with sitting. The pain can be on one or both sides and in any of the areas innervated by the pudendal nerve, depending on which nerve fibers and which nerve branches are affected. The skin in these areas may be hypersensitive to touch or pressure (hyperesthesia or allodynia).
Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, knife-like or aching pain, feeling of a lump or foreign body in the vagina or rectum, twisting or pinching, abnormal temperature sensations, hot poker sensation, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse, and sexual dysfunction – persistent genital arousal disorder (genital arousal without desire) or the opposite problem - loss of sensation.
It is not uncommon for PN to be accompanied by musculoskeletal pain in other parts of the pelvis such as the sacroiliac joint, piriformis muscle, or coccyx.
It is usually very difficult to distinguish between PN and pelvic floor dysfunction because they are frequently seen together. Some people refer to this condition as pelvic myoneuropathy which suggests both a neural and muscular component involving tense muscles in the pelvic floor.
Possible Causes of PN
Numerous possible causes for pudendal neuropathy:
inflammatory or autoimmune illness
frequent infections
friction of the nerve from tight muscles, tendons, or enlarged ligaments
tension / strain on the nerve due to i.e. sports involving repetitive hip flexion like heavy weight lifting
compression of the nerve such as with prolonged sitting at work or frequent long drives or cycling
a nerve entrapment similar to carpel tunnel syndrome
trauma to the nerve from an accident i.e. car /fall / mechanical damage
exercise
childbirth
surgery i.e. sacroiliac joint fusion, hysterectomy
occasionally the problem originates in the spine or sacral area rather than the peripheral pudendal nerve.
sometimes there is no apparent explanation
11Treatment which may relieve the pain:
Nerve Block
A nerve block is an injection given at a precise site near the nerve to block pain. As the course of the Pudental nerve is variable it may be difficult to find the right place to do a nerve block. Scans may be used to locate the right place(s) for the injection(s). Typically, three places are injected . The injections are usually a local anesthetic or a slow-releasing steroid given. More than one treatment may be needed to get the pain under control.
Physical Therapy
Sometimes physical therapy can help a patient. The goal of physical therapy is to release the pressure from the tight tissues around the nerve. The pelvic floor may be too tight leading to pudendal nerve compression.
Treatment may include lengthening of the pelvic floor using myofascial release treatments to loosen and release the band(s) of tight tissue and therefore relieve the pressure / pinching of the nerve.
Activity modification
Activity modification to stop or change activities which causes increase in pain will allow the irritated / inflamed tissue to settle down physical activities. These activities may include riding your bike, jogging, working out with weights or whatever activities aggravate the problem.
If sitting is a problem you should use a cushion that relieves the pressure on the painful area – i.e. making a cut-out in the cushion where it causes pressure on the painful area(s)
Pudendal Nerve and Neuralgia12
Physical therapy has proven to be a very successful treatment option for pudendal neuralgia, pudendal nerve irritation and pudendal nerve entrapment.
The pudendal nerve originates from the lumbo-sacral plexus (L4-S4). It consists of both sensory fibers (80%) and motor fibers (20%).
The pudendal nerve branches into 3 smaller nerves:
Inferior rectal nerve: supplies the anal canal, peri-anal skin, rectum, and external anal sphincter.
Perineal nerve: supplies the perineum, vagina, urethra, male scrotum, labia, transverse perineal muscle, and urethral sphincter.
Dorsal nerve of the clitoris or penis: supplies skin of the clitoris/penis, bulbocavernosus, and ischiocavernosus muscles.
Irritation of the pudendal nerve (severe pain in the distribution of the nerve), i.e. pudendal neuralgia, may result in sensory symptoms in any or all areas it supplies and spasms of the muscles supplied by it. A common site for pudendal nerve irritation may be at the Alcock’s Canal, the region between the sacrospinous and sacrotuberous ligaments, and/or at the obturator internus muscle.
The sensory symptoms could manifest as itching, burning, tingling, cold sensations, and/or burning and shooting pain. The sensory symptoms may extend into the groin, abdomen, legs, and buttocks. The pudendal nerve is the only peripheral nerve that has both somatic and autonomic fibers. Thus, a person can experience increased heart rate and blood pressure, decreased motility of the colon, decreased blood flow, and perspiration with pudendal nerve stimulation.
Signs and symptoms may include the following, but they vary between individuals:
Pelvic pain with sitting, but improvement with standing or sitting on a toilet seat.
Discomfort with tight clothing.
Bladder and/or bowel symptoms (hesitancy, frequency, urgency, retention, constipation, pain
Dyspareunia
Genital pain
Anal pain
Abnormal pudendal nerve motor latency test
Pudendal nerve block may decrease symptoms
Physical Therapy Treatment may include:
rehabilitation of the pelvic floor, abdominal, gluteal, lumbosacral and hip rotator muscles
pudendal nerve mobilization, connective tissue mobilization and myofascial trigger point release of the surrounding muscles and tissues.
range of motion and strengthening of certain muscles to improve core and lower extremity balance and stability
Surgical Management of the Pudendal Nerve
Surgery for pudendal nerve entrapment should be considered your last option, because it is an extensive surgery. We advise that you try physical therapy two to three times/week, including a home exercise program and relaxation techniques, for a minimum of 6 months before considering surgery. If you experience an improvement in your symptoms, even if it is only 25% during that 6 months, then we recommend that you continue PT for another 6 months, prior to considering surgery.
Trigger point injections and pudendal nerve blocks, also compliment the physical therapy treatment, but are not always necessary.
Post-operative Symptoms
In some cases, patients may experience post-operative pain. In this situation, physical therapy plays a big role in recovery. With the TIR surgery, men may have pain at the incision site and women may have vaginal scarring. Sacro-iliac joint dysfunction may also be present. In the TG approach, the gluteal muscle is severed and sciatic neural tension may occur.
13Osteoporosis
Osteoporosis is the thinning of bone tissue and loss of bone density over time.
Causes, incidence, and risk factors
Osteoporosis is the most common type of bone disease.
Researchers estimate that about 1 out of 5 American women over the age of 50 have osteoporosis. About half of all women over the age of 50 will have a fracture of the hip, wrist, or vertebra (bones of the spine)- often due a fall. In people with osteoporotic bones a fracture may be the result as the bone break more easily.
Osteoporosis occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or both. Calcium and phosphate are two minerals that are essential for normal bone formation. Throughout youth, your body uses these minerals to produce bones. If you do not get enough calcium, or if your body does not absorb enough calcium from the diet, bone production and bone tissues may suffer. As you age, calcium and phosphate may be reabsorbed back into the body from the bones, which makes the bone tissue weaker. This can result in brittle, fragile bones that are more prone to fractures, even without injury.
Usually, the loss occurs gradually over years. Many times, a person will have a fracture before becoming aware that the disease is present. By the time a fracture occurs, the disease is in its advanced stages and damage is severe.
The leading causes of osteoporosis are a drop in estrogen in women at the time of menopause and a drop in testosterone in men. Women over age 50 and men over age 70 have a higher risk for osteoporosis.
Other causes include:
Being confined to a bed
Chronic rheumatoid arthritis, chronic kidney disease, eating disorders
Taking corticosteroid medications (prednisone, methylprednisolone) every day for more than 3 months, or taking some antiseizure drugs
Hyperparathyroidism
Vitamin D deficiency
Being Caucasian, female and especially having a family history of osteoporosis increases the risk of developing osteoporosis.
Other risk factors include:
Absence of menstrual periods (amenorrhea) for long periods of time
Drinking a large amount of alcohol
History of hormone treatment for prostate cancer or breast cancer
Low body weight
Smoking
Too little calcium in the diet
Symptoms
There are no symptoms in the early stages of the disease.
Symptoms occurring late in the disease include:
Bone pain or tenderness
Fractures with little or no trauma
Loss of height (as much as 6 inches) over time
Low back pain due to fractures of the spinal bones
Neck pain due to fractures of the spinal bones
Stooped posture or kyphosis, also called a "dowager's hump"
Signs and tests
Bone mineral density testing/ bone density test (specifically a densitometry or DEXA scan) measures how much bone you have. The test result is used to predict your risk for bone fractures in the future.
Treatment
The goals of osteoporosis treatment are to:
Control pain from the disease
Slow down or stop bone loss
Prevent bone fractures with medicines that strengthen bone
Minimize the risk of falls that might cause fractures
Different treatments for osteoporosis:
Lifestyle changes
A variety of medications.
Medications are used to strengthen bones when:
Osteoporosis has been diagnosed by a bone density study.
Osteopenia (thin bones, but not osteoporosis) has been diagnosed by a bone density study, if a bone fracture has occurred.
BISPHOSPHONATES
Bisphosphonates are the primary drugs used to both prevent and treat osteoporosis in postmenopausal women.
Bisphosphonates taken by mouth include
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)
Most are taken by mouth, usually once a week or once a month.
Bisphosphonates given intravenously are used less often.
CALCITONIN
Calcitonin is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or injection. The main side effects are nasal irritation from the spray form and nausea from the injectable form.
Calcitonin appears to be less effective than bisphosphonates.
PARATHYROID HORMONE
Teriparatide (Forteo) is approved for the treatment of postmenopausal women who have severe osteoporosis and are considered at high risk for fractures. The medicine is given through daily shots underneath the skin. You can give yourself the shots at home.
RALOXIFENE
Raloxifene (Evista) is used for the prevention and treatment of osteoporosis. Raloxifene can reduce the risk of spinal fractures by almost 50%. However, it does not appear to prevent other fractures, including those in the hip. It may have protective effects against heart disease and breast cancer, though more studies are needed.
The most serious side effect of raloxifene is a very small risk of blood clots in the leg veins (deep venous thrombosis) or in the lungs (pulmonary embolus).
EXERCISE
Regular exercise can reduce the likelihood of bone fractures in people with osteoporosis. Some of the recommended exercises include:
Weight-bearing exercises -- walking, jogging, playing tennis, dancing
Resistance exercises -- free weights, weight machines, stretch bands
Balance exercises -- tai chi, yoga
Riding a stationary bicycle
Using rowing machines
Avoid any exercise that presents a risk of falling, or high-impact exercises that may cause fractures.
DIET
Get at least 1,200 milligrams per day of calcium and 800 - 1,000 international units of vitamin D3. Vitamin D helps your body absorb calcium.
Follow a diet that provides the proper amount of calcium, vitamin D, and protein. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses to form and maintain bones is available.
High-calcium foods include:
Cheese, Ice cream, Leafy green vegetables, such as spinach and collard greens, Low-fat milk, Salmon, Sardines (with the bones), Tofu, Yogurt
STOP UNHEALTHY HABITS
Quit smoking, if you smoke. Also
Limit alcohol intake. Too much alcohol can damage your bones, as well as put you at risk for falling and breaking a bone.
PREVENT FALLS
It is critical to prevent falls.
Avoid sedating medications
Remove household hazards to reduce the risk of fractures.
Make sure your vision is good.
Other ways to prevent falling include:
Avoiding walking alone on icy days
Using bars in the bathtub, when needed
Wearing well-fitting shoes
MONITORING
Your response to treatment can be monitored with a series of bone mineral density measurements taken every 1 - 2 years.
Osteoarthritis - wear and tear type of arthritis also called spondylosis involving disc(s) and facet joint(s ) – see below under spondylosis.
Spinal stenosis
Spinal stenosis ( from : http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001477/ )
Other names include :Pseudo-claudication; Central spinal stenosis; Foraminal spinal stenosis; Degenerative spine disease; Back pain - spinal stenosis
Spinal stenosis is narrowing of the spinal column that may cause pressure on the spinal cord, or narrowing of the openings (called neural – or intervertebral - foramina) where spinal nerves leave the spinal column.
Causes, incidence, and risk factors
Spinal stenosis usually occurs as a person ages and the disks become drier and start to bulge. At the same time, the bones and ligaments of the spine thickens or grow larger due to arthritis or long-term swelling (inflammation).
Spinal stenosis may also be caused by:
Arthritis of the spine, usually in middle-aged or elderly people
Bone diseases, such as Paget's disease of bone and * achondroplasia – see later
Defect or growth in the spine that was present from birth (congenital defect)
Herniated or slipped disk, which often happened in the past
Injury that causes pressure on the nerve roots or the spinal cord
Tumors in the spine
Symptoms
Often, symptoms will get worse slowly over time. Most often, symptoms will be on one side of the body or the other, but may involve both legs.
Symptoms include:
Numbness, cramping, or pain in the back, buttocks, thighs, or calves, or in the neck, shoulders, or arms
Weakness of part of a leg or arm
Symptoms are more likely to be present or get worse when you stand or walk. They will often lessen or disappear when you sit down or lean forward. Most people with spinal stenosis cannot walk for a long period of time.
Patients with spinal stenosis may be able to ride a bicycle with little pain.
More serious symptoms include:
Difficulty or poor balance when walking
Problems controlling urine or bowel movements
Signs and tests
During the physical exam, your doctor will try to find the location of the pain and figure out how it affects your movement. You will be asked to:
Sit, stand, and walk. Your doctor may also ask you to try walking on your toes and then your heels.
Bend forward, backward, and sideways
Lift your legs straight up while lying down. If the pain is worse when you do this, you may have sciatica, especially if you also feel numbness or tingling in one of your legs.
The doctor will also move your legs in different positions to check your strength and your ability to move.
To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many places with a pin, cotton swab, or feather tests how well you feel. Your doctor will tell you to speak up if there are areas where you have less feeling from the pin, cotton, or feather.
A brain and nervous system (neurological) examination can confirm leg weakness and decreased sensation in the legs. The following tests may be done:
EMG. Spinal MRI or spinal CT scan, X-ray of the spine
Treatment
When your back pain does not go away, or it gets more painful at times, learning to take care of your back at home and prevent repeat episodes of your back pain can help you avoid surgery.
Your doctor and other health professionals will help you manage your pain and keep you as active as possible.
Your doctor may refer you for physical therapy. The physical therapist will help you try to reduce your pain, using stretches. The therapist will show you how to do exercises that make your neck muscles stronger.
You may also see a massage therapist, and someone who performs acupuncture. Sometimes a few visits will help your back or neck pain.
Cold packs and heat therapy may help your pain during flare-ups.
A number of different medications can help with your back pain.
Surgery
If the pain does not respond to these treatments, or you lose movement or feeling, you may need surgery. Surgery is done to relieve pressure on the nerves or spinal cord. Spinal stenosis symptoms often become worse over time, but this may happen very slowly.
People who had long-term back pain before their surgery are likely to still have some pain afterwards. Spinal fusion probably will not take away all the pain and other symptoms.
Even when using MRI scans or other tests, it is hard for your surgeon to always predict whether you will improve and how much relief surgery will provide.
Expectations (prognosis)
Many people with spinal stenosis are able to be active for many years with the condition, although they may need to make some changes in their activities or work.
Spine surgery will often partly or fully relieve symptoms. However, people who had long-term back pain before their surgery are still likely to have some pain afterward.
Spine problems are possible after spine surgery. The area of the spinal column above and below a spinal fusion are more likely to be stressed when the spine moves. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may be more likely to have future problems.
* Paget’s disease of the bone ( from: http://www.nlm.nih.gov/medlineplus/ency/article/000414.htm )
Paget's disease is a disorder that involves abnormal bone destruction and regrowth, which results in deformity.
Causes
The cause of Paget's disease is unknown, although it might have to do with genes or a viral infection early in life.
The disease occurs worldwide, but is more common in Europe, Australia, and New Zealand.
In people with Paget's disease, there is an abnormal breakdown of bone tissue, followed by abnormal bone formation. The new bone is bigger, but weaker and filled with new blood vessels.
The disease may only be in one or two areas of the skeleton, or throughout the body. It often involves bones of the arms, collarbones, leg, pelvis, spine, and skull.
Symptoms
Most patients have no symptoms. Paget's disease is often diagnosed when an x-ray is done for another reason.
If they do occur, symptoms may include:
Bone pain, joint pain or stiffness, and neck pain (the pain may be severe and present most of the time)
Bowing of the legs and other visible deformities
Enlarged head and skull deformities
Fracture
Headache
Hearing loss
Reduced height
Warm skin over the affected bone
** Achondroplacia
Achondroplasia is a disorder of bone growth that causes the most common type of dwarfism.
Causes, incidence, and risk factors
Achondroplasia is one of a group of disorders called chondrodystrophies or osteochondrodysplasias.
Achondroplasia may be inherited as an autosomal dominant trait, However, most cases appear as spontaneous mutations. This means that two parents without achondroplasia may give birth to a baby with the condition.
Symptoms
The typical appearance of achondroplastic dwarfism can be seen at birth. Symptoms may include:
Abnormal hand appearance with persistent space between the long and ring fingers
Bowed legs
Decreased muscle tone
Disproportionately large head-to-body size difference
Prominent forehead (frontal bossing)
Shortened arms and legs (especially the upper arm and thigh)
Short stature (significantly below the average height for a person of the same age and sex)
Spinal stenosis
Spine curvatures called kyphosis and lordosis
Signs and tests
During pregnancy, a prenatal ultrasound may show excessive amniotic fluid surrounding the unborn infant.
Examination of the infant after birth shows increased front-to-back head size. There may be signs of hydrocephalus ("water on the brain").
X-rays of the long bones can reveal achondroplasia in the newborn.
Treatment
There is no specific treatment for achondroplasia. Related abnormalities, including spinal stenosis and spinal cord compression, should be treated when they cause problems.
Expectations (prognosis)
People with achondroplasia seldom reach 5 feet in height. Intelligence is in the normal range. Infants, who receives the abnormal gene from both parents, do not often live beyond a few months.
Spondylosis
14Lumbar spondylosis is a degenerative condition which affects the spine – especially the lumbar and the cervical sections. In a patient with lumbar spondylosis, the spine is compromised by a narrowing of the space between the vertebrae, causing a variety of health problems ranging from back pain to neurological issues. This condition is usually caused by old age, as the spine undergoes changes as people grow older, and many of these changes contribute to degeneration of the vertebrae. Spondylosis, which can appear in the thoracic vertebrae as well, is also known as spinal osteoarthritis.
In a classic case of lumbar spondylosis, the space between discs in the lumber spine becomes narrowed – see pictures below. As a result, the patient develops numbness, tingling, and pain which seem to radiate out from the area. These symptoms are the result of pressure on the nerves as they exit the spinal cord. If the spondylosis is allowed to progress, it can lead to a narrowing of the spinal canal, resulting in impingement of the spinal cord, which can cause poor bladder control, unsteady gait, and other severe neurological problems.
Over the course of the development of lumbar spondylosis, the vertebrae tend to become stiff, and they must fuse or immobilize. This leads to decreased flexibility and increased back pain as the patient's spine may become contorted or compromised by the immobilized vertebrae. Lumbar spondylosis can also be characterized by the development of bone spurs and bony overgrowths around the spine which can pinch nerves.
Degenerative changes of the spine – can also be called osteoarthritis of the spine.
As your spine ages, it's more likely to experience bone spurs or herniated disks. These problems can reduce the amount of space available for your spinal cord and the nerves that branch off it.
15Lumbar spondylosis: clinical presentation and treatment approaches
Introduction
Low back pain (LBP) affects approximately 60–85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15–45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable.
Terminology
The terms lumbar osteoarthritis, disk degeneration, degenerative disk disease, and spondylosis are used in the literature to describe anatomical changes to the vertebral bodies and intervertebral disk spaces that may be associated with clinical pain syndromes.
Spinal osteoarthritis (OA) is a degenerative process defined radiologically by joint space narrowing, osteophytosis, subchondral sclerosis, and cyst formation. Osteophytes included within this definition fall into one of the two primary clinical categories. The first, spondylosis deformans describes bony outgrowths arising primarily along the anterior and lateral perimeters of the vertebral end-plate apophyses. These hypertrophic changes are believed to develop at sites of stress to the annular ligament and most commonly occur at thoracic T9–10 and lumbar L3 levels. These osteophytes have minimal effect on intervertebral disk height and are frequently asymptomatic, with only rare complications arising from their close anatomic relationship to organs anterior to the spine.
By contrast, intervertebral osteochondrosis describes the formation of more pathological end-plate osteophytes ( = bone spurs ), associated with disk space narrowing, vacuum phenomenon, and vertebral body reactive changes. If protruding within the spinal canal or intervertebral foramina, these bony growths may compress nerves with resulting radiculopathy or spinal stenosis. Moreover, these bony projections may limit joint mobility and invade other organs or tissues. The term “osteoarthritis” suggests pathology limited to bone. Nevertheless, in this context, it has clear implications for the health of neighboring disks and nerve roots.
Comparatively, degenerative disk disease (DDD) refers to back pain symptoms attributable to intervertebral disk degeneration. Such pathologic changes include disk desiccation, fibrosis, and narrowing. The anulus may bulge, fissure, or undergo mucinous degeneration. Also included within the anatomic definition of DDD are defects and sclerosis of the end-plates, and osteophytes at the vertebral apophyses. With these bony changes included in the radiographic description of both OA and DDD, there exists diagnostic overlap between the conditions. As a result, these terms are often used interchangeably in the medical literature to describe similar phenomena.
Spondylosis of the lumbar spine, the subject of this paper, is a term with many definitions. In the literature, it has been utilized in many different contexts, employed synonymously with arthrosis, spondylitis, hypertrophic arthritis, and osteoarthritis. In other instances, spondylosis is considered mechanistically, as the hypertrophic response of adjacent vertebral bone to disk degeneration (although osteophytes may infrequently form in the absence of diseased disks). Finally, spondylosis may be applied nonspecifically to any and all degenerative conditions affecting the disks, vertebral bodies, and/or associated joints of the lumbar spine]. For purposes of this review, we will use this final, broad definition of spondylosis, recognizing the high incidence of coincident degenerative changes, and the dynamic interplay between adjacent disks, vertebra, and nerves that create the clinical pain syndromes within the axial spine and associated nerves.
Epidemiology
Radiographic evidence of degenerative disease of the lumbar spine among asymptomatic individuals is impressive. MRI imaging in asymptomatic patients over age 60 years reveals disk protrusions in 80% and degenerative spinal stenosis in 20%. A study comparing radiographic evidence of spine degeneration among categories of men who were without pain, with moderate pain, or with severe lower back pain found similar frequency of disk space narrowing and bone spurs among all three groups.
Furthermore, degenerative changes may appear in young individuals without decades of spine loading. Lawrence found 10% of women aged 20–29 to demonstrate evidence of disk degeneration. Lumbar spondylosis, while affecting 80% of patients older than 40 years, nevertheless was found in 3% of individuals aged 20–29 years in one study. The high incidence of degeneration among young and asymptomatic individuals highlights the challenge involved in establishing causality between imaging findings and pain symptoms in affected patients.
Clinical presentation
Pain within the axial spine at the site of these degenerate changes is not surprising as nociceptive pain generators have been identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura, and myofascial structures within the axial spine.
A Diagnostic Approach
The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.
Radiographic studies, whether plain film, CT, CT myelogram, or MRI, may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression. However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disk herniation or neurological deficit. Furthermore, there remains a frequent disconnection between the symptom severity and the degree of anatomical or radiographic changes. While correlations between the number and severity of osteophytes and back pain exist, the prevalence of degenerative changes among asymptomatic patients underlies the difficulty assigning clinical relevance to observed radiographic changes in patients with LBP.
16SPONDYLOLYSIS represents a weakness or stress fracture in one of the bony bridges that connect the upper with the lower facet joints of the vertebra. It is the most common cause of low back pain in young athletes. One-half of all paediatric and adolescent back pain in athletic patients is related to various disturbances in the posterior elements including spondylolysis. The most common clinical presentation of spondylolysis is low back pain. This is aggravated by activity and is frequently accompanied by minimal or no physical findings. A pars stress fracture or early spondylolysis are common.
This defect can either be asymptomatic or associated with significant low back pain (LBP). This condition is present in up to 6% of the population. Although the aetiology of this lesion is still unclear, it has been shown to have both hereditary and acquired risk factors, with an increased prevalence in men and athletes participating in certain high-risk sports.
Spondylolysis is indeed, a common cause of low back pain in preadolescent and adolescent athletes (50%) and it particularly presents a clinical problem in this population. It occurs with higher frequency in people engaged in certain activities that appear to put unusual stress on their lower spine. Gymnasts, football linemen, weightlifters, wrestlers, dancers, and drivers are the most commonly affected individuals.
Plain radiography with posteroanterior (P - A), lateral and oblique views have proved very useful in the initial diagnostics of low back pain, but imaging studies such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans are more sensitive in the establishment of the diagnosis.
Several treatment options are available. Surgical treatment is indicated only for symptomatic cases when conservative methods fail. The fact that early and multiple imaging studies may have a role in the diagnosis of pars lesions and the selection of the optimal treatment approaches is also highlighted.
The vast majority of spondylolitic defects occur at the L5 level (85 - 95%), with L4 being the second most commonly involved level (5 – 15%) whereas higher lumbar areas are rarely affected.
Spondylolisthesis occurs in a significant proportion of individuals with bilateral spondylolysis. It appears that approximately 50 - 81% of people suffering from spondylolysis have associated spondylolisthesis. This is defined as: the complete bilateral fractures of the pars interarticularis resulting in the anterior slippage of the vertebra. Predicting risk factors for progression of the slip to spondylolisthesis has proven to be difficult. See below.
Comment: it seems that spondylolysis may be a precursor to spondylolisthesis.
See drawing below for Spondylolysis and Spondylolisthesis
Left, The pars interarticularis is found in the posterior portion of the vertebra. Center, Spondylolysis occurs when there is a fracture of the pars portion of the vertebra. Right,Spondylolisthesis occurs when the vertebra shifts forward due to instability from the pars defect.
17Spondylolisthesis
Spondylolisthesis is a condition in which a bone (vertebra) in the lower part of the spine slips out of the proper position onto the bone below it.
Causes, incidence, and risk factors
In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).
In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae.
Other causes of spondylolisthesis include bone diseases, traumatic fractures, and stress fractures (commonly seen in gymnasts). Certain sport activities -- such as gymnastics, weight lifting, and football -- put a great deal of stress on the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.
Symptoms
Spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no symptoms.
The condition can produce increased lordosis (also called swayback), but in later stages may result in kyphosis (roundback) as the upper spine falls off the lower spine.
Symptoms may include:
Lower back pain
Muscle tightness (tight hamstring muscle)
Pain in the thighs and buttocks
Stiffness
Tenderness in the area of the slipped disc
Nerve damage (leg weakness or changes in sensation) may result from pressure on nerve roots and may cause pain radiating down the legs.
Signs and tests
The doctor will perform a physical exam. A straight leg raise may be uncomfortable or painful.
X-ray of the spine can show if a vertebra is out of place, and whether there are any fractures.
Treatment
Treatment varies depending on the severity of the condition. Most patients get better with strengthening and stretching exercises combined with activity modification, which involves avoiding hyperextension of the back and contact sports.
Nonsurgical treatments are tried first. This may include:
Anti-inflammatory medicines to reduce back pain
A stiff back brace
Physical therapy
You should take a break from activities until your symptoms go away. In most cases, you can resume activities slowly.
Surgery to fuse the slipped disc may be needed if you have severe pain that does not get better with treatment, a severe slip of the vertebra, or any neurological changes. Such surgery has a higher rate of nerve injury than most other spinal fusion surgeries. A brace or body cast may be used after surgery.
Periodic x-rays can show whether the vertebra is changing position over time.
Expectations (prognosis)
Conservative therapy for mild spondylolisthesis is successful in about 80% of cases.
When necessary, surgery leads to satisfactory results in 85 - 90% of people with severe, painful spondylolisthesis.
Complications
If too much slippage occurs, the bones may begin to press on nerves. Surgery may be necessary to correct the condition.
Other complications may include:
Chronic back pain
Infection
Temporary or permanent damage of spinal nerve roots, which may cause sensation changes, weakness, or paralysis of the legs
Prevention
People with marked lordosis should avoid back hyperextension (leaning way back), weight lifting, and contact sports.
Lower back pain, although common in preadolescent and adolescent children, should be evaluated, especially in the presence of marked lordosis
Pelvic floor insufficiency ( bladder and bowel / dysfunction/ incontinence )
18Women's Health
Pelvic Floor Dysfunction
What causes pelvic floor dysfunction? A deconditioning of the pelvic floor muscles causes such pelvic floor dysfunction as incontinence, pelvic organ prolapse, or pelvic pain. A woman may have lost her vaginal tissue strength following a normal birth delivery and have an increased risk of pelvic organ prolapse. Other causes include nerve injuries during delivery, impact trauma, muscular trauma, fascial tearing, constipation and straining, lack of estrogen, sexual abuse, obesity, medications, behavioral habits, or musculoskeletal factors.
Incontinence
What is incontinence? Incontinence is an involuntary loss of urine, which can occur when there is more pressure in the bladder than in the sphincter. It is not only embarrassing but can also cause a hygiene problem. The different classifications of incontinence are as follows: Urge incontinence, Stress incontinence, Mixed incontinence, Overflow incontinence, Reflex incontinence, Functional incontinence, Enuresis
Urge incontinence – The bladder is overactive. The person visits the bathroom frequently, feels “an urge” to urinate, is unable to “hold it” long enough to get to the toilet, urinates more than eight times per 24-hour period, awakens more than once during the night to urinate, or leaks a moderate-to-large amount. Any of these symptoms is indicative of urge incontinence.
Stress incontinence – The urethra is incompetent and won’t remain closed; therefore, the sphincter doesn’t close. Without warning, the person may lose a small volume of urine while laughing, coughing, or jumping or at any time when there is an increase in intra-abdominal pressure. This is a result of weak pelvic floor muscles. Pelvic traumas, such as childbirth or impact injuries, are common causes.
Mixed incontinence – This is a combination of urge and stress incontinence.
Overflow incontinence – The bladder is under active and does not empty well. This is the result of an outlet obstruction or under active neurogenic bladder. There is no urge present, and the bladder fails to empty normally. Self-catheterization is the usual management strategy, although timed voiding and functional voiding training may be helpful.
Reflex incontinence – There is no sensation and no control of the sphincters. The cause is a suprasacral lesion such as those experienced by a person with a CVA or spinal cord injury.
Functional incontinence – A person is unable to get to the bathroom in time. It could be due to a lack of mobility, such as experienced by an elderly person; limitations in the person’s environment, such as in a skilled nursing facility; or poor cognition.
Enuresis – There is a moderate loss of urine with no stress or sensation. The bladder contracts but the person doesn’t feel it. This sometimes happens with children who experience a problem with bedwetting. A bedwetting device used consistently will help train the child to awaken as soon as he or she begins to urinate. The alarm will sound and awaken the child, thus providing the biofeedback that the child needs to urinate.
Pelvic Organ Prolapse
What is pelvic organ prolapse? The symptoms of a pelvic organ prolapse include a bulging feeling in the vagina that worsens as the day progresses, urinary incontinence, or constipation. The types of pelvic organ prolapse are listed below:
Cystocele – The bladder bulges into the vagina through the tissue between the bladder and vagina, causing the bladder to come down into the vagina; it does not break through the tissue. It is graded from 1 to 3 according to the amount of descent.
Rectocele – The anterior wall of the rectum bulges into the posterior wall of the vagina and can cause a feeling of increased pressure and difficulty moving bowels.
Urethrocele – The tissue between the vagina and the urethra weakens, causing the urethra to push into the vagina.
Uterine prolapse – The uterus slips into the vagina, causing a bulging sensation. It is measured in grades between 1 and 4, with 4 being the most involved. Enterocele – Organs such as the small intestine can bulge through the vagina. This is more commonly seen following a hysterectomy. This does not mean that after a hysterectomy you are likely to have an enterocele.
Ultrasound and MRI.
Real-time diagnostic ultrasound and MRI is being used to evaluate PFM action during contraction. Ultrasound can be performed either with the probe placed suprapubically or at the perineum (curved-array ultrasound probe or with the probe inserted into the vagina or rectum ).
With the subjects in a sitting position, a mean inward lift of the PFM of 10.8 mm (SD=6.0) was measured by MRI. This finding corresponds with results from a recent study using ultrasound where a mean lift of 11.2 mm was visualized with the subjects positioned supine. There is consensus that both ultrasound and MRI should be considered an investigational imaging technique in the evaluation of female urinary incontinence and pelvic-floor dysfunction. Ultrasound is increasingly being used clinically because this technology is becoming more economically available to physical therapists.
19Pelvic Floor Muscle Function and Urinary Incontinence: A Role for Physical Therapy
The pelvic floor muscles are comprised of two layers of muscles. The deep layer of the pelvic floor is known as the levator ani muscle group. The superficial layer is known as the urogenital diaphragm muscles (consisting not only of the deep transverse and superficial transverse perineal muscles but also the bulbocavernosus and ischiocavernous muscles, and the anal sphincter muscle). (http://incontinet.com/kegelpix.htm) The functions of the pelvic floor muscles are to squeeze around the pelvic openings and to provide and inward lift.1, 2 When these two muscle group layers are not contracting simultaneously, or if the contraction is preceded by an increase in abdominal pressure, stress urinary incontinence can occur.
Stress Incontinence is defined by the International Continence Society as the complaint of any involuntary leakage of urine.4 Stress incontinence, the most common type of urinary incontinence in women, is defined as the involuntary leakage of urine on effort or exertion, such as sneezing or coughing.
There is good evidence to support the use of pelvic floor muscle training to treat stress urinary incontinence.1 Pelvic floor muscle training can improve the muscle control, timing of superficial and deep layer contractions, and the pelvic floor strength. Further, strengthening the pelvic floor muscles improves quality of life by improving incontinence, increasing support of pelvic viscera and sexual functioning.
Without proper instruction, many women are unable to volitionally contract these muscle groups on demand as the pelvic floor muscles are located at the floor of the pelvis and seldom used consciously. One common error is the substitutions of gluteal, hip adductor and/or abdominal muscles rather than contraction the pelvic floor muscles.
Assessment of pelvic floor muscle strength can be done through clinical observation (although visual observation alone is often inadequate), vaginal palpation, ultrasound and MRI, or electromyography. Two main reasons for physical therapist to conduct high-quality assessment of pelvic floor muscle function and strength are: 1) to ensure proper pelvic floor muscle contraction technique prior to performing a strength exercise program, 2) to measure and assess program outcomes and adjust the training parameters (intensity, frequency, or duration) appropriately as indicated.1
Arab et al. (2010). Assessment of Pelvic Floor Muscle Function in Women with and without Low Back Pain Using Transabdominal Ultrasound
The purpose of this study was to investigate the PFM function in women with and without LBP using transabdominal ultrasound. A cross-sectional design was used to compare 40 nonpregnant women between the ages of 20 and 50 years old (20 with LBP; 20 without LBP). Each participant underwent transabdominal ultrasound normalized to their calculated BMI; PFM function differs according to each individuals BMI ( = Body Mass Index – a measure for if a person is weight in relation to height is within normal or not.) Baseline was established as the base of the bladder before contraction, and the change in distance of the base of bladder from pre and post contraction was used to determine significance of findings. Study results found a significant difference (p = .04) in the transabdominal ultrasound measurements of PFM function btw subjects with LBP and those without LBP. Participants with LBP displayed a pattern of decreased pelvic floor function when measured with transabdominal ultrasound.
20Clinical Bottom Line
Transabdominal ultrasound has proven that the PFM and trunk musculature co-contract to provide stability to the lumbar spine and pelvis. Lack of neuromuscular control in the PFM can be associated with trunk instability, which results in LBP. It is important for the physical therapist to consider pelvic floor dysfunction when evaluating and treating patients with LBP. Although recent research has made many gains in relating LBP and PFD, much more progress is needed to definitively establish the relationship between the two conditions and identify successful intervention techniques.
21What is the pelvic floor? The pelvic floor is a large hammock of muscles stretching from side to side across the floor of the pelvis. It is attached to your pubic bone in front, and to the the tail end of your spine behind. The openings from your bladder, your bowels and your womb all pass through your pelvic floor.
What does the pelvic floor do? . It supports your pelvic organs and the contents of your abdomen, especially when you are standing or exerting yourself. . It supports your bladder to help it stay closed. It actively squeezes when you cough or sneeze to help avoid leaking. . It is used to control wind and when "holding on" with your bowels. . It helps to increase sexual awareness both for yourself and your partner during sexual intercourse.
What weakens the pelvic floor muscles? Pelvic floor muscles weaken for similar reasons to other muscles in our bodies: natural ageing and inactivity. But pelvic floor muscles are also often weakened through hormonal changes in women's bodies, and through pregnancy and childbirth. Factors such as being overweight, ongoing constipation and a chronic cough can put extra pressure on the pelvic floor and pelvic surgery can also have damaging effects, particularly in men. Weak pelvic floor muscles are very common. A new US study shows that 25% of women suffer from moderate to severe pelvic floor muscle weakness, with the figure rising to 30% or more of obese and older women. (Nygaard and others, 2008).
Why do I need to do pelvic floor exercises? A poorly toned, weak pelvic floor will not do its job properly. Women with weak pelvic floor muscles frequently experience incontinence and reduced sexual response. But research has shown that the pelvic floor responds to regular exercise. With regular exercise, it is possible for most women to reduce or completely overcome the symptoms of weak pelvic floor muscles, no matter what their age. A regime of pelvic floor exercises, introduced earlier in life, will also prevent many of the problems associated with weak pelvic floor muscles emerging later. It is never too early or too late to begin to exercise the pelvic floor. Research has also shown that pelvic floor exercise can provide relief from chronic pelvic pain syndrome. A woman with already badly weakened pelvic floor muscles may need the advice of a women's health physiotherapist or other health professional before embarking on an exercise program, but many women with mild symptoms prefer to try a simple exercise program for themselves initially. Pelvic floor exercises are often also called Kegel exercises, after their originator, Dr Arnold Kegel and are widely promoted as the starting point for building pelvic floor strength. Any woman can try these exercises for herself. Be aware that if they are not done correctly, they can aggravate a problem. Follow the instructions below, but seek the advice of a health professional, such as your gp or a women's health physiotherapist, if you have doubts about your ability to do the exercises correctly. How to do unassisted pelvic floor exercises Exercise 1 Squeeze and draw in the muscles around your back passage, vagina and front passage and lift up inside as if trying to stop passing wind and urine at the same time. Try to hold the muscles strong and tight as you count to 8. Now let them go and relax. You should have a distinct feeling of letting go. Repeat the "Squeze, Lift and Hold" movement and let go It is best to rest in between each lift up of the muscles. If you can't hold for a count of 8, just hold for as long as you can. Repeat this "Squeeze, Lift and Hold" contraction as many time as you can, up to a limit of 8-12 contractions. Try to do three sets of 8 to 12 squeezes each, with a rest in between. Do this whole training plan (three sets of 8 to 12 squeezes) each day while lying down, sitting or standing. Try to vary the positions you use so that your muscles get used to working in different situations. Exercise 2 The ability to work these muscles quickly helps them react to sudden stresses from coughing, laughing or exercise. Practice some quick contractions, drawing in the pelvic floor and holding for just one second before releasing the muscles. Do these steadily, aiming for a strong muscle tightening with each contraction up to a maximum of 10 times. Repeat a set of quick contractions after each three sets of Squeeze Lift and Hold contractions in Exercise 1. When you do your pelvic floor contractions, you may sense a gentle drawing in of the lower abdominal area (not all women will sense this, so don't worry if you don't). This is desirable muscle activity as these deep lower abdominal muscles can also work with the pelvic floor muscles. However, you should not strongly and intentionally draw in your general abdominal area while you contract your pelvic floor muscles. I f you do pelvic floor exercises regularly, you will see optimum results within 3 to 6 months, but you should continue them for life to fully protect your pelvic floor.
How to achieve better results with your pelvic floor exercises There is a growing amount of research showing many women achieve better results when they use pelvic floor exercise devices to assist them in doing pelvic floor exercises. Dr Kegel, the originator of the kegel exercise program, never intended his exercises to be conducted on an empty vagina. He developed an exercising product similar to the perineometers (eg PFX2 and PX-IQ) in use today. Somewhere along the line, his message has been lost and for many years women have been encouraged to try unassisted exercising. For many women, this presents difficulties and they may be able to achieve better results with the assistance of a pelvic floor exercise or strengthening device. Many good pelvic floor exercisers have been available for some time but are often hard to track down, particularly for women who want to exercise independently at home. Pelvic Floor Exercise brings together a range of the best devices available on the Australian market, to make choosing and buying easier.
Why are women sometimes unsuccessful in strengthening their pelvic floor? Often because they don't exercise often enough, and for long enough. Women report that they don't remember, they find it hard to fit exercises into daily life, they feel uncertain about whether the exercises are working and whether they are doing them correctly, particularly in the early stages. Many women find that using a pelvic floor exercise device produces better results than unassisted exercising, so they are encouraged to keep going. Maintaining your own motivation is half the battle with home-based exercising.
PELVIC FLOOR EXERCISE ( from the website of The Australian Physiotherapy Association : www.physiotherapy.asn.au/ )
HOT TIPS
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Infections including TB of the bone(s) of the spine
22OSTEOMYELITIS
Introduction:
Osteomyelitis is an infection of the bone. It can happen in any bone in the body, but it most often affects the long bones (leg and arm), vertebral (spine), and foot bones. You can have a bacterial infection (usually from Staphylococcus) or, more rarely, a fungal infection. Osteomyelitis is rare in the U.S. It tends to affect more men than women, and is most often seen in children and people over 50.
Bone can become infected when bacteria travels through the bloodstream from another spot in your body, or the bone itself can become infected directly. Osteomyelitis can be acute (symptoms last a few months) or chronic (symptoms can last years), and the type of disease determines the treatment. Osteomyelitis is a serious condition that requires prompt medical treatment.
Signs and Symptoms:
The symptoms of osteomyelitis include:
Pain, swelling, warmth, and redness at the site of the affected bone
Persistent back pain that is not relieved by rest, heat, or painkillers
Abscesses with pus in tissue surrounding the painful bone
Fever, in some cases
Fatigue
Osteomyelitis in the hip, pelvis, or back may cause no symptoms
What Causes It?:
An infection, caused by bacteria or a fungus, can develop in the bone or spread to the bone from elsewhere in the body. Osteomyelitis can happen after a fracture or other injury, or as the result of a joint replacement. The infection can also spread beyond the bone, creating abscesses in muscles and other tissues outside the bone. The types of infections are:
Those that travel through the bloodstream, which are most common in children
Those that happen after an injury (such as fractured bones that break the skin) or surgery (such as joint replacement)
Those that happen due to poor circulation (caused by diabetes, for example), which keeps the body from getting rid of the infection
Those that occur in the spine (vertebral osteomyelitis)
Treatment Options:
Chronic osteomyelitis is treated with surgery and antibiotics. Acute and vertebral osteomyelitis may be treated with antibiotics alone, depending on the condition. Your health care provider may also put you in a cast or splint to immobilize the affected bones and joints.
Drug Therapies
The medication you need depends on the type of bacteria or fungus that caused your osteomyelitis. You may need intravenous (IV) antibiotics, or you may take oral antibiotics. Courses of antibiotics lasting several weeks should clear up infections identified early. With chronic osteomyelitis, you may need to take antibiotics for years or even the rest of your life.
Surgical Procedures
In some cases you may need surgery. Surgical procedures for osteomyelitis include:
Draining the infected area, to get rid of pus or fluid
Removing bone and tissue (debridement)
Restoring circulation to the bone. The doctor may replace any diseased bone with a graft of bone or muscle from elsewhere in your body, to help restore blood flow to the bone
Removing any foreign objects (such as screws or pins used to set the bone previously
Complementary and Alternative Therapies
Osteomyelitis should be treated with prescription antibiotics. You can use alternative therapies along with conventional treatment to strengthen your immune system and help you recover, but do not treat osteomyelitis solely with alternative therapies. Make sure to tell all of your health care providers about any alternative therapies or supplements you may be using.
TB - Extrapulmonary tuberculosis
Although the lungs are the major site of damage caused by tuberculosis, many other organs and tissues in the body may be affected. The usual progression is for the disease to spread from the lungs to locations outside the lungs (extrapulmonary sites). In some cases, however, the first sign of disease appears outside the lungs. The many tissues or organs that tuberculosis may affect include:
Bones. TB is particularly likely to attack the spine and the ends of the long bones.
23Pott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. Pott’s disease results from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining intervertebral disc space. If only one vertebra is affected, the disc is normal, but if two are involved, the disc, which is avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare.
Children are especially prone to spinal tuberculosis. If not treated, the spinal segments (vertebrae) may collapse and cause paralysis in one or both legs.
Late complications
Vertebral collapse resulting in kyphosis
Spinal cord compression
Paraplegia (so called Pott's paraplegia)
Prevention
Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis. Patients who have a positive PPD test (but not active tuberculosis) may decrease their risk by properly taking medicines to prevent tuberculosis. To effectively treat tuberculosis, it is crucial that patients take their medications exactly as prescribed.
Therapy
Non-operative – antituberculous drugs
Analgesics
Immobilization of the spine region by a brace
Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine
Richards intramedullary hip screw – facilitating for bone healing
Kuntcher Nail – intramedullary rod
Austin Moore – intrameduallary rod (for Hemiarthroplasty)
Thoracic spinal fusion as a last resort
Transverse myelitis is an inflammation/? Infection of the spinal cord causing spinal cord problems. Although it is a neuro problem, the pt will present with back pain and you may initially see the pt in OPD as a back pain patient.
24What is bone cancer?
Bone cancer is a malignant (cancerous) tumor of the bone that destroys normal bone tissue. Not all bone tumors are malignant. In fact, benign (noncancerous) bone tumors are more common than malignant ones. Both malignant and benign bone tumors may grow and compress healthy bone tissue, but benign tumors do not spread, do not destroy bone tissue, and are rarely a threat to life.
Malignant tumors that begin in bone tissue are called primary bone cancer. Cancer that metastasizes (spreads) to the bones from other parts of the body, such as the breast, lung, or prostate, is called metastatic cancer, and is named for the organ or tissue in which it began. Primary bone cancer is far less common than cancer that spreads to the bones.
25Definition
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A spinal tumor is a cancerous (malignant) or noncancerous (benign) growth that develops within or near your spinal cord or within the bones of your spine. Although back pain is the most common symptom of a spinal tumor, it's also an extremely common problem in people who don't have spinal tumors. In fact, most back pain isn't caused by a tumor.
A spinal tumor or a growth of any kind can affect nerves in the area of the tumor, leading to pain, neurological problems and sometimes paralysis. Whether cancerous or not, a spinal tumor can threaten life and cause permanent disability.
Treatment for a spinal tumor may include surgery, radiation therapy, chemotherapy or other medications.
Symptoms
Depending on the location and type of spinal tumor, various signs and symptoms can develop, especially as a tumor grows and affects your spinal cord or on the nerve roots, blood vessels or bones of your spine. Spinal tumor symptoms may include:
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Back pain, often radiating to other parts of your body
Loss of sensation or muscle weakness, especially in your arms or legs
Difficulty walking, sometimes leading to falls
Decreased sensitivity to pain, heat and cold
Loss of bowel or bladder function
Paralysis that may occur in varying degrees and in different parts of your body, depending on which nerves are compressed
Back pain is a common symptom of both noncancerous and cancerous spinal tumors. Pain may also spread beyond your back to your hips, legs, feet or arms and may become more severe over time in spite of treatment.
Spinal tumors progress at different rates. In general, cancerous spinal tumors grow more quickly, whereas noncancerous spinal tumors tend to develop very slowly.
Causes
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It's not clear why most spinal tumors develop. Experts suspect that defective genes play a role, although it's usually not known whether such genetic defects are inherited, occur spontaneously or are caused by something in the environment, such as exposure to certain chemicals. In some cases, however, spinal tumors are linked to known inherited syndromes, such as neurofibromatosis.
The parts of your spine that are likely to be affected by a spinal tumor include the:
Vertebrae. Your spine is made up of small bones (vertebrae) stacked on top of one another that enclose and protect the spinal cord and its nerve roots.
Spinal cord. Your spinal cord is a double-layered, long column of nerve fibers that carries messages to and from your brain. Wrapped around the entire spinal cord are three protective membranes (meninges).
Trauma of the spine
- fracture of the bone of the spine – vertebrae - without neurological symptoms
- fracture of the bone of the spine with neurological symptoms – spinal cord injury (SCI) meaning a combined ortho and neuro issue
- fractures of the rib(s)
- fractures of the pelvis
26CERVICAL SPINE
Most injuries that involve the neck or cervical spine are the result of a violent collision that compresses the cervical spine against the shoulders. This force can be so great that a vertebra fractures or even bursts into small fragments For example, striking your head against the bottom of a pool in shallow water or “spear”" tackling using the crown of your helmet to stop an opposing football player can fracture the cervical spine.
Cervical spine injuries may also occur during motor vehicle accidents when the head is violently jerked either backwards or forwards. This type of accident may not cause a fracture but instead injure the muscles and ligaments of the neck. The resulting injury is a neck sprain, which is commonly called whiplash.
Regardless of the cause, cervical spine fractures are serious injuries; they may involve spinal cord damage that can result in partial or complete paralysis or even death.
27Treatment
Treatment will depend on which of the seven cervical vertebrae are damaged and the kind of fracture sustained. A minor compression fracture can be treated with a cervical brace worn for 6 to 8 weeks until the bone heals. A more complex or extensive fracture may require traction, surgery, and internal fixation, 2 to 3 months in a rigid cast, or a combination of these treatments.
Improvements in athletic equipment and rule changes have reduced the number of sports-related cervical fractures over the past 20 years.
You can help protect yourself and your family if you:
Always wear a seat belt when you are driving or a passenger in a car.
Never dive in a shallow pool area, and be sure that young people are properly supervised when swimming and diving.
Wear the proper protective equipment for your sport and follow all safety regulations, such as having a spotter and appropriate cushioning mats.
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29Fractures of the Thoracic and Lumbar Spine
Cause
Types of Spinal Fractures
Symptoms
Examination
Treatment
Complications
Long-Term Outcomes
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A spinal fracture is a serious injury.
The most common fractures of the spine occur in the thoracic (midback) and lumbar spine (lower back) or at the connection of the two (thoracolumbar junction). These fractures are typically caused by high-velocity accidents, such as a car crash or fall from height.
Men experience fractures of the thoracic or lumbar spine four times more often than women. Seniors are also at risk for these fractures, due to weakened bone from osteoporosis.
Because of the energy required to cause these spinal fractures, patients often have additional injuries that require treatment. The spinal cord may be injured, depending on the severity of the spinal fracture.
Understanding how your spine works will help you to understand spinal fractures. Spine Basics
Cause
Fractures of the thoracic and lumbar spine are usually caused by high-energy trauma, such as:
Car crash
Fall from height
Sports accident
Violent act, such as a gunshot wound
Spinal fractures are not always caused by trauma. For example, people with osteoporosis, tumors, or other underlying conditions that weaken bone can fracture a vertebra during normal, daily activities.
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Types of Spinal Fractures
A compression fracture of the lumbar (lower) spine.
There are different types of spinal fractures. Doctors classify fractures of the thoracic and lumbar spine based upon pattern of injury and whether there is a spinal cord injury. Classifying the fracture patterns can help to determine the proper treatment. The three major types of spine fracture patterns are flexion, extension, and rotation.
Flexion Fracture Pattern
Compression fracture. While the front (anterior) of the vertebra breaks and loses height, the back (posterior) part of it does not. This type of fracture is usually stable and rarely associated with neurologic problems.
Axial burst fracture. The vertebra loses height on both the front and back sides. It is often caused by a fall from a height and landing on the feet.
Extension Fracture Pattern
Flexion/distraction (Chance) fracture. The vertebra is literally pulled apart (distraction). This can happen in accidents such as a head-on car crash, in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt.
Rotation Fracture Pattern
Transverse process fracture. This fracture is uncommon and results from rotation or extreme sideways (lateral) bending, and usually does not affect stability.
Fracture-dislocation. This is an unstable injury involving bone and/or soft tissue in which a vertebra may move off an adjacent vertebra (displaced). These injuries frequently cause serious spinal cord compression.
Symptoms
The primary symptom is moderate to severe back pain that is made worse by movement.
When the spinal cord is also involved, numbness, tingling, weakness, or bowel/bladder dysfunction may occur.
In the case of a high-energy trauma, the patient may have a brain injury and may have lost consciousness, or "blacked-out." There may also be other injuries — called distracting injuries — which cause pain that overwhelms the back pain. In these cases, it has to be assumed that the patient has a fracture of the spine, especially after a high-energy injury (motor vehicle crash).
Treatment
Flexion Fracture Pattern
Nonsurgical treatment. Most flexion injuries (compression fractures, burst fractures) can be treated in a brace for 6 to 12 weeks. By gradually increasing physical activity and doing rehabilitation exercises, most patients avoid post injury problems.
Surgical treatment. Surgery is typically required for unstable burst fractures that have:
Significant comminuted fractures
Severe loss of vertebral body height
Excessive forward bending or angulation at the injury site
Significant nerve injury due to parts of the vertebral body or disk pinching the spinal cord
These fractures should be treated surgically with decompression of the spinal canal and stabilization of the fracture. Decompression involves removing the bone or other structures that are pressing on the spinal cord. This procedure is also called a laminectomy.
Extension Fracture Pattern
The treatment plan for extension injuries will depend on:
Where the spine fails
Whether the bones can be fit together again (reduction) using a brace or cast
Nonsurgical treatment. Extension fractures that occur only through the vertebral body can typically be treated nonsurgically. These should be observed closely in a brace or cast for 12 weeks.
Surgical treatment. Surgery is usually necessary if there is an injury to the posterior (back) ligaments of the spine. In addition, if the fracture falls through the disks of the spine, surgery should be performed to stabilize the fracture.
Rotation Fracture Pattern
Nonsurgical treatment. Transverse process fractures are predominantly treated with gradual increase in motion, with or without bracing, based on comfort level.
Surgical treatment. Fracture-dislocations of the thoracic and lumbar spine are caused by very high-energy trauma. They can be extremely unstable injuries that often result in serious spinal cord or nerve damage. These injuries require stabilization through surgery. The ideal timing of these surgeries can often be complicated. Surgery is sometimes delayed because of other serious, life-threatening injuries.
Surgical Procedure
The ultimate goal for surgery is to achieve adequate reduction (fitting the bones together), relieve pressure on the spinal cord and nerves, and allow for early movement.
Many types of instruments are used in surgery, including metal screws, rods, and cages to stabilize the spine.
Complications
There are several complications associated with fractures of the thoracic and lumbar spine. One potentially fatal complication is blood clots in the legs, which may develop from immobility. These clots can travel to the lungs and cause death (pulmonary embolism). Pneumonia and pressure sores are also common complications of spinal fractures.
There are also specific surgical complications, including:
Bleeding
Infection
Spinal fluid leaks
Instrument failure
Nonunion
Complications can be reduced by early treatment, mechanical methods (lower leg compression stockings), and medication to protect against clots, as well as proper surgical technique and postoperative programs.
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Long-Term Outcomes
Regardless of whether the patient is treated with surgery, rehabilitation will be necessary after the injury has healed.
The goals of rehabilitation are to reduce pain, regain mobility, and return the patient to as close to pre-injury state as possible. Both inpatient and outpatient physical therapy may be recommended to meet these goals.
Issues that may complicate these goals include inadequate reduction of the fracture, neurologic injury (paralysis), and progressive deformity.
RIB FRACTURE
30Definition
A broken rib, or fractured rib, is a common injury that occurs when one of the bones in your rib cage breaks or cracks. The most common cause of broken ribs is trauma to the chest, such as from a fall, motor vehicle accident or impact during contact sports.
Many broken ribs are merely cracked. While still painful, cracked ribs aren't as potentially dangerous as ribs that have been broken. In these situations, a jagged piece of bone could damage major blood vessels or internal organs, such as the lungs.
In most cases, broken ribs heal on their own in one or two months. Adequate pain control is important, so you can continue to breathe deeply and avoid lung complications, such as pneumonia.
Symptoms of a broken rib may include:
Pain when you take a deep breath
Pain that gets worse when you press on the injured area, or when you bend or twist your body
CAUSES
Direct impact
Motor vehicle accidents
Falls
Child abuse
Contact sports
Repetitive trauma
Sports such as golf or rowing
Severe and prolonged coughing spells
31PELVIC FRACTURE
Anatomy
The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.
Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. With all of these vital structures running through the pelvis, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.
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Cause
Growing teens, especially those involved in sports, are one group of people at risk for a particular type of pelvic fracture. Many "pulled muscles" may actually be undetected avulsion fractures of the pelvis. These fractures usually occur with sudden muscle contractions. A small piece of bone from the ischium where the hamstring muscles attach is torn away by these muscles. This type of fracture does not make the pelvis unstable or injure internal organs.
Also at risk for pelvic fractures are elderly people with osteoporosis. An individual may fracture the pelvis during a fall from standing, such as when getting out of the bathtub or descending stairs. These injuries usually do not damage the structural integrity of the pelvic ring, but may fracture an individual bone.
However, most pelvic fractures involve high-energy forces, such as those generated in a motor vehicle accident, crush accident or fall. Depending on the direction and degree of the force, these injuries can be life-threatening and require surgical treatment.
Treatment
Nonsurgical Treatment
Stable fractures, such as the avulsion fracture experienced by an athlete, will normally heal without surgery. The patient will have to use crutches or a walker, and will not be able to put all of his or her weight on one or both legs for up to three months, or when the bones are healed. The doctor may prescribe medication to lessen pain. Because mobility may be limited for several months, the physician may also prescribe a blood-thinner to reduce the risk of blood clots forming in the veins of the legs.
Surgical Treatment
Pelvic fractures that result from high-energy trauma are often life-threatening injuries because of the extensive bleeding. In these cases, doctors may use an external fixator to stabilize the pelvic area. This device has long screws that are inserted into the bones on each side and connected to a frame outside the body. The external fixator allows surgeons to address the internal injuries to organs, blood vessels and nerves.
What happens next depends on the type of fracture and the patient's condition. Each case must be assessed individually, particularly with unstable fractures. Some pelvic fractures may require traction. In other cases, an external fixator may be sufficient. Unstable fractures may require surgical insertion of plates or screws.
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Outcome
Stable pelvic fractures heal well. Pelvic fractures sustained during a high-energy incident, such as an automobile accident, may have significant complications, including severe bleeding, internal organ damage, and infection. However, these are due more to the associated injuries than to the fracture.
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If these injuries are addressed, the fracture usually heals well. People may walk with a limp for several months because of damage to the muscles around the pelvis. These muscles take a long time to become strong again. Subsequent problems, such as pain, impaired mobility, and sexual dysfunction, are usually the result of damage to nerves and organs that is associated with the pelvic fracture.
Rheumatological problems
32Rheumatoid Arthritis ( R.A. )
Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.
Causes, incidence, and risk factors
The cause of RA is unknown. It is an autoimmune disease, which means the body's immune system mistakenly attacks healthy tissue.
RA can occur at any age, but is more common in middle age. Women get RA more often than men.
Infection, genes, and hormone changes may be linked to the disease.
Symptoms
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected.
The disease often begins slowly, usually with only minor joint pain, stiffness, and fatigue.
Joint symptoms may include:
Morning stiffness, which lasts more than 1 hour, is common. Joints may feel warm, tender, and stiff when not used for an hour.
Joint pain is often felt on the same joint on both sides of the body.
Over time, joints may lose their range of motion and may become deformed.
Signs and tests
There is no test that can determine for sure whether you have RA. Most patients with RA will have some abnormal test results, although for some patients, all tests will be normal.
Two lab tests that often help in the diagnosis are:
Rheumatoid factor test
Anti-CCP antibody test
Other tests that may be done include:
Complete blood count, C-reactive protein, Erythrocyte sedimentation rate, Joint x-rays, Synovial fluid analysis
Treatment
RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.
Physical therapy
Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.
Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.
Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.
Rheumatoid Arthritis Symptoms in the Spine (from: http://www.spine-health.com/conditions/arthritis/rheumatoid-arthritis-spine)
Rheumatoid arthritis of the spine can lead to neck pain, back pain and/or pain that radiates into the legs or arms. In advanced cases, the joint deterioration in the spine can lead to compression of the spinal cord and/or the spinal nerve roots.
The symptoms of rheumatoid arthritis in the spine are generally similar to the symptoms of osteoarthritis (also called degenerative arthritis). The range of symptoms is broad. When rheumatoid arthritis affects the joints in the spine, it is far more common for the neck (cervical spine) to be affected than for the lower back. Pain is the most common symptom, especially pain at the base of the skull as rheumatoid arthritis most commonly affects the joints connected to the upper cervical vertebrae
Comments from KK: As RA can cause ligaments to become lax. It is very important to note that the ligaments of the C0-2 complex of the upper cervical spine may not stabilize those segments. In fact this part of the spine may be subluxed. Patients with spinal RA may exhibit a typical posture of “forward neck” associated with subluxation. In RA patients with involvement of the upper cervical spine joint mobilization might not be safe.
Otherwise PT treatment for the spine can follow the recommendation for RA in general noted earlier. Posture corrections and gentle dorsal-glide exercise for the upper cervical spine can be used in trying to correct some of the “forward head position”.
OTHER RHEUMATOID / AUTO-IMMUNE SYSTEM PROBLEMS
Ankylosing Spondylitis ( AS) from http://www.mayoclinic.com/health/ankylosing-spondylitis/DS00483
AS is an inflammatory disease that can cause some of the vertebrae in your spine to fuse together. This fusing makes the spine less flexible and can result in a hunched-forward posture. A severe case of AS can make it impossible for you to lift your head high enough to see forward.
AS affects men more often than women. Signs and symptoms of AS typically begin in late adolescence or early adulthood. Inflammation also can occur in other parts of your body — such as your eyes and bowels.
There is no cure for AS, but treatments can decrease your pain and lessen your symptoms.
Symptoms
Early signs and symptoms of AS may include pain and stiffness in your lower back and hips, especially in the morning and after periods of inactivity.
These symptoms may come on so gradually that you don't notice them at first. Over time, symptoms may worsen, improve or stop completely at irregular intervals.
The areas most commonly affected are:
The joint between the base of your spine and your pelvis
The vertebrae in your lower back
The places where your tendons and ligaments attach to bones, mainly in your spine, but sometimes along the back of your heel
The cartilage between your sternum and ribs
Your hip and shoulder joints.
Causes
AS has no known specific cause, though genetic factors seem to be involved. In particular, people who have a gene called HLA-B27 are at significantly increased risk of developing AS.
Imaging tests
X-rays. X-rays allow your doctor to check for changes in your joints and bones, though the characteristic effects of ankylosing spondylitis may not be evident early in the disease.
Computerized tomography (CT). CT scans combine X-ray views taken from many different angles into a cross-sectional image of internal structures. CT scans provide more detail, and more radiation exposure, than do plain X-rays.
Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, MRI scans are better at visualizing soft tissues such as cartilage.
Treatment
The goal of treatment is to relieve your pain and stiffness, and prevent or delay complications and spinal deformity. AS treatment is most successful before the disease causes irreversible damage to your joints.
Medications Nonsteroidal anti-inflammatory drugs (NSAIDs) are the medications doctors most commonly use to treat AS. They can relieve your inflammation, pain and stiffness. However, these medications also can cause gastrointestinal bleeding.
If NSAIDs aren't helpful, other drugs may be suggested
Therapy Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Your doctor may recommend that you meet with a physical therapist to provide you with specific exercises designed for your needs.
Range-of-motion and stretching exercises can help maintain flexibility in your joints and preserve good posture. In addition, specific breathing exercises can help to sustain and enhance your lung capacity.
As your condition worsens, your upper body may begin to stoop forward. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture. Even if portions of your spine eventually fuse, you'll be able to get around and perform daily functions more easily if your spine fuses in an upright position.
Other
If you smoke, quit. Smoking is generally bad for your health, but it creates additional problems for people with AS. Depending on the severity of your condition, AS can affect the mobility of your rib cage. Damaging your lungs by smoking can further compromise your ability to breathe.
