Wednesday, 18 May 2016

Muscle Cramps in Adults and Elderlies

Sudden painful involuntary contractions of the muscle in any body part that may be visible or palpable are known as muscle cramps. The legs are the most common body part that suffered from muscle cramps. Muscle cramps can happen any time and they are many cases reported at night time. Each episode can last from a few seconds to several minutes with different severity. The duration and frequency of the attacks varies from person to person. There is no significant underlying causes in most of the cases.

There are two main proposed mechanisms that may contribute to muscle cramps in adults and elderlies. The motor nerve terminals which control the contractions of a muscle are abnormally excitable. The other mechanism suggested that there is an instability in the anterior horn cells due to spinal disinhibition. This may lead to explosive hyperactivity of motor neurons (nerves that control the muscle) and high frequency contractions of several muscle units at the same time.

Risk factors for muscle cramps include motor neuron disease, peripheral neuropathy, radiculopathy, electrolyte disturbances, haemodialysis, uraemia, liver cirrhosis, hypothyroidism, pregnancy and vigorous exercise. There are several medications that may increase the risk of muscle cramps such as diuretics, steroids, nifedipine, morphine and statins.

Most of the cases for muscle cramps are usually self-limiting. It is recommended to exhaust non-pharmacological interventions such as manual therapy, moderate stretching exercise, cryotherapy, thermotherapy, decreasing exercise intensity and electrical stimulation therapy before commencing medications.

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Friday, 13 May 2016

Causes for Exercise-associated Muscle Cramps

Exercise-associated muscle cramps (EAMC) is a painful contraction of a muscle in a shortened position. The soreness after the cramps can last up to a few days. Acute muscle cramps can be easily alleviated by gentle stretching the affected muscle. There are a few proposed theories for the cause of EAMC. The dehydration-electrolyte imbalance theory and the neuromuscular theory of EAMC are the most commonly known causes.

The dehydration-electrolyte imbalance theory proposes that EAMC is a result of fluid and electrolyte depletion due to inadequate fluid ingestion and replacement. This leads to sensitisation of select nerve terminals and results in EAMC. Exercise in hot and humid conditions may facilitate muscle cramps by increasing the rate and amount of fluid and electrolytes lost. Miners are more prone to develop muscle cramps due to the hot and humid working environment. There are more cases of muscle cramps during the period of high risk for heat illness. However, there are reported cases where marathon runners developed EAMC in cool, temperature-controlled environments around 10 to 12 degree Celsius.

The neuromuscular theory suggests that EAMC is a result of an imbalance between excitatory impulses from muscle spindles and inhibitory impulses from Golgi tendon organs due to muscle overload and neuromuscular fatigue. A decrease in the inhibition from the GTO and an increase in the excitatory stimuli from muscle spindles may present during neuromuscular fatigue. This will lead to a heightened excitatory state at the spinal level. Therefore, EAMC often occurs when the muscle contracts in a shortened state, especially at the end of competitions and physical work.

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Sunday, 8 May 2016

Exercise-associated Muscle Cramps

Exercise-associated muscle cramps commonly occur during or shortly after exercise. Athletes are more susceptible to muscle cramps up to 8 hours following exercise in a cramp prone state. Isolated exercise-associated muscle cramps involved continuous contraction and shortening of a single multi joint muscle such as calf muscles, quadriceps and hamstrings. Generalised exercise-associated muscle cramps may involve multiple and bilateral muscles. Typical symptoms of exercise-associated muscle cramps include acute pain, stiffness, visible bulging or knotting of the muscle and possible muscle soreness that can last up to several days. Other causes to skeletal muscle cramps may be due to metabolic, neurologic or endocrine pathology.

There are two theories for the cause of exercise-associated muscle cramps, the dehydration-electrolyte theory and the neuromuscular theory. Maintaining hydration and adequate electrolyte levels is beneficial to alleviate the symptoms of exercise-associated muscle cramps. There are recommendations that adding 0.3-0.7 g/L of salt or higher amounts of sodium (3.0-6.0 g/L) to their drinks based on the frequency of muscle cramps. A volume of fluid loss which is less than 2% of body weight reduction is recommended to maintain proper hydration in athletes. Monitoring the body weight of the athlete helps to ensure sufficient fluid replacement.

Stretching, quinine and beta-blockers are shown to be effective in alleviating muscle cramps. Moderate stretching of the affected muscle is most commonly used to relax the muscle. Exercises that improve the neuromuscular system such as plyometric exercise and endurance training may be beneficial to prevent exercise-associated muscle cramps by delaying neuromuscular fatigue.

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Tuesday, 3 May 2016

Leg Length Difference in Scoliosis

Scoliosis is a complicated three-dimensional deviation of the spine which includes the lateral bending of the spine, increased lordosis or kyphosis and rotation and torsion of the vertebrae. Spinal buckling of scoliosis causes distortion of the spine in all direction. There are several types of scoliosis and each of them has a slightly different etiology. Scoliosis can be found as part of a recognisable disorder. It can be due to neurologic, muscular, congenital bone anomalies or developmental disorders. Spinal deformity is commonly seen in neurofibromatosis or poliomyelitis. Painful muscle spasm can result in scoliosis. Non-painful scoliosis can result from a muscle imbalance due to compensation for biomechanical asymmetry. However, the majority of the scoliosis are idiopathic. There is no single causative factor identified in idiopathic scoliosis.

Pelvic unleveling due to a difference in leg length contributes to scoliosis. Unequal leg length can be measured by physical examinations and postural radiography. The distance between the umbilicus and the medial malleolus can be measured and compared to look for leg length discrepancy. The distance between the anterior superior iliac spine and the medial malleolus can be measured. X-rays of the pelvic in a standing position can be taken to look for unleveling of the humeral heads or the iliac crests. These three measurements can be taken and compared to obtain an accurate leg length difference. Correction of the leg length discrepancy can be done by a heel lift on the side of the short leg.

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Thursday, 28 April 2016

Lower Back Pain in Children and Adolescence

The prevalence of lower back pain in children and adolescence has increased over the years due to a change in lifestyle and daily activities. This poses the affected kids at higher risk of low back pain in the adulthood life. There are a few risk factors that may have been contributed to the lower back pain in this age group. Ergonomics of school furniture, school bag weight and mechanics, trauma, history of scoliosis and participation in strenuous physical activities may be associated with lower back pain in children. Psychological and psychosocial factors may complicate a low back pain case in this age group.

Uncomplicated mechanical low back pain is the most common diagnosis for lower back pain in young persons. It is rare to have pathological causes such as neoplasm and infection. Most of the cases are self-limiting or have a favourable result with conservative management. Uncomplicated low back pain in kids normally resolves in one week with conservative management. Pathological causes or other non-pathological causes should be considered if the uncomplicated low back pain is not responding to conservative management.

Intervertebral disc can be another source of low back pain in kids. Lumbar disc herniation (protrusion, extrusion and sequestration) may cause low back pain. History of trauma prior to lower back pain is a common finding in lumbar disc herniation. Annular tears and inflammation of the structures around the intervertebral joint can lead to symptomatic lumbar disc herniation with pain and movement restrictions.

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Saturday, 23 April 2016

Differential Diagnosis and Treatment of Carpal Tunnel Syndrome

How to differentiate carpal tunnel syndrome with other conditions that have similar symptoms in the hand? Abrasions or bruises on the wrist and hand due to trauma can cause acute injury to the muscle, soft tissue and median or ulnar nerves. Obvious bony deformities of the wrist and fingers such as boutonniere deformity, swan neck deformity and ulnar deviation of the wrist are common in rheumatoid arthritis. Osteoarthritis of the small joints in the hand may present with carpal or phalanx bossing. Severe carpal tunnel syndrome with thumb muscles atrophy usually involve other neuropathy syndromes and carpometacarpal arthritis.

Lifestyle modification is part of the conservative treatments for carpal tunnel syndrome. Constant irritation of the median nerve at the wrist should be minimised. Repetitive motions of the wrist that may be stretching or compressing the median nerve should be avoided. Taking frequent breaks from causative motions helps to alleviate the symptom. Ergonomic equipment such as wrist rest or mouse pad can be utilised to reduce the irritation on the nerve. Frequent keyboard users can look for keyboard alternatives such as a digital pen, voice recognition or dictation software.

Neutral or cock-up wrist splint has shown good results by providing symptoms relief. Physiotherapy and chiropractic treatment are effective in symptom relief. Treatment goals for conservative therapy include pain management, reduce the inflammation, minimise median nerve irritation and maintain the function of the wrist and hand.

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Monday, 18 April 2016

How to Evaluate and Diagnose Carpal Tunnel Syndrome

Typical carpal tunnel syndrome shows pain or paresthesia in the palmar side of the thumb, index and middle fingers. Occasionally the symptom can radiate proximally to the wrist and forearm. Phalen test and Tinel sign are most commonly used to reproduce the patient’s symptoms. In Phalen test, patient’s wrist is placed in a bent position for one minute and observed for the reproduction of the symptoms. The median nerve is percussed at the wrist where it travels under the flexor retinaculum. This is the most likely site of irritation for the median nerve.

There may be a weakness of the abductor pollicis brevis muscle in the thumb. The health care practitioner can ask the patient to rest the hand on the table with the palm facing the ceiling. Instruct the patient to raise the thumb up towards the ceiling as the practitioner applies a downward pressure. The patient may have a difficulty maintaining the thumb at that position. In severe cases, atrophy or wasting of the thenar muscles of the thumb may be noted.

History and physical examinations of the patient should be sufficient to lead to the diagnosis of carpal tunnel syndrome. However, in certain complicated cases or unusual presentations, adjunctive tests may be useful to confirm the diagnosis. Electrodiagnostic testing such as nerve conduction studies and electromyography may be useful to quantify the severity. Carpal tunnel syndrome of different severity can have different treatment options. Decreased median nerve conduction velocity supports the diagnosis.

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