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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Wednesday, 13 April 2016

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a very common nerve entrapment neuropathy which causes irritation of the median nerve at the wrist. Half of the carpal tunnel syndrome cases reported symptoms of different severity in both wrists and hands. Compression and irritation of the median nerve when it travels under flexor retinaculum at the wrist often result in pain, numbness and tingling sensation along its distribution area. Carpal tunnel syndrome can be irritating or debilitating and the symptoms can cause a huge impact on the quality of daily life.

The cause of this syndrome is usually unknown but can be associated with certain conditions and injuries. Conditions that are commonly related to carpal tunnel syndrome include obesity, pregnancy, arthritis, hypothyroidism, diabetes mellitus and direct trauma. Overuse injury caused by repetitive maneuvers is a very common cause. There is limited space available at the wrist for the contents to pass through the wrist. Conditions that lead to swelling and inflammation at the wrist joint are more likely to irritate the median nerve that passes through the carpal tunnel.

Irritation of the median nerve may cause typical pain and paresthesias along the distribution of the median nerve, most commonly involve the thumb, index finger and middle finger. Pain and paresthesia may at times radiate into the forearm, arm and shoulder. Patients may claim that their fingers are swollen and useless. They may notice a loss of grip strength or weakness in the thumb. The flick sign – patients awaken by the pain and paresthesia at night may find that shaking the hand or flicking the wrist helps to alleviate the symptoms.

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Friday, 8 April 2016

The Effect of Delayed Onset Muscle Soreness on Muscle Strength

A significant reduction in muscle strength and power has been observed during DOMS, especially during eccentric activity. These reductions usually present 24-48 hours following DOMS-induced exercises. Strength reductions in concentric and isometric muscle actions are not as significant as eccentric exercises. Concentric and isometric muscle strengths usually take about 4 days to recover, whilst eccentric muscle strength may take up to 8-10 days to recover to initial baseline levels. These muscle strength reductions will cause muscle imbalance between agonist and antagonist muscle groups. There will be an increased risk of injury in an athlete as a result of altered strength in these two muscle groups.

Muscle or connective tissue injuries during eccentric exercises may result in altered recruitment patterns or altered temporal sequencing of muscle activation patterns. This unusual muscle recruitment patterns during a set of movements are known as muscle dysfunction. Muscle co-ordination and joint motion are affected due to muscle dysfunction. High force eccentric activity may cause damage to fast twitch muscle fibres. There is an electromechanical delay that contributes to the altered temporal sequencing of muscles. This electromechanical delay refers to the time lag between the onset of muscle and nerve activation and muscle contraction.

EMG assessment has been used to identify muscle dysfunction in agonist and antagonist muscle groups. Agonist and antagonist muscle groups are muscles that carry out similar or opposing functions during joint movements. EMG assessment has been shown to be useful in patella-femoral pain and neck and back pain. The compensatory increase in EMG activity in an uninjured area or in other muscle groups is noted.

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Sunday, 3 April 2016

Adverse Effects of Delayed Onset Muscle Soreness on Joint Kinematics

Research has shown that delayed onset muscle soreness (DOMS) has various effects on the kinematics of running gait. These changes are thought to be the compensatory mechanism of the body to the reduced range of motion of the joints following DOMS. The available range of motion of the ankle, knee and hip joints is important for athletes in order to perform optimal training intensity, especially to obtain optimal running gait. Normal and maximum range of joint motion is necessary to prevent and reduce the risk of sports injury

Downhill running is an example of eccentric training activity which requires the contraction of elongated quadriceps muscles to maintain the stability of the knees. It has been shown that the maximum ankle dorsiflexion and plantar flexion during the support phase, maximum knee joint flexion in swing and support phases and maximum hip flexion in touch down phase are reduced post-downhill running. The ability of the knee and hip joints to absorb shock is reduced and the ankle needs to compensate this by increasing the range of dorsiflexion during support phase. Abnormal stress will be placed on the ankle joint and this will lead increased risk of injury at the ankle joint.

DOMS results in a shortening and tightness of the muscle connective tissue. This will lead to a reduced range of joint motion and joint stiffness. Swelling of the affected muscles or connective tissues is an acute inflammatory response to muscle damage or injury.

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