Posts tagged back injury
Physiotherapy Assessment of Muscle Strength
Muscle strength is very important for all of our functional activities, from heavy work such as climbing stairs or a hill to fine work such as sewing or typing on a keyboard. While losing feeling in a part of the body can be more disabling, losing muscle power always has consequences for our function and our independence, especially as we get much older when our power levels decline anyhow. We may lose muscle power for a wide variety of reasons: disuse; pain; injury; disease or neurological illness. Physiotherapists are skilled at the assessment of muscle power and in progressive strengthening techniques to restore power within the patient's capacity.
The Oxford Scale is the rating system used by physiotherapists for the assessment and recording of muscle power when required. Knowledge of muscle anatomy is vital so that the joint can be positioned correctly and the tendon and muscle palpated so whether there is any muscle action can be judged. The muscle is rated on the Oxford Scale from one to five and written down as 2/5 or 4/5, at times with a plus or minus sign to show the muscle has more or less strength but not enough to go down or up the scale. The physiotherapist ensures the joint is in the optimal position to enable the muscle to function easily and for easy visualisation of the tendon and muscle.
The physiotherapist will ensure the joint is positioned best for good visibility of the muscle, easy manual palpation of the tendon and muscle belly and the correct alignment for the expected strength of the muscle. Palpating the tendon and muscle, the physiotherapist will ask the patient to perform the muscle action desired, feeling for any contraction or movement. If there is none then the score is 0/5 and 1/5 if there is a just discernable contraction or a twitch, without apparent joint movement. If the joint can be moved through its whole motion but only without gravity resisting then the grade is 2/5, for which the joint needs careful positioning. 3/5 grade would be recorded when the joint can be moved through its range against gravity, an example being straightening the knee from bent in sitting.
To be rated as 4/5 on the Oxford Scale a muscle must be able to move its joint through full range against resistance and gravity. The physiotherapist will decide what degree of resistance is reasonable for this test, bearing in mind the characteristics of the patient such as age, sex, activity levels and medical status. The normal rating of 5/5 is given only when the muscle can move the joint painlessly to the extent that the tester feels is entirely adequate, given the personal status of the patient. Full power for a younger, strong man will be very different for a child or old person.
Grade three out of five for the shoulder muscles might be the ability to lift the arm above the head, but if this cannot be easily done or to full range then the muscle can be graded as three minus to indicate its inability to be fully grade three. If the physiotherapist can resist the muscle firmly but it still doesn't seem to be strong enough for a five, then the rating can be four plus. Physiotherapists go through all the muscles to be tested and rate them all on a muscle testing chart as a record of the muscle strength, which can be retested over time to chart recovery.
Physiotherapists begin muscle strengthening techniques in a position where gravity is eliminated, allowing a weak muscle to be repetitively exercised. As the patient's ability increases they can perform more functional activities of daily life which strengthens the muscles in a co-ordinated way which reflects normality. Next, resistance against muscle action is increased as muscle strength improves in response to the level of intensity of resistance and not just repetition. High intensity causes muscle fibre breakdown which repairs with increased size and power until the next intensity workout repeats the process. Progression is then moved to functional exercise with bodyweight resistance as dynamic movement is more useful.
Ankylosing Spondylitis Treatment by Physiotherapy
Ankylosing spondylitis belongs to a group of disorders called the spondyloarthropathies, a group which also includes psoriatic arthritis, reactive arthritis and arthritis related to inflammatory bowel disease. All these conditions are linked by the genetics of a gene on white blood cells called HLA B27 and by the presence of enthesitis, inflammation at the points where ligaments and tendons insert into bone. This can lead to fibrosis at these sites and then bone formation, causing joint fusion (ankylosis) in some cases.
The commonest spondyloarthropathy is Ankylosing spondylitis, which occurs as a reflection of the occurrence of the HLA B27 gene in the population. The gene occurs much less commonly near the equator and much more commonly in northern latitudes, and this is also the pattern with the development of AS. White race people are more commonly affected with around 0.1 to 1.0 percent overall, varying with latitude. Only 1 or 2 people of a hundred with the HLA B27 gene actually develop AS, but if they have a close relative who has the condition the likelihood rises to 15 to 20%.
Three males to every one female is the ratio of patients with Ankylosing spondylitis, as female patients may have much less obvious symptoms and so be missed from the diagnosis. Young men are the commonest presenting group with most consulting a doctor before they are 40 and up to 20% before they are sixteen years old. 25 years is the average age that someone goes down with the symptoms and is uncommon to find a diagnosis of AS in a person over fifty. It is easily overlooked as it can look like mechanical back pain if care is not taken. On questioning how they are in the morning, a typical answer is very stiff.
Low back pain is the major diagnostic alternative but AS patients are generally younger and the inflammatory process leads to different symptoms:
Morning back stiffness lasting half an hour and often longer Back pain improved with exercise Back pain worsened with rest Night pain later on in the night Other joints may be affected Fatigue is common Active inflammatory disease can cause systemic affects such as unwellness, weight loss or fever
On examination the physiotherapist can find a stiff lumbar spine with reduced movements from normal, postural abnormality such as a flat lumbar spine and an increased thoracic kyphosis. In later stages neck movements may also be involved and chest expansion will be reduced from normal. In the third of patients who get peripheral involvement, enthesitis develops in areas subject to mechanical stresses, the most common being the insertion of the plantar ligament in the foot and the insertion of the tendo Achilles to the heel. These areas will be palpated by the physio to help confirm the spread of the disease, helping to focus the treatment plan later on.
The physiotherapist initially notes the postural changes which have occurred in an AS patient such as any spinal deformities, round shoulders, bent knees or an increased cervico-thoracic curve and poking chin posture. The physio will record ranges of movement of the spine and include the neck, thorax and lumbar ranges, also assessing any peripheral joints which may be affected. Any entheses which are reported as painful are palpated to confirm the presence of an inflammatory process, and if the AS is very active then the physiotherapist might also find effusions in the joints, perhaps with a feeling of unwellness, night sweats and poor rest.
Physiotherapists will concentrate on treating the inflamed areas first such as the areas where the ligaments insert into the bone, using insoles, cold, ultrasound and stretching techniques. Routine spinal range of motion exercises are taught to patients with an emphasis on getting to end ranges, concentrating initially on the anti-gravity muscles such as thoracic and lumbar extensors. Neck rotation and retractions and thoracic rotations are also important functional movements not to lose. Patients should rest themselves in good postures such as prone or supine with only one pillow, to avoid accentuating the typical spinal deformities. Treatment for AS in a hydrotherapy pool is beneficial and soothing and patient education important so they keep up their programme.
