Treatment of Osteitis Pubis

Osteitis Pubis is a condition that many consider rare, however, it is probably more common than you may think. The incidence of groin pain, in some sports, is as high as 13% (Ekstrand and Ringbord, 2001). Thus, it is highly likely that as a sports physiotherapist you will encounter may athletes with a diagnosis of osteitis pubis. Therefore, as is frequently stated on this site, you need to be aware of the current research and evidence based practice, even in a world with limited research

OVERVIEW
Osteitis pubis is defined as a painful inflammatory process involving the pubic symphysis and surrounding structures including the pubic rami, cartilage, musculotendinous and ligamentous pelvic structures (Batt et al, 1995). It is suggested that this is caused by repetitive stresses of the pubic symphysis during strenuous physical activity, most commonly secondary to reduced hip range of motion (LeBlanc and LeBlanc, 2003).

TREATMENT
The following discussion regarding treatment decisions is guided by the systematic review by Choi et al (2011). Whilst they searched for the best available evidence, they were unable to identify any RCTs regarding treatment decisions for osteitis pubis. Therefore, the following recommendations are based on clinical experience and case studies/series. Hint, hint… not a lot of rock solid evidence going around.

CONSERVATIVE MANAGEMENT
This generally involves the three mainstays of an inflammatory musculoskeletal condition: relative rest, NSAIDs, and physiotherapy!
Physiotherapy treatment, as always, should be based on the individual athlete and their assessment findings. Thus, as stated above, you should assess for biomechanical and functional impairments and treat accordingly. The components of a successful conservative rehabilitation program included (Wollin and Lovell, 2006):

*.Manual techniques to restore full range of motion in the lumbar, sacral and hip joints. This included soft tissue, MET, mobilisation and manipulative techniques
.*.Core Control Exercises (TrA and Pelvic Floor Training)
*.Adductor Strengthening (Progression of gentle isometric through to loaded isotonic strengthening)
*.Gluteal Strengthening
*.PNF patterns
*.Stationary Bike
*.Return to running program
*.Graduated and progressive return to play

Whilst this is by no means a recipe for your patients, it should serve as an indicator of the components of a successful rehabilitation program. In this small case series (n=4) all players returned to play at a mean timeof 13 weeks.The results of this study mirrored the overall findings of Choi et al (2011) who found that the mean return toplay for all patients undergoing conservative management was 9.55 weeks.

INJECTIONAL THERAPY
The studies examined two types of injectional therapy corticosteroid or prolotherapy.

*.Corticosteroid Injections: Overall 58.6% of patients RTP in 8 weeks, whilst there was no response in approximately 20% of patients.
*.Prolotherapy Injections: Topol et al (2005) examined prolotherapy injections in patients with chronic groin pain and found much more promising than the corticosteroid injections! 91.7% of the athletes RTP in 9 weeks, and there was a 8.3% no response rate.

SURGICAL MANAGEMENT
As you may expect surgical management should only be considered as a last resort. Dependant on the choice of surgery, which is widely variable in clinical practice, it can be a season ending operation. Therefore, it is not a decision to make lightly. The case series literature describes three surgical techniques (Choi et al, 2011).

These are discussed below:
1.Curettage of Pubic Symphysis: 72% RTP at an average of 5.6 months
2.Arthrodesis of the Pubic Symphysis: 87% RTP at an average of 6.6 months, with a 25% complication rate.
3.Polypropylene Mesh Placement into the Preperitoneal Retropubic Space: 92.3% RTP at an average of7.2 weeks.

HOME MESSAGES
*.There is a dearth of quality research to guide treatment decisions for osteitis pubis.
*.Conservative management should always be the first line of treatment for osteitis pubis.
*.Optimal management is individualised and always looks “beyond the groin”!
*.Prolotherapy could be used if physiotherapy fails (but it hurts!).
*.Surgery is a last resort only

Source-
http://www.thesportsphysiotherapist.com/osteitis-pubis-treatment-decisions-in-a-world-with-limited-research/

Lumbar Canal Stenosis and Associated Deformities

Degenerative lumbar spinal stenosis results from pathological degeneration of the facet joints, disc herniation, hypertrophy and buckling of the ligamentum flavum, and spondylolisthesis. Degenerative changes in the three-joint complex (the intervertebral disc and two facet joints) explain the fluctuation in symptoms with alterations in posture, load, and duration of load. Lumbar intervertebral disc degeneration represents a cascade of events involving disc herniation, bulging of the disc and ligamentum flavum into the canal, and resulting chronic facet arthrosis, sclerosis, and osteophytic growth. Hypertrophy of the ligamentum flavum is also an important element in the development of spinal stenosis. Lumbar spinal encroachment induces ligamentum flavum hypertrophy, which further aggravates stenosis. Disease of the nerve roots and cord, however, does not typically result directly from compression of the nerves. Rather, the resulting stenosis causes decreased flow of cerebrospinal fluid, which represents approximately 60% of the nutritional supply to the cauda equina, and increased venous pressure. In such a scenario, any concurrent spinal deformities may critically compromise the nerve roots and cord, as well as exacerbate neurological symptoms of lumbar stenosis.

Spondylolisthesis can be caused by congenital, developmental, traumatic, neoplastic, or degenerative conditions. In degenerative spondylolisthesis, the most common type observed with lumbar stenosis, anterior/posterior displacement of a VB results from facet joint erosion and attenuation of the muscular, capsular, and ligamentous structures. Fourfold more common in females than in males, degenerative spondylolisthesis occurs most frequently at the L4-5 and L5-S1 levels.Disc degeneration causes spondylolisthesis with resulting segmental hypermobility, compounded by arthritis in sagittal facet joints.

There are many other spinal deformities associated with the LCS. For the detailed article visit-

http://www.medscape.com/viewarticle/448310_2

Athletic performance improved even after deception revealed

Indiana University researchers say a little deception caused cyclists in their 4-kilometer time trial to up their performance even after they realized they had been tricked.

The findings support the idea that the brain plays a powerful role in how hard athletes push their bodies.

"The idea is that there's some sort of governor in your brain that regulates exercise intensity so you don't overheat, or run out of gas, so to speak," said Ren-Jay Shei, a doctoral student in the IU School of Public Health-Bloomington. "In this case, the governor was reset to a higher upper limit, allowing for improved performance."

For the study, 14 trained, competitive male cyclists participated in four time trials. For each session, they rode cycle ergometers, which are stationary bikes that measure such variables as speed and power output and display the readings on computer monitors on the handlebars.

For the full research, visit-

http://www.medicalnewstoday.com/releases/277537.php

Vibration Exercise- A Relief for Fibromyalgia

Whole-body vibration exercise may reduce pain symptoms and improve aspects of quality of life in individuals diagnosed with fibromyalgia, research shows. Whole-body vibration exercise involves standing, sitting or lying on a machine with a vibrating platform that causes muscles to contract and relax as the machine vibrates. The machines primarily are used by researchers but have begun appearing in fitness centers and are sold commercially.

A pilot study by Indiana University researchers found that whole-body vibration exercise may reduce pain symptoms and improve aspects of quality of life in individuals diagnosed with fibromyalgia.

For the whole study, visit-

http://www.sciencedaily.com/releases/2014/05/140529154009.htm

Structured physical activity program can help maintain mobility in vulnerable older people

A carefully structured, moderate physical activity program can reduce risk of losing the ability to walk without assistance, perhaps the single most important factor in whether vulnerable older people can maintain their independence, a study has found.

Older people who lose their mobility have higher rates of disease, disability, and death. A substantial body of researchhas shown the benefits of regular physical activity for a variety of populations and health conditions. But none has identified a specific intervention to prevent mobility disability.

In this large clinical study, researchers found that a regular, balanced, and moderate physical activity program followed for an average of 2.6 years reduced the risk of major mobility disability by 18 percent in an elderly, vulnerable population. Participants receiving the intervention were better able to maintain their ability to walk without assistance for 400 meters, or about a quarter of a mile, the primary measure of the study. Results of the large clinical trial, conducted by researchers at the University of Florida, Gainesville and Jacksonville, and colleagues at seven other clinics across the country, were published online on May 27, 2014, in the Journal of the American Medical Association. The researchers were supported by the National Institute on Aging (NIA) and the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health.

For the whole study, visit-

http://www.nih.gov/news/health/may2014/nia-27.htm

The Effects of Virtual Reality-based Yoga on Physical Function in Middle-aged Female LBP Patients

The objective of this research was to determine the effects of a virtual reality-based yoga program on middle-aged female low back pain patients. Thirty middle-aged female patients who suffered from low back pain were assigned to either a physical therapy program or a virtual reality-based yoga program for a period of four weeks. Participants could check their posture and weight bearing on a monitor as they shifted their weight or changed their postures on a Wii balance board. There were a total of seven exercise programs. A 30-minute, three times per week, virtual reality-based Wii Fit yoga program or trunk stabilizing exercise was performed, respectively. Repeated-measures analysis of covariance revealed significant differences in between before and after VAS, algometer, Oswestry low-back pain disability index (ODI), Roland Morris disability questionnaire (RMDQ), and fear avoidance beliefs questionnaire (FBQ) scores. The VAS, algometer, ODI, RMDQ, and FBQ scores exhibited significant differences in groups. Regarding the effect of time-by-group interaction, there were significant differences in VAS, ODI, ODI, and FBQ scores.

The study concluded that for middle-aged female patients who have low back pain, a virtual reality-based yoga program was shown to have positive effects on physical improvements, and the program can be employed as a therapeutic medium for prevention and cure of low back pain.

For the full study, visit-

http://www.physiospot.com/research/the-effects-of-vr-based-wii-fit-yoga-on-physical-function-in-middle-aged-female-lbp-patients/

Physiotherapy Definitions- At Indian level & International level

1. World Health Organization (WHO): "Physiotherapists assess, plan and implement rehabilitative programs that improve or restore human motor functions, maximize movement ability, relieve pain syndromes, and treat or prevent physical challenges associated with injuries, diseases and other impairments. They apply a broad range of physical therapies and techniques such as movement, ultrasound, heating, laser and other techniques. They may develop and implement programmes for screening and prevention of common physical ailments and disorders" (Reference: http://www.who.int/hrh/statistics/Health_workers_classification.pdf )

2. The International Labour Organization (ILO ): Physiotherapists and related associate professionals treat disorders of bones, muscles and parts of the circulatory or the nervous system by manipulative methods, and ultrasound, heating, laser or similar techniques, or apply physiotherapy and related therapies as part of the treatment for the physically disabled, mentally ill or unbalanced. The International Labour Organization (ILO) is the international organization responsible for drawing up and overseeing international labour standards. It is the only 'tripartite' United Nations agency that brings together representatives of governments, employers and workers to jointly shape policies and programmes promoting Decent Work for all. (Reference: http://www.ilo.org/public/english/bureau/stat/isco/isco88/3226.htm )

3. International Standard Classification of Occupations (ISCO) is a tool for organizing jobs into a clearly defined set of groups according to the tasks and duties undertaken in the job. The World Health Organization (WHO) has classified physiotherapists in professional group (ISCO Code 2264) and paramedical professionals have been classified in a separate entity (ISCO code 2240). (Reference: http://www.who.int/hrh/statistics/Health_ workers_classification.pdf)

4. World Confederation of Physical Therapy (WCPT) : Physical therapists are qualified and professionally required to: -undertake a comprehensive examination/assessment of the patient/client or needs of a client group -evaluate the findings from the examination/assessment to make clinical judgments regarding patients/clients -formulate a diagnosis, prognosis and plan -provide consultation within their expertise and determine when patients/clients need to be referred to another healthcare professional -implement a physical therapist intervention/treatment programme -determine the outcomes of any interventions/treatments -make recommendations for self-management. (Reference: http://www.wcpt.org/what-is-physical-therapy)

5. Delhi Council for Physiotherapy & Occupational Therapy Bill 1997 : “Physiotherapy” means physiotherapeutic system of medicine which includes examination, treatment, advice and instructions to any persons preparatory to or for the purpose of or in connection with movement dysfunction, bodily malfunction, physical disorder, disability, healing and pain from trauma and disease, physical and mental conditions using physical agents including exercise, mobilization, manipulation, mechanical and electrotherapy, activity and devices or diagnosis, treatment and prevention. (Reference: http://delhiassembly.nic.in/aspfile/billspassed/141997.htm)

6. Maharashtra State OTPT Council: "Physiotherapy" means a branch of modern medical science which includes examination, assessment, interpretation, physical diagnosis, planning and execution of treatment and advice to any person for the purpose of preventing, correcting, alleviating and limiting dysfunction, acute and chronic bodily malfunction including life saving measures via chest physiotherapy in the intensive care units, curing physical disorders or disability, promoting physical fitness, facilitating healing and pain relief and treatment of physical and psychosomatic disorders through modulating physiological and physical response using physical agents, activities and devices including exercise, mobilization, manipulations, therapeutic ultrasound, electrical and thermal agents and electrotherapy for diagnosis , treatment and prevention. (Reference: http://www.msotptcouncil.com/OTPTActs.aspx )

Seronegative Spondyloarthropathies

Visit-

http://www.ncbi.nlm.nih.gov/books/NBK27224/

For the full information about seronegative spondyloarthropathies

Predictors of Clinical Outcome After Acute Achilles Tendon Ruptures

Abstract

Background: In patients with an acute Achilles tendon rupture, it has not been possible to determine the superiority of a single specific treatment modality over other treatments with respect to symptoms and function. When several pertinent treatment protocols are available for an injury, it is of interest to understand how other variables, such as age, sex, or physical activity level, affect outcome to better individualize the treatment.

Purpose: To investigate predictors of both symptomatic and functional outcomes after an acute Achilles tendon rupture.

Study Design: Cohort study (Prognosis); Level of evidence, 2.

Methods: Ninety-three patients (79 men and 14 women; mean age, 40 years) were evaluated prospectively at 3, 6, and 12 months. The main outcome measures in this study were the Achilles tendon Total Rupture Score (ATRS) for symptoms and maximum heel-rise height for function. The independent variables evaluated as possible predictors of outcome included treatment, sex, age, body mass index (BMI), physical activity level, symptoms, and quality of life.

Results: Treatment, age, BMI, physical activity level, heel-rise height at 6 months, and the ATRS at 3 months were eligible for further analysis. Only male sex was included for the prediction models. The 4 different multiple linear regression models (predicting the ATRS at 6 and 12 months and heel-rise height at 6 and 12 months) were significant (P < .001-.002), and the R 2 values for the models were 0.222 to 0.409. Surgical or nonsurgical treatment is a moderate predictor of symptoms and a weak predictor of heel-rise height after an acute Achilles tendon rupture. At the 6-month follow-up, surgical treatment was associated with a larger heel-rise height, but the opposite was seen at 12 months. Surgical treatment resulted in a lower degree of symptoms. Increasing age was a strong predictor of reduced heel-rise height, and an increase in age of 10 years reduced the expected heel-rise height by approximately 8%. A higher BMI was also a strong predictor of a greater degree of symptoms, and a 5-unit higher BMI predicted a reduction of approximately 10 points in the ATRS.

Conclusion: The present study identified important possible predictors of outcome. Despite having a wide range of clinically relevant variables, the models had a limited ability to predict the final individual outcome. In general, the models appear to be better at predicting function than symptoms.

For the full text, kindly visit-

http://m.ajs.sagepub.com/content/42/6/1448?etoc

Physiotherapy- One of the Most Satisfying Jobs

WHY PHYSIOTHERAPY COUNCIL-

Here are the points that strongly advocate why Physiotherapy council is needed....

The objectives of the council are as follows:-

1. Maintenance of uniform standard of physiotherapy education ,both undergraduate and postgraduate.

2. Recommendation for recognition/derecognition of physiotherapy qualification of physiotherapy institution of India or foreign country.

3. Permanent registration/provisional of physiotherapy with recognised physiotherapy qualification.

4. Reciprocity with foreign countries in the matter of manual recognition of physiotherapy qualification.

The rules,regulation & function of council are:-

1. Graduate physiotherapy education regulation. (admission,selection,migaration,training etc.)

2. Postgraduate physiotherapy education regulation. (selection,schedule,examination,period of training,genral condition to be observed by postgraduate teaching institutions ect.)

3.. Teacher eligibility qualification.

4. Code of physiotherapy ethics regulation.

5. Physiotherapy council regulation.

6. Eligibility certification regulation.

7. Screen test regulation.

8. Inspection/visitation with a view to maintain proper standards of physiotherapy education of state.

9. Permission to start new physiotherapy college, new courses including P.G. or higher courses, increases of seats etc.

10. Registration:
a) Permanent registration
b) Provisional registration
c) Registration of additional qualification
d) Issue of good standing certificate for physiotherapy going abroad.

11. Recruitment of the physiotherapists.

History of Physiotherapy

Physiotherapy concentrates on the psychological, physical, emotional and social well being of a person. Apart from curing various ailments related to joints and bones, the treatment aims to develop, restore and maintain maximum movement and functional ability. The treatment was formulated a couple of centuries ago. Today, it is undertaken to cure almost every ailment and injuries related to the bones, muscles and joints. A person undergoing physiotherapy is guaranteed to find relief over time. If we go back to the history and origin of Physiotherapy, we see that the treatment has been existence since the ancient period. Check out some more interesting information on the background of physiotherapy, through the lines below.

Interesting Information On Background & Origin Of Physiotherapy-

The ancient form of modern Physiotherapy, or physical therapy, dates back to 460 BC, when Hippocrates and Hector used massage and hydrotherapy (water therapy) to treat their patients. However, the actual Physiotherapy, which is practiced today, was formulated in 1894, when a group of four nurses in Great Britain established the Chartered Society of Physiotherapy. Formal training programs were soon started by other countries, following the treatment formulated by the Chartered Society.

The School of Physiotherapy, established by the University of Otago in New Zealand in 1913, and Reed College in Portland (Oregon), founded in 1914, are the early examples of the institutions that taught Physiotherapy. From 1917 to 1918, the therapy was performed widely, to cure people injured in the World War I. The treatment was considered as ‘rehabilitation therapy’ during that time. The people who were employed to provide aid to the injured patients were named ‘reconstruction aides’. They were trained nurses’ who had the knowledge of physical education and massage therapy.

The year 1921 holds significance in the history of Physiotherapy. A research paper on the therapy was published in the PT Review, in March 1921, in the United States. It was during this time that Mary McMillan, the first Physiotherapy aide, established the American Women’s Physical Therapeutic Association. The organization’s name was later on changed to the American Physiotherapy Association (APTA). Due to her significant contribution in the reconstruction aide services, Mary McMillan came to be known as the ‘Mother of Physiotherapy’.

More and more research papers were published about physiotherapy in the following years. The treatment was further promoted by the Georgia Warm Springs Foundation. The foundation, in the year 1924, proposed the therapy as a treatment for polio. Massage, exercise and traction were the common practices carried on in physiotherapy in the 1940s. In the following decade, the British Commonwealth countries started the practice of undertaking manipulative therapy for spine and joint pains.

Until the early 1950s, Physiotherapy was performed only in hospitals. It was only in the late 1950s that physical therapists started treating the patients beyond hospitals. Public schools, universities, skilled nursing facilities, medical centers and rehabilitation centers were chosen by the physiotherapists to treat their patients. In 1974, many doctors in the United States specialized in Physiotherapy. A separate division – the Orthopedic Section – was formed in the APTA, for the physical therapists who had specialized in Orthopedics.

In India, it started during the second World War in 1945 in Bombay (now, Mumbai) to take care of the injured militants.

The manual therapy was popularized worldwide in 1974, when the International Federation of Orthopedic Manipulative Therapy was established. Further development in the field of physiotherapy was recorded in the 1980s, when the use of computers became prevalent in Medical Science. Various devices, such as electrical stimulators, were introduced for practicing physiotherapy, which increased the effectiveness of the treatment. In the present time, the therapy is practiced for curing a number of disorders and injuries, ranging from the most common back pain to musculoskeletal and sports injuries.