Chronic Musculoskeletal Disorders and Physical Therapy Management

1. CHRONIC MUSCULOSKELETAL DISORDERS
(An Evidence based assessment & PT management)

2. Areas of body mostly affected due to chronic MSD :
1. Neck
2. Shoulders
3. Wrists
4. Back (Upper and Lower)
5. Hips
6. Legs
7. Knees
8. Feet

3. Commonly encountered chronic MSDs:
- Osteoarthritis (OA)
- Rheumatoid Arthritis (RA)
- Gout
- Fibromyalgia
- Tendinitis ( Tennis Elbow and Golfer’s Elbow )
- Carpal Tunnel Syndrome (CTS)
- Scoliosis
- exaggerated kyphosis and lordosis
- Frozen Shoulder

4. OSTEOARTHRITIS (OA)
• It is believed to be caused by trauma, either overt or as an
accumulation of microtrauma over years, although there is also a
hereditary form called primary osteoarthritis that occurs primarily in
middle-aged women.
• Most commonly affected areas : Knees, hands, hip.
• Joint space narrowing
• Sclerosis
• Osteophytosis
• Subchondral cyst or geode

7. • Quadriceps sets
• Standing terminal knee extensions
• Seated leg presses
• Partial squats (not deep)
• Step-ups
• Flexibility and ROM exercises
• Calf, hamstring, and quadriceps stretching
• Knee flexion to extension
• Stationary biking
• Unloading Braces

10. RHEUMATOID ARTHRITIS (RA)
• Rheumatoid arthritis (RA) is a chronic autoimmune multisystemic
inflammatory disease which affects many organs, but predominantly
attacks the synovial tissues and joints. There is a female predominance,
with the disease being 2-3 times more common in women.
• morning stiffness lasting at least 1 hour before maximal improvement
• soft tissue swelling of 3 or more joints observed by a physician
• swelling of the proximal interphalangeal, metacarpophalangeal, or wrist
joints
• symmetric swelling
• rheumatoid nodules
• the presence of rheumatoid factor; and
• radiographic erosions and/or periarticular osteopenia in hand and/or wrist
joints.

13. • The therapy goals in most cases are:
• Improvement in disease management knowledge
• Pain control
• Improvement in activities of daily living
• Improvement in stiffness
• Prevent or control joint damage
Patient questionnaires – not joint counts, radiographic scores, or laboratory tests – provide the
most significant predictors of severe 5 year outcomes in patients with RA, including functional
status, work disability, costs, joint replacement surgery and premature death.
•
Physiotherapy Modalities
• Cold/Hot Applications: cold = for acute phase; heat = for chronic phase and used before
exercise
• Electrical Stimulation: transcutaneous electrical nerve stimulation (TENS) is used to relieve pain
• Hydrotherapy = balneotherapy: allows exercise with minimal load on the joints.
=> Simply being in another environment, where the patient can relax has a positive effect on the
disease's progression (physically as well as on mentally)

14. • Rehabilitative Treatment
• Joint Protection Strategies:
• • Rest & Splinting: Orthosis and splinting prevent the development of deformities and support joints
• Therapy Gloves: to control and manage hand pain, to maintain or restore the patient’s hand function, or to psychologically help to
relax or calm the wearer. Wearing therapy gloves led to the improvement in hand grip strength. The glove can be worn during the day
or at night. They are made of various materials: nylon, wool and elastane fibres.
• Compression Gloves: moderate joint swelling and consequently reduce the pain
• Assistive Devices and Adaptive Equipment: arrangements (like elevated toilet seats,...) to facilitate activities of daily living
• Massage Therapy: improve flexibility and welfare (dimension of: depression, anxiety, mood and pain)
• Therapeutic Exercise:
• There is evidence suggesting that exercise improves general muscular endurance and strength without detrimental effects on disease
activity or pain in rheumatoid arthritis. However, few studies have investigated the effect of exercises for the rheumatoid hand. Some
improvement in strength, mobility and/or function with no negative effects have been reported, although the long term effectiveness
has not been established due to various weaknesses in trial design.
• Before beginning an exercise program, it is important to have a global evaluation of the situation: joint-inflammation local or systemic,
state of the disease, age of the patient and grade of collaboration.
• ROM exercises : in acute phase: isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day ; load = 40%
1RM.
in chronic phase: isotonic exercises (= active exercises with constantly the same tension) for example: swimming, walking, cycling ->
minimum 4 repetitions for each joint in 2 to 3 days
increases the mobility of the joint
• stretching: to be avoided in acute cases
• strengthening: use light weights
important for stabilisation of the joint and prevention of traumatic injuries.
• aerobic condition exercises -> improve the muscle endurance and aerobic capacity
• routine daily activities

15. GOUT
• Gout is a metabolic disorder; however, because the clinical presentation
closely resembles arthritis, gout is also classified as a form of crystal-
induced arthritis. There are three main types of gout, all of which usually
begin monoarticularly at the first metatarsophalangeal joint and are
characterized by sudden pain, swelling, and redness.
• Gout is caused by monosodium urate crystal deposition in tissues leading
to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate
nephropathy. The biologic precursor to gout is elevated serum uric acid
levels (i.e., hyperuricemia).
• Gout and pseudogout are the 2 most common crystal-induced
arthropathies. They are debilitating illnesses in which pain and joint
inflammation are caused by the formation of crystals within the joint
space.

16. • Predominantly seen in men (most common inflammatory disease in men
over age 30)
• There are four stages of gout, although diagnosis does not require the
presence or occurance of each stage. The four stages are:
• Asymptomatic hyperuricemia ( serum urate > 7mg/dl)
• Acute gouty arthritis
• Intercritical gout
• Chronic tophaceous gout
• Chronic tophaceous gout is characterized by increased pain, deformity
(from tophi), decreased ROM, and subsequent functional loss.[1] [2] Due to
the treatments used for gout today, chronic tophaceous gout is rare.

18. • Physical therapy management of gout falls under preferred practice pattern for: Impaired joint
mobility, motor function, muscle performance, and range of motion associated with localized
inflammation.
• The physical therapist should be aware that any patient with a history of gout, hyperuricemia,
and/or a septic joint presentation should be refered for medical evaluation prior to treatment.
• During acute exacerbations the physical therapist should focus on reinforcement of management
program and splinting, orthotics, or other assistive devices to protect the affected joint(s).
• A 2002 study in the Journal of Rheumatology found that the use of cryrotherapy to alleviate the
pain associated with acute bouts of gout may be effective.
• During intercritical phases physical therapists may offer assistance with maintinance of ROM,
strength, and function. The physical therapist can also assist the patient in the creation of a
suitable exercise routine and keeping thier weight under control.
• There is a Randomized Clinical Trial which suggests that Electroacupuncture in combination with
blood letting puncture and cupping has relatively good results as a treatment for Gout. The
treatment is effective mostly because the blood uric acid decreased significantly after the
treatment was given to the patients.
• There is another study about Electroacupuncture combined with local blocking therapy on acute
gouty arthritis that shows an improvement in health status of the patients. This treatment is
positive and it also decreases blood uric acid levels.

19. FIBROMYALGIA
• Fibromyalgia is a syndrome characterized by widespread chronic
unabated pain in addition to a host of several additional co-
morbidities that can severely impact and disrupt a person’s daily life.
The symptoms associated with fibromyalgia may originate from
abnormal central nervous system output. Fibromyalgia isn't just one
condition; it's a complex syndrome involving many different factors.
• Fibromyalgia is characterized by sensitization of the central nervous
system, which explains the wide variation in symptoms.
• Fibromyalgia is more prevalent among women and the vast majority
of those with fibromyalgia are women.

20. • Morning stiffness
• Tingling or numbness in hands and feet
• Headaches, migraines
• Constipation, diarrhea
• Thinking and memory abnormalities (“fibro fog”)
• Painful menstrual periods
• Fatigue
• Trouble sleeping
• Jaw Pain
• Abnormal muscle pain and malaise after exercise
• Dizziness or light-headedness
• Skin and chemical sensitivities
• Deep, aching, throbbing, shooting, radiating, stabbing pain
• Non-cardiac chest pain, heart palpitations, shortness of air, profuse sweating
• Feeling of swollen extremities
• Sensitivities to all the senses (loud noises, bright lights, some foods, odors, etc…)
• Feelings of depression, anxiety

22. • Heredity: Current research indicates that those with a family history
of fibromyalgia are more likely to develop the condition than those
without a genetic predisposition.
• Stressful and/or Traumatic Events: Psychological stress including but
not limited to post traumatic stress disorder in addition to a myriad of
other stressful events has been linked to the onset of fibromyalgia.
• Bodily Injury: The onset of fibromyalgia has been linked with
repetitive injuries as well as severe motor vehicle accidents and war
injuries.
• Infection: Several infections have been potentially associated with the
onset of fibromyalgia including hepatitis C, the Epstein-Barr virus,
parovirus and Lyme disease.
• Disease: The presence of autoimmune disorders has been associated
with fibromyalgia, including Rheumatoid arthritis and Lupus.

23. • PT MANAGEMENT
• According to the most recent Cochrane Review (2007) assessing the benefits of Exercises in the management
of Fibromyalgia "There is 'gold' level evidence that supervised aerobic exercise training has beneficial effects
on physical capacity and FM symptoms. Strength training may also have benefits on some FM symptoms.
Further studies on muscle strengthening and flexibility are needed. Research on the long-term benefit of
exercise for FM is needed."
• Light aerobic exercise most days of the week is highly recommended for those with fibromyalgia. In a
systematic review published in the Journal of Rheumatology it was concluded that aerobic exercise training
only offers those with fibromyalgia significant beneficial effects on physical function, well-being and
potentially pain. Strength training and flexibility, however, have yet to be studied in depth.
• Another study found that structured physiotherapy alone, not including aerobic exercise, as well
as amitriptyline medications alone significantly decreased disability of those with fibromyalgia as measured
by the Fibromyalgia Impact Questionnaire (FIQ). Physiotherapy consisted of the following:
• -Relaxation techniques
• -Stretching
• -Strengthening
• Manual lymph drainage therapy and connective tissue massage have also been studied in women with
fibromyalgia. Researchers used the Fibromyalgia Impact Questionnaire and the Nottingham Health Profile to
measure the impact of the treatment. Their research suggests that both manual lymph drainage therapy and
connective tissue massage show improvements in both the FIQ and the Nottingham Health Profile. However,
there were significantly greater improvements in the group that received manual lymph drainage therapy,
suggesting that manual lymphatic drainage therapy may be preferred over connective tissue massage.

24. TENNIS ELBOW (LATERAL EPICONDYLITIS)
• Lateral epicondylitis is the most common overuse syndrome in the elbow. Lateral epicondylitis or
tennis elbow is an injury involving the extensor muscles of the forearm. These muscles originate
on the lateral epicondylar region of the distal of the humerus.
• The most common type of lateral elbow pain is lateral epicondylitis. In occupations requiring
repetitive upper extremity activities and particularly those involving computer use, heavy lifting,
forceful forearm pronation and supination, and repetitive vibration, lateral epicondylitis is
repeatedly seen. The clinical examination of lateral epicondylitis is often clear. This is shown with
local tenderness over the common forearm extensor tendon insertion at the lateral epicondyle.
This can be extended to the extensor mass, with less annular ligament. Pain can be reproduced
with resisted wrist and middle finger extension and with gripping activities. It is possible that
symptoms are generated by passive wrist flexion with elbow extension. It is often seen that the
flexibility and the strength in the wrist extensor and posterior shoulder muscles are deficient.
However, in the workplace where repetitive elbow and wrist motion is involved, lateral
epicondylitis occurs. On the lateral epicondyle it’s about 7 times more common than on the
medial epicondyle.
• Lateral epicondylitis is classified as an overuse injury. Overuse of the muscles and tendons of the
forearm and elbow together with repetitive gripping or manual tasks can put too much strain on
the elbow tendons. These gripping or manual tasks require manipulation of the hand that causes
maladaptation in tendon structure that lead to pain over the lateral epicondyle. Mostly, the pain
is located anterior and distal from the lateral epicondyle.

25. • Patients often report weakness in their grip strength or difficulty
carrying objects in their hand, especially with the elbow extended.
They have complaints of pain just distal to and localized tenderness
over the lateral epicondyle.
• Patients will commonly have pain with palpation of the lateral
epicondyle, resisted wrist, or second or third finger extension (Cozen's
sign).

27. • A positive sign is tenderness to palpation at the anterior epicondyle
• Cozen's sign:
• The patient is positioned with the upper extremity relaxed. The examiner
stabilizes the patient’s elbow with one hand and the patient is instructed to make
a fist, pronate the forearm, and radially deviate the wrist. At last, the patient is
instructed to extend the wrist against resistance that is provided by the examiner.
An altenative is resisted extension of the middle finger that can cause pain at the
extensor carpi radialis brevis origin. The test is positive if the patient experiences
a sharp, sudden, severe pain over the lateral epicondyle.
• Chair test: The patient grasps the back of the chair while standing behind it and
attempts to raise it by putting their hands on the top of the chair back. Pain
reproduction at the lateral epicondyle is a positive test.
• Mill's Test: The patient is positioned in standing with the upper extremity relaxed
at side and the elbow extended. The examiner passively stretches the wrist in
flexion and pronation. Pain at the lateral epicondyle or proximal
musculotendinous junction of wrist extensors is positive for lateral epicondylitis.
• The coffee cup test (by Coonrad and Hooper) where picking up a full cup of coffee
is painful.

28. • Physical therapy interventions including elbow joint mobilization with
movement combined with exercise has been shown to have better results
than corticosteroid injection at 6 weeks and to wait and see at 6 weeks but
not 52 weeks. Recent research regarding cervicothoracic joint mobilization
in conjunction with local treatment for lateral epicondylalgia has shown
improvements in strength, pain, and tolerance to activity compared to local
treatment alone.
• Physical therapy management including only the use of ultrasound,
massage, and exercise has been shown to be no better than a "wait and
see" treatment method. Activity modification, when possible, can help
prevent recurrent episodes of lateral epicondylalgia, as well as use of a
counterforce brace as needed.

29. • Mills Mobilisation
• The commonly used Mill's manipulation, is a small-amplitude high-
velocity thrust performed at the end of elbow extension while the
wrist and hand are held flexed. “ It’s used to pull apart the two edges
of the tear and relieve tension on the painful scar lying between the
edges, imitating the mechanism of spontaneous recovery. This motion
allows the self-perpetrating post-traumatic inflammation to subside
with permanent lengthening of the tendon. This approach was
described by Mills.”

30. • Eccentric exercises
• There are three principles of eccentric exercises. These are load (
resistance), speed (velocity) and frequency of contractions.
• Load ( resistance)
• Increasing the load ensures the tendon is subjected to greater
stress and forms the fundamental basis of the progression of the
exercise programme. The basis of all physical training programmes
is formed by this principle of progressive overloading. According to
the patient’s symptoms, it is important that the load of these
eccentric exercises should be increased. If it’s not increased then
the possibility of re-injury will be high.
• Speed ( velocity)
• The speed (velocity) of contractions is also a fundamental principle
of successful eccentric exercises. In each treatment session the
speed of the eccentric training should be increased. Hence the
load on the tendon increases to stimulate the mechanism of the
injury.
However the therapists must ensure that the patients perform the
eccentric exercises slowly to avoid pain.
• Frequency of contractions
• The frequency of contractions is the third principle of eccentric
exercises. There can be variations of sets and repetitions in the
literature.
According to the therapists 3 sets of 10 repetitions can normally
be performed without overloading the injured tendon, as
determined by the tolerance of the patient. The elbow is in full
extension, forearm in pronation and the arm is supported. The
greatest strengthening result for the extensor tendons of the wrist
is reached in this position. This is a recommendation and the
frequency must be patient specific.
• Flexbar® exercise
• The Flexbar® is an effective and beneficial
eccentric exercise for patients with lateral
epicondylitis. This resistance device is easy to use
at home and is an excellent example of true
“evidence-based practice” in physical therapy.
Instructions for the 5 Steps of the Exercise:
• Hold FlexBar® in the affected (right) hand. Make
sure it's in full wrist extension..
• The other end of the device must be held with
your unaffected (left) hand.
• Twist FlexBar® with unaffected wrist while
holding.
• The FlexBar® exercise is performed each day for 3
sets of 15. It takes 4 seconds to complete each
repetition and between each set of 15 repetitions
there is 30 seconds of rest. Once the patients can
perform 3 sets of 15, they progress to another
colour FlexBar® with a higher intensity of eccentric
resistance. After an average of 7 weeks (with 10
clinic visits) the patient will have a resolution of
symptoms. The treatment should be continued
until this resolution occurs.

31. GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)
• Medial epicondylitis or ‘golfer’s elbow’ is mostly a tendinous overload
injury leading to microtearing. Thereby tendon degeneration appears
instead of repair. The most sensitive region is located near the origin
of the wrist flexors on the medial epicondyle of the humerus.
Sometimes the patient also experiences pain on the ulnar side of the
forearm, the wrist and occasionally in the fingers.
• Most frequently the pathology occurs in the musculotendinous origin
of the flexor carpi radialis and pronator teres. But large diffuse tears
can also occur in the palmaris longus, flexor digitorum superficialis
and flexor carpi ulnaris.

33. • Medial epicondylitis has a lower incidence than lateral epicondylitis
(tennis elbow), with the former containing only 9 to 20% of all
epicondylitis diagnoses. The ‘golfer’s elbow’ and ‘pitcher’s elbow’ are
synonyms.
• The patient usually complains about pain of the elbow distal to the
medial epicondyle of the humerus with radiation up and down the
arm, most common on the ulnar side of the forearm, the wrist and
occasionally in the fingers.
Local tenderness over the medial epicondyle and the conjoined
tendon of the flexor group, without evidence of swelling or erythema,
are also characteristics that can occur. Other symptoms are stiffness
of the elbow, weakness in the hand and the wrist and a numb or
tingling feeling in the fingers (mostly ring and little finger).
• The pain is evoked by resisted flexion of the wrist and by pronation.
The pain is usually accompanied by a weakness of hand grip. Pain can
begin suddenly or can develop gradually over time.

34. • Examination:
• Tenderness to palpation (usually over m. pronator teres and m. flexor carpi
radialis)
• Local swelling and warmth
• Medial epicondylitis test :
• It includes a passive and an active test to determine medial epicondylitis. In
severe cases of epicondylitis, the patient will complain of pain when he
simply shakes hands or pulls an open door. For the active resistance test,
the patient should resist wrist flexion. This must be carried out with elbow
extended while fully supinating the forearm. For the passive test, the
therapist extends the wrist with the elbow extended.
• Range of motion in the beginning of the disease can be full, but later on
there is a possibility of a decreased range of motion
• An evaluation of the entire upper extremity kinetic chain can be needed. A
particular focus goes to the shoulder and the scapular strength, motion
and stabilization. Overuse injuries in the elbow often occur with shoulder
or scapular dysfunction

35. • Physical Therapy Management
• Nonsurgical treatment
The main goal of the conservative treatment is to obtain pain relieve and an inflammation reduce. These two things will help to achieve a
proper rehabilitation and later a return to activities.
• Nonsurgical treatment can be divided into three phases.
• - Phase 1: The patient immediately has to stop the offending activities. It’s not recommended to stop all activities or sports since that can
cause atrophy of the muscles.
• The therapy starts with ‘PRICEMM’, which stands for ‘prevention/protection, rest, ice, compression, elevation, modalities and medication'. The
affected elbow should be iced several times a day for about a quarter. This improves the local vasoconstrictive and analgesic effects. As for
medication the patient can take nonsteroidal anti-inflammatory medication (NSAID).
If the patient’s condition doesn’t improve, a period of night splinting is adequate. This is usually accompanied with a local corticosteroid
injection around the origin of the wrist flexor group. Some examples of a physical therapy modality are ultrasound and high-voltage galvanic
stimulation (but there’s not yet a study that notes their efficacy).
Counterforce bracing is recommended for athletes with symptoms of medial epicondylitis. It can also aid when the patient is returning to
sport.
- Phase 2: As soon as we see an improvement of phase 1, a well guided rehabilitation can be started. The first goal of the second phase is to
establish full, painless, wrist and elbow range of motion. This is soon followed by stretching and progressive isometric exercises. These
exercises first should be done with a flexed elbow to minimize the pain. Although not yet conclusive, is the belief that strength training
decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and
strengthening exercises resulting in a better and faster recovery process of the affected tendon in Medial epicondylitis. As soon as the patient
has made some progress the flexion of the elbow can be decreased. As the flexibility and the strength of the elbow area return, concentric and
eccentric resistive exercises are added to the rehabilitation program. The final part of this phase is a simulation of sport or occupation of the
patient.
• Phase 3: When the patient is able to return to his sport it is necessary to take a look at his equipment and/or technique. These precautions
ought to be taken to allow a safe return to activities.
• Postoperative management
• 7 to 10 days after the operation, the splint and skin sutures are removed. At this point the physical therapy can start. The beginning of the
treatment is characterized by gentle passive and active hand, wrist and elbow exercises. 3 to 4 weeks later gentle isometrics can be done and
at 6 weeks the patient can start with more resistive exercises. At last a progressive strengthening program has to be followed. In normal cases
the patient can return to activities 3 to 6 months after the operation

36. CARPAL TUNNEL SYNDROME (CTS)
• Carpal Tunnel Syndrome (CTS) is a cause of functional impairment and
chronic wrist pain of the hand. It results from compression of the
median nerve as it passes through the carpal tunnel. An increase in
synovial fluid pressure and tendon tension/inflmmation can cause
compression of the median nerve in the carpal tunnel. Excessive
repetitive movements of the arms, wrists or hands from activities
such as painting or typing can aggravate the carpal tunnel bringing
out the symptoms of carpal tunnel syndrome.
The compression of the median nerve may results from numerous
factors, several of which can easily be remembered by using the
mnemonic PRAGMATIC: Pregnancy secondary to fluid retension,
Renal dysfunction, Acromegaly, Gout and pseudogout, Myxedema or
mass, Amyotrophy, Trauma, Infection, and Collagen disorders.

37. • The clinical features of this syndrome include intermittent pain and
paresthesias in median nerve distribution of the hand, muscle
weakness, and night pain. Usually, people with CTS first notice a
numbness or "falling asleep" sensation in their thumb, index and
middle finger at night. As the symptoms progress, people with CTS
may complain of burning pain and numbness along the median nerve
distribution (radial three and a half digits on the palmar side; index,
middle and ring finger on dorsal surface of the hand) up into the
center of their forearm.
• Median nerve conduction study and EMG study are two diagnostic
test that can be performed to diagnosis CTS.
Tinel’s sign and Phalen’s test are two special test that can be
performed in the clinic to help diagnose.

39. Nonoperative treatment may include the following:
• A prefabricated wrist splint, which places the wrist in a neutral
position, may be worn at night; daytime splinting may be done if the
patient's job allows.
• Pressure in the carpal tunnel is lowest with the wrist in 2 ± 9 degrees
of extension and 2 ± 6 degrees of ulnar deviation. Prefabricated
splints typically align the wrist in 20 to 30 degrees of extension;
however, CTS is treated more effectively with the wrist in neutral.
• Activity modification
• Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for
control of inflammation, but they are not as effective as steroid
injections.
• Any underlying systemic disease (such as diabetes, rheumatoid
arthritis, or hypothyroidism) must be controlled.

40. SCOLIOSIS
• Scoliosis is a sideward’s curving of the spine, resulting in one or even
two curves, making the spine look like a S. In some cases the spine
even shows a rotation component.This rotation starts when the
scoliosis becomes more pronounced. This is called a torsion-scoliosis,
causing a gibbus. Scoliosis can be present from birth. It is then called
congenitive scoliosis. Other sorts of scoliosis can be developed during
growth, any causes for this are still not found. We then speak
of idiopathic scoliosis. There are several types of idiopathic scoliosis.
They are classified by location of the (single or double) curve in the
spine.

41. Scoliosis may be structural or non-structural.
• I. Non-structural scoliosis
• A non-structural curve will usually have no rotational element, being a pure coronal plane deformity. A non-structural scoliosis may be due
to:
• Pelvic tilt secondary to leg length inequality
• Pain or irritation (seen with disc prolapsed and other painful conditions, such as osteoid osteoma, typically triggering muscle spasm).
The key feature of non-structural scoliosis is that the curve is reversible. It will spontaneously straighten when the underlying cause is
corrected or removed. For example: In the case of pelvic tilt scoliosis, the curve will disappear when the pelvis is leveled and this can be
achieved by sitting the patient or by equalizing any leg-length-discrepancy with blocks.
• II. Structural scoliosis
• A structural curve will usually have a rotational element. The structural scoliosis is irreversible and may be classified according to the
underlying etiology:
• Idiopathic scoliosis (70%) = Scoliosis without detectable underlying cause. This is the most common type.
• Congenital scoliosis (15%) = The scoliosis is present from birth. The vertebral disorders that cause congenital scoliosis may be due to either
failure of formation or failure of segmentation or a combination of these, leading to a mixed deformity.
• Neuromuscular scoliosis (10%) = Scoliosis due to neuromuscular diseases such as cerebral palsy, poliomyelitis,….
• Trauma, tumour and infection are also possible causes, but are not frequently encountered.
• Rare conditions, including hereditary and mesenchymal abnormalities such as neurofibromatosis, Marfan’s syndrome, EhlerseDanlos
syndrome etc. make up the remainder.

42. • Symptoms for scoliosis can be:
- Sideways curvature of the spine
- Sideways body posture
- One shoulder raised higher than the
other
- Clothes not hanging properly
- Local muscular aches
- Local ligament pain
• Screening procedures for scoliosis are
done either by the Adam forward bend
test or using other optical techniques
like a scoliometer, while the
radiographic measurement of Cobb
angle is considered as the golden
standard.
• The Cobb angle is the angle between
lines drawn along the upper end plate of
the most tilted vertebrae above the
curve’s apex and the lower end plate of
the most tilted vertebrae below the
apex.

43. • 1. Preparation (warming up + stretch)
• Warming –up consisted of eight minutes walking on a
treadmill or an elliptical machine.
After the warming –up each patient had to do some
stretching exercises:
• - Spine forward stretching:
• The patient sits on the floor with a straight back and
the legs stretched. The patient has to bring her trunk
forwards
• Goal: Stretching the posterior muscle chain and
mobilizing the vertebral spine
• - Upper rolling
• The patient lies supine with the arms besides the body.
The patient has to raise both legs till the toes touches
the floor. Than this person has to unroll her spine
slowly (vertebra by vertebra)
• Goal: stretching the posterior chain, mobilizing the
spine and strengthen the abdomen
• - Child position
• The patient sits in a four support position and has to
stretch her spine, her arms are stretched and she has
to push her hands against the floor. Then she has to
lower her spine.
• Goal: Stretching the thoracic paravertebral, lumbar and
gluteal regions and mobilizing the vertebral spine

44. • Forward leg pull
• The patient sits in a four support position. Then she has to raise the
right arm and leg while the spine stays aligned. Than the same
exercise but change arm and leg.
• Goal: Stretching the concavity of the vertebral spine.
• 2. Specific exercises:
• For these exercise they made use of Swiss balls, FlexBall Quarks,..
It’s important that the patients learn to breathe right during
exercise.
• - Hip movements with a large ball (65 cm diameter)
• Goal: Strengthening the gluteal muscles and developing the
equilibrium
• - Inverted abdominal skills with a ball (55 cm diameter)
• Goal: Strengthening the infraabdominal region and the ischiotibial
muscles.
• - Rising into a seated position:
• Goal: Strengthening the M. rectus abdominis
• - Lateral spine movement on a step chair with a spring of 0.1410 kgf
positioned in the rings to provide major resistance
• Goal: Stretching the lateral muscle chain according to the direction
of convexity of the scoliosis.

45. • 3. Returning to a relaxed
position (relaxation) :
• It consist out three movements,
the patient has to repeat each
exercise three times for five
minutes.
• All exercises has to be
performed rapidly. The purpose
of these exercises are metabolic
recovery and relaxation of the
used muscles.

46. ADHESIVE CAPSULITIS (FROZEN SHOULDER)
• Adhesive capsulitis, commonly referred to as frozen shoulder, is
associated with synovitis and capsular contracture of the shoulder
joint and can be classified as either primary or secondary. In clinical
practice it can be hard to differentiate adhesive capsulitis from other
shoulder pathologies. Since the physical therapy management of
adhesive capsulitis is much different than that of other shoulder
pathologies it can be detrimental to the patient if they are
misdiagnosed.
• characterized by painful and limited active and passive glenohumeral
range of motion of ≥ 25% in at least two directions most notably
shoulder abduction and external rotation.

48. • Adhesive capsulitis can be classified as primary or secondary. Frozen shoulder is
considered primary if the onset is idiopathic while secondary results from a
known cause or surgical event. Three subcategories of secondary frozen shoulder
include systemic (diabetes mellitus and other metabolic conditions), extrinsic
(cardiopulmonary disease, cervical disc, CVA, humerus fractures,Parkinson’s
disease), and intrinsic factors (rotator cuff pathologies, biceps tendonitis,calcific
tendonitis, AC joint arthritis).
• Adhesive capsulitis is often more prevalent in women, individuals 40-65 years old,
and in the diabetic population, with an occurrence rate of approximately 2-5% in
the general population.
• The literature reports that adhesive capsulitis progresses through three
overlapping clinical phases:
• Acute/freezing/painful phase: gradual onset of shoulder pain at rest with sharp
pain at extremes of motion, and pain at night with sleep interruption which may
last anywhere from 3-9 months.
• Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of
glenohumeral motion in capsular pattern. Pain is apparent only at extremes of
movement. This phase may occur at around 4 months and last til about 12
months.
• Resolution/thawing phase: Spontaneous, progressive improvement in functional
range of motion which can last anywhere from 1 to 3.5 years.

49. EXAMINATION
• Shoulder External Rotation (ER)/ Internal Rotation (IR) / ABduction (ABd) (seated) should be
performed.
• Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to
the uninvolved side.
• Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular
pattern. A capsular pattern is a proportional motion restriction unique to every joint that
indicates irritation of the entire joint. The shoulder joint has a capsular pattern where external
rotation is more limited than abduction which is more limited than internal rotation (ER
limitations > ABD limitations > IR limitations). In the case of adhesive capsulitis, ER is significantly
limited when compared to IR and ABD, while ABD and IR were not seen to be different.
• Glenohumeral joint:
• Anterior
• Inferior
• Posterior
• Posterior Capsule Stretch
• In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited but
joint mobility will be restricted in all directions.

50. • SPECIAL TESTS :
• Hand-to-neck
• Shoulder flex + abduction + ER
• Similar to ADLs like combing hair,
putting on a neclace
• Hand-to-scapula
• Shoulder ext + adduction + IR
• Similar to ADLs like snapping a bra,
putting on a jacket, getting into back
pocket
• Hand-to-opposite scapula
• Shoulder flex + horiz ADDuction
1) PAIN
• Strong component of night pain
• Pain with rapid or unguarded
movement
• Discomfort lying on the affected
shoulder
• Pain easily aggravated by movement
2) MOVEMENT
• Global loss of active and passive ROM
• Pain at end-range in all directions
3) ONSET > 35 years of age

51. PT MANAGEMENT
• Initial Phase: Painful, Freezing
• Pain relief should be the focus of the initial
phase, also known as the Painful, Freezing Phase.
During this time, any activities that cause pain
should be avoided and pain-free activities should
be allowed. Better results have been found in
patients who performed pain-free exercise,
rather than intensive physical therapy.
• In patients with high irritability, range of motion
exercises performed with low intensity and a
short duration can alter joint receptor input,
reduce pain, and decrease muscle
guarding. Stretches may be held from one to five
seconds at a pain-free range, two to three times
a day.
• A pulley may be used to assist range of motion
and stretch, depending on the patient’s ability to
tolerate the exercise. Core exercises
include pendulum exercise, passive supine
forward elevation, passive external rotation with
the arm in approximately forty degrees of
abduction in the plane of the scapula, and active
assisted range of motion in extension, horizontal
adduction, and internal rotation.
• Second Phase: Adhesive
• During the adhesive phase, the focus of
treatment should be shifted towards more
aggressive stretching exercises in order to
improve range of motion. The patient should
perform low load, prolonged stretches in
order to produce plastic elongation of tissues
and avoid high load, brief stretches, which
would produce high tensile resistance.
• Third Phase: Resolution
• During stage three, also known as the
Resolution Phase, treatment is progressed
primarily by increasing stretch frequency and
duration, while maintaining the same
intensity, as the patient is able to tolerate.
The stretch can be held for longer periods,
and the sessions per day can be increased. As
the patient’s irritability level becomes low,
more intense stretching and exercises using a
device, such as a pulley, can be performed to
assist tissue remodeling influence.

52. • Mechanical changes that occur as a result of mobilizations may
include the break- up of adhesions, realignment of collagen, or
increased fiber glide when specific movements stress certain parts of
the capsular tissue. These techniques are intended to increase joint
mobility by inducing changes in synovial fluid formation. High-grade
mobilization techniques (HGMT) have been shown to be helpful for
improving range of motion in patients with adhesive capsulitis for at
least three months.
• Patients who received HGMT received these mobilizations at
Maitland Grades III and IV according to the subjects' tolerance with
the intention of "treating the stiffness.“
• 1.Anterior glides.
• 2.Posterior glides.
• 3. Superior and Inferior glides.
• 4. Scapular Mobilization.