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PHYSIOTHERAPY

MODULE

for ENGLISH 1

BY

YUDI ANJANGSANA, DRS. SE. MM

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MEDICAL REHABILITATION:

PHYSIOTHERAPY DEPARTMENT

2012

MEETING 1

What is physiotherapy?

What is physiotherapy?

“Physiotherapy is a health care profession concerned with human function and movement and maximising potential:

 it uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status

 it is science-based, committed to extending, applying, evaluating and reviewing the evidence that underpins and informs its practice and delivery  the exercise of clinical judgement and informed interpretation is at its core.”

The above definition is taken from the Chartered Society of Physiotherapy Curriculum Framework (January 2002). See the Chartered Society of Physiotherapy website for details

Physiotherapists work in a great variety of settings such as orthopaedics, intensive care, paediatrics, mental illness, stroke recovery, occupational health, ergonomics, musculoskeletal treatment in hospitals and private practice, and care of the elderly.

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Physiotherapy is a science-based healthcare profession which views movement as central to health and well being. Physiotherapists aim to identify and make the most of movement ability by health promotion, preventive advice, treatment and rehabilitation.

Core skills used by chartered physiotherapists include manual therapy, therapeutic exercise and the application of electrophysical modalities.

Physiotherapists believe it is of vital importance to take note of psychological, cultural and social factors which influence their clients. They try and bring the patients into an active role to help make the best of independence and function.

Physiotherapy is an autonomous profession (practitioners make their own clinical judgements and treatment choices) and practice reflection (reviewing their own behaviour and success in their work and taking action as appropriate to solve problems they identify in themselves).

Systematic clinical reasoning is used in a problem-solving approach to patient-centred care.

What do physiotherapists do?

Chartered physiotherapists work with a broad variety of physical problems, especially those associated with the neuromuscular, musculoskeletal, cardiovascular and respiratory systems. They may work alone, with physiotherapy colleagues or teams and with other healthcare professionals in multi-professional teams.

These are examples of the areas physiotherapists work in:

 Outpatients - treating spinal and joint problems, accidents and sports injuries.  Intensive Care Units - keeping limbs mobile and chests clear.

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 Care of Elderly - maintaining mobility and independence, rehabilitation after falls, treatment of arthritis, Parkinson’s disease, chest conditions.

 Neurology - helping people restore normal movement and function in stroke, multiple sclerosis and other conditions.

 Orthopaedics and Trauma - restoring mobility after hip and knee replacements and spinal operations, treating patients after accidents.

 Mental Illness - taking classes in relaxation and body awareness, improving confidence and self-esteem through exercise.

 People with Learning Difficulties - using sport and recreation to develop people, assessing and providing specialist footwear, seating and equipment.  Occupational Health - treating employees in small to large organisations and

companies, looking at work habits to prevent physical problems such as repetitive strain injury.

 Terminally Ill (Palliative Care) - working in the community or in hospices, treating patients with cancer and AIDS.

 Paediatrics - treating sick and injured children, those with severe mental and physical handicaps, and conditions like cerebral palsy and spina bifida

 Community - treating a wide variety of patients at home and giving advice to carers.

 Private Sector - working independently in private practice, clinics, hospitals, and GP surgeries, treating a wide range of conditions.

 Education and Health Promotion - teaching people about many conditions and lifestyle choices. This may include back care, ergonomics, taking exercise classes and cardiac rehabilitation groups.

 Sports clinics - treating injuries in sportsmen and women, advising on recovering fitness and avoiding repeated injury.

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How Do I Choose A Physiotherapist?

Choosing a physiotherapist is not easy. You want someone you can trust, someone who will listen to you and understand your problem and your goals.

As you will be spending reasonably large sums of money, you also want someone who will give you value for your money, who will be honest with you about the amount of treatment needed and how long it should go on for.

Fortunately most therapists of whatever persuasion are honest and trustworthy people. But there is still a lot you can do to make sure your therapist fits your requirements.

Physiotherapist Qualifications

Physiotherapy is a 3 year degree course at one of the universities offering this course throughout the UK and Ireland. There are accelerated, 2 year, courses for those who already have a relevant qualification, eg in Sports Therapy. There is a requirement for a minimum number of clinical hours (ie time spent with patients) to be completed before qualification.

A qualified physiotherapist is a safe and effective practitioner in many areas but does not have the specialised knowledge to cope with complex cases. That knowledge is gained in the first few years of practice, often in a rotational scheme which allows experience in many different clinical areas.

How Do I Know If A Physio Is What They Claim?

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The HPC has the duty to regulate this and many other professions (but not doctors or dentists who have their own regulatory bodies). The HPC investigates complaints, takes action against individuals who have been shown to have broken the rules and ensures the continuing competence of practitioners.

The vast majority of physiotherapists belong to the Chartered Society of Physiotherapy, our professional and representative body. However, this is NOT a legal requirement and your physio may be entirely correct and above board if they do not belong.

What Kind Of Physio Is Best For Me?

The answer here is similar as for doctors. If you have a kidney problem you don’t book in to see an orthopaedic specialist. So it’s worth narrowing your search down to the therapists with the specific skills which suit your problem. However, for many more straightforward problems, most physiotherapists will be able to carry out an appropriate assessment and treatment plan.

 If you are a high level sports person or have a specialised need (such as rehabilitation after anterior cruciate ligament reconstruction), it would be worth finding a practice who are routinely managing such conditions.

 For pregnancy or incontinence problems there are physios who specialise in women’s health.

 If you have a complex musculoskeletal problem, perhaps not better after previous attempts at treatment, you could look for a therapist with MACP (Manipulation Association of Chartered Physiotherapists) or M.Sc. Manual Therapy after their name. Both these qualifications involve Masters Degree level study and indicate highly skilled practitioners in these fields.

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and a review by the Pain Management Clinic in your local hospital would be a good first step.

A Good Physio Clinic

There are a whole series of checks you can make as you go through the process of making and attending an appointment. You should feel comfortable the whole way through and feel you know what is going on. This starts with the reception welcome and the efficiency and accuracy of the booking process.

Your therapist should greet you, introduce themselves and give you an overview of how the appointment is going to unfold. There will be the subjective examination where you will tell your story and respond to the questions of the therapist.

This is followed by the objective examination where your therapist will look at the part of your body appropriate to your problem. For most conditions you will need to remove at least some of your clothes. If you have a neck problem you will need to remove your upper body clothing and for a low back pain problem you will need to remove lower body clothing also. The clinic should provide you with shorts to wear (or you could bring your own).

You should feel very comfortable during this process. If you would prefer a female or male therapist you need to make it clear when you book in.

After the examination is completed your physio should give you a working diagnosis and the kind of treatment they have in mind, with some idea of how long that should go on for. Once you consent the treatment can go ahead and you should clearly understand what is being aimed for and why various techniques are being performed.

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Is physiotherapy the right career?

It’s a big decision to choose a career, so unless you have always known what you wanted to do it is worth finding out as much as you can about it.

Physiotherapy is the most popular degree course in the UK and the last numbers I heard were about 18 applicants for every place. This means it is very competitive and the universities can be picky in who they choose to admit.

If you are going to succeed in getting onto a physiotherapy course you will need to have a combination of academic achievement and personal experience and initiative.

Remember, the admissions people need something to single you out as an outstanding candidate in some way, or they may pass you over.

You may want to look at your strengths and weaknesses in the following categories: (on this page)

 Understanding of physiotherapy and the demands of the training  Academic achievement or likely to be achieved

 Evidence of initiative in other areas of life

 Evidence of other ‘life skills’

 Good presentation of yourself, and persistence

Understanding physiotherapy and the demands of training

Get a good understanding of physiotherapy before you go near that UCAS application form.

Sources include:

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Physiotherapy - a questions and answers careers book. 1996. Trotman &Co Ltd,

Richmond. 0 85660 278 7

Work experience - this can be helpful but you may find it difficult to arrange.

Physiotherapy departments have a lot of pressure on them with workload, staffing shortages and commitments to student placements.

Try other areas of healthcare, as these may be just as suitable as physiotherapy departments themselves. University admissions tutors are looking for the ability to communicate with all types and ages of people, and a talent for relating to those with illness or disability.

Careers guidance officers/departments should be able to help with the details. Well written letters, in good English, make a good impression.

Physiotherapy assistant posts. In my department we usually have at least one

person who is applying or intending to apply to train. Assistant posts are very valuable experience but are very competitive when they come up. Jobs in other care-related areas, such as nursing homes, may also equip you with a better understanding of people and therapy.

Hospital departments may run open days. It may be worthwhile sending an

enquiring letter with a stamped, addressed envelope.

Academic requirements for entry

To see detail of these requirements and opportunities please go to Chartered Society of Physiotherapy - UK Qualifying Programmes

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Three or four years of full-time study is typical to become a Chartered Physiotherapist. There is a large amount of self-directed study, and clinical placements of 4-6 weeks, which may not near where you live or study.

This is a “full-time” programme and you must be certain of your your ability to commit yourself completely for the years the courses require.

Part Time Programmes

Part-time physiotherapy study programmes do exist in the UK, and some have been set up for physiotherapy assistants who wish to train.

Accelerated Programmes

Accelerated physiotherapy programmes offer the ability to acquire a licence to practice physiotherapy if you have certain qualifications. A degree in a relevant discipline such as a biological science, psychology or sports science, (usually first class or upper second class degree level), may make you eligible. Successful graduates will be eligible to apply for state registration and membership of the Chartered Society of Physiotherapy.

The minimum entry requirements are the same as those for all degree programmes. There is strong competition for places and conditional offers of a place are set higher than the minimum. A variety of qualifications may be accepted and you need to check directly with the individual university before you apply.

More physiotherapy qualifying places have become available due to the Government’s NHS Plan but competition for places is likely to continue.

Evidence of initiative in other areas of life

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“Just” academic qualifications may not be enough and you may have to work on other aspects of your life which show initiative and involvement in the life of the community. This means things you choose to do which you do not have to, such as extra study, service or activities. They may show leadership, proactivity and persistence, giving the picture of a rounded person who has lots of parts to him or her.

Evidence of other ‘life skills’

As well as having the ability to cope with the academic demands of an honours degree course, admissions tutors look for evidence of other qualities and skills in prospective students:

 communication, helping and caring skills

 sensitivity and tolerance

 ability to use initiative

 potential to undertake an intensive course of study

 reliability, honesty and trustworthiness

 enthusiasm, dedication and determination

Good presentation of yourself, and persistence

Good presentation of yourself is vital as many people deciding on your future will have a very short time of contact with you. You need to impress them suitably in a short time.

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Application forms need to be carefully filled out and attention paid to what exactly is asked for, with appropriate documents and payment.

If you should go for interview then a conservative appearance will help persuade the listeners and lookers that you are person who could be trusted with the welfare of often vulnerable people.

Good social skills are obvious and the absence of them gives immediate cause for concern. Are you familiar with meeting people in positions of influence over you? You can practice your style with others you may know, who will often be happy to give advice.

A tip for those applying…about SPORT

Sports physiotherapy is a very small part indeed of the physiotherapy spectrum. Most physios work in other clinical areas and never have any sports experience. If you are very keen on sports, be aware of a few thoughts:

 In your training, you will very likely do no sports-related work, but have to cover many

clinical areas. As a junior physiotherapist in the NHS (the biggest employer by far), sports physiotherapy is uncommon.

 Admission tutors may look unfavourably on an application which concentrates heavily

on sports, or on a very sports-oriented view in interview. This is because physiotherapy is so much more than this and very diverse.

 On a personal note, sports contestants are perfectly worthy of attention, but are

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MEETING 2

Arthritis

Arthritis (strict meaning: joint inflammation) is a general term given to joint changes and diseases which occur in our bodies.

Unfortunately there is a lot of confusion as to what arthritis really means, and many people fear the diagnosis when there is really no need. The latest treatments for Rheumatoid Arthritis involve a much more detailed scientific understanding of the underlying mechanisms of this important disease. And the new treatments are much

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Traumatic arthritis

If you sprain your ankle or knee and it swells up, that is technically called an arthritis even though it is short-lived and very likely to heal and settle down.

Osteoarthritis

(OA)

This is the age-related joint change which increases as we get older, but is also connected with our family history. We are more likely to suffer from OA if our parents have it.

Arthritic diseases

This is a large group of conditions varying from the not very serious to the disabling and life changing. They are true diseases which often have systemic (body wide) effects on the person way beyond their joints. The commonest of these diseases is rheumatoid arthritis.

Bone diseases

Even though they are not strictly part of the arthritic diseases group, the diseases of bone are an increasingly significant part of rheumatology. Osteoporosis is the most well known.

In addition to the links above Physiotherapy Site covers the following arthritis-related issues:

1. What are the causes of Osteoarthritis? 2. What is the development of osteoarthritis?

3. What is the value of using glucosamine for joints?

4. What is the best course of management of osteoarthritis? 5. What is the natural history of osteoarthritis?

6. What are the signs/symptoms of osteoarthritis?

7. How will we cope with arthritis given the ageing of Britain? 8. What is visco supplementation?

In addition you may find useful the following Arthritis links

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Up until recently doctors have been working somewhat in the dark when treating this common and disabling condition.

This is because we had little understanding of the underlying reasons for the condition and so could not target treatments to the causes of the disease.

Rheumatoid Arthritis

Rheumatoid arthritis is a common and very troublesome disease. It affects one in a hundred people in the UK, causing a reduction in life expectancy comparable to Non-Hodgkin’s Lymphoma or three artery Coronary Heart Disease. So it’s an important condition and the cause of significant pain, distress, disability and some shortening of life.

Scientific Research

The important change over the last few years is that a revolution in the understanding of the underlying mechanisms for the disease has occurred. This, along with new and powerful drugs, has enabled rheumatologists to directly target the disease processes. The results have been startlingly good.

Inflammation - The Scientific Basis

This is complicated. As part of the immune response, white blood cells (WBCs) take in proteins and break them down into peptides. With these the WBCs form structures called Major Histocompatibility Complexes (MHCs) on their surfaces. T-lymphocytes recognise these MHC and peptide combinations and secrete cytokines. Cytokines are chemical messages from one cell to another and can be thought of as local hormones.

Cytokines Influence Inflammation

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increase inflammation in the tissues, others decrease it and it is the balance between the two which determines the state of inflammation in the person.

TNF Alpha

Tissue necrosis factor alpha (TNF Alpha) is one of the most powerful increasers of inflammation in rheumatoid joints. High levels of this chemical have been found in RA joints and the levels of TNF Alpha relate well to the levels of pain the individual is suffering from. This indicates that the TNF levels are an important indicator of what is going on in inflamed joints, as well as being significantly responsible for causing the inflammation.

TNF makes cells produce more cytokines and this can increase the inflammation greatly. Anyone who has had a severely inflamed joint (just one is enough) knows just how bad that can be.

Anti-TNF Drugs

Once the importance of TNF was realised, the drug companies worked to develop drugs which would inhibit the production of TNF. Available at the moment are Infliximab, Adelinimab and Etanercept. This are either given intravenously or injected just under the skin. There is no oral treatment for these compounds yet.

Many cells have TNF Alpha receptors on their surfaces, areas which accept TNF Alpha chemicals produced by other cells and which causes the receptor cells to become inflamed. In the same way, many cells produce TNF Alpha. The drugs capture and bind the TNF Alpha molecules and prevent the receptors from receiving them, thus reducing the inflammation in the cells.

Good results from TNF Blockers

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The results of treatment by TNF blockers are MUCH better. Doctors can now seriously talk about inducing remission (stopping the disease activity) in rheumatoid arthritis for the first time.

The State Of The Art

TNF Alpha is a pro-inflammatory (promotes inflammation) cytokine for which there are now highly effective inhibitors available. In ankylosing spondylitis the results are good too, with an especial improvement in low back pain at night, a very useful property of these drugs. They might also have a role to play in sciatica, migraine and complex regional pain syndrome, but it is not clear yet how useful they will be.

Causes and incidence of Osteoarthritis

Osteoarthritis (OA) is the commonest cause of joint disability in developed world, and listed in the top 10 of the global disease burden according to the World Health Organisation.

In white North Americans and North Europeans, about one-third of adults between 25 to 74 years have signs of osteoarthritis on their x-rays in at least one joint. In the US, 6% of those over 30 and 12% over 65 have a troublesome osteoarthritis knee.

Most common areas to be affected by OA are the hands, followed by feet, knees and hips. See Development of Osteoarthritis for a more technical account of the condition.

Risk factors for Osteoarthritis

Key risk factors are genetic, non-genetic and environmental

Genetic factors

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 Sex - more common in females

 Inherited disorders of type 2 collagen (a main component of joints, ligaments,

skin).An example is Stickler’s syndrome

 Genetic mutations of the type 2 collagen gene

 Other inherited joint or bone disorders

 Race and ethnic origin

Non-genetic factors

 Increasing age

 Being overweight

 Reduction in female sex hormones (eg after menopause) - this is not clear

 Developmental diseases of bones and joints, and any acquired during life.

 Knee trauma is a significant risk factor, such as anterior cruciate, meniscal and

ligamentous injuries.

 Previous joint surgery such as “cartilage”(properly called menisci) removal from

knees

 Race and ethnic origin

Environmental factors

 Occupations and physical effort of work

 Excessive repetitive joint use

 Major accidents/injuries to joints

 Leisure and sports activities

Risk factors are complex and may vary both from joint to joint and even within certain areas of one joint.

Age

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Women

Women are at higher risk of developing OA than men, especially after the menopause but the reasons for this are complex and not well understood.

Weight

Obesity is strongly associated with knee (and to a lesser extent hip) OA, perhaps due to the increase in stress put through the joint when the person is overweight. However, systemic factors may be involved because obesity is linked to hand OA too.

Jobs

Occupations and sport are also associated with developing OA. Jobs which involve kneeling, squatting and stair climbing are connected with higher rates of knee arthritis. Heavy repetitive joint use appears to increase OA risk.

Jobs involving repetitive heavy lifting (eg farming) show higher rates of hip arthritis.

Sport

Sport participation is connected with lower limb arthritis. Jogging, however, does not seem to increase the risk of OA if the person’s joints are normal.

Other risks

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Development of osteoarthritis

Osteoarthritis symptoms develop slowly and are therefore difficult to detect.

The onset of symptoms

Many joints with signs of OA on examination or on xrays show no symptoms as far as the person is concerned. Onset of symptoms is usually insidious (medic speak for slow and sneaky) and people can seldom indicate exactly when they felt the trouble started.

The typical onset of OA in a joint is variable but people often notice changes in a joint related to, or immediately after, some activity with that joint. This can be a vague and occasional ache or pain in the joint, sometimes with mild joint stiffness and aching in the muscles near the joint.

Range of motion of the joint may also be affected, either slowly by gradually becoming aware of a restriction in doing a normal activity or quickly by having a minor injury. A small injury can set off a process where all the symptoms of OA will develop over a few days, in some cases rather severely. OA changes were almost certainly present in the joint prior to the injury, which converts a previously trouble-free joint into a painful and stiff one.

Aches and pains in our joints and muscles is a normal part of human life, and people with OA may just notice an increase in the severity and frequency of these normal symptoms. This is usually taken as nothing to worry about and part of the ageing process until the severity of the symptoms drives the person to consult a doctor.

A disease of articular cartilage?

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Articular cartilage has two main functions:

1. To absorb stress by compressing under mechanical load 2. To provide smooth, friction-free joint movement

The cartilage matrix (the chemical and biological constituents) is in a state of constant change in life, which in healthy people is a balance between the processes of building up and breaking down. OA is seen by some people as a failure to maintain this balance, due either to a reduction in formation or an increase in breakdown.

Patients with well-defined OA often show changes in the bone underlying the cartilage on their x-rays. These changes are increasingly thought to be a cause of OA rather than a consequence. The cartilage relies on the mechanical health of the underlying bone to maintain its own normal function.

Underlying bone the culprit?

In one model (view) of OA the idea is that a stiffening of the underlying bone results in bone which is no longer a good shock absorber for the cartilage. This may result from repetitive micro fractures in the bone.

There are various lines of evidence which support this view, as well as the inverse association between OA and diseases of low bone density such as osteoporosis. This means that when the bone density is low the occurrence of OA is much less common, indicating bone density is important.

In people with hip OA, bone density is higher on x-ray than the density of people with normal x-rays, and not just at the hip but also in other areas away from the hips.

Inflammation?

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increased cartilage loss.

MEETING 3

Glucosamine and Chondroitin

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problem.You can try this type of product by clicking on the image for this liquid form of glucosamine, said to have a much faster and more complete uptake than capsules.

Osteoarthritis (OA) is the most widespread type of arthritis, a degenerative condition of the joints. Acute inflammation is uncommon in OA and it is mostly a “wear-and-tear” disease involving degeneration of joint cartilage and the formation of bony spurs in various joints.

Joint trauma, repetitive joint stresses in jobs, and obesity are risk factors. OA is very common over 60 years of age, but not always troublesome.

You will have seen advertising and promotion of glucosamine and chondroitin as a treatment for OA.

What are these substances?

Glucosamine, an amino sugar, is a natural substance made by your body, an essential building block of joint cartilage, ligaments, bones and blood vessels, and is thought to promote the formation and repair of cartilage.

Chondroitin, a carbohydrate, is a natural cartilage component linked to levels of water retention and elasticity and to the inhibition of enzymes that break down cartilage. Both compounds are manufactured by the body.

You can buy both these dietary supplements as tablets from your local health food shop or chemist and they are often taken together.

What does the research say?

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supplements are extracted from the cartilage of cows.

Studies on people have shown that both may relieve arthritic pain and stiffness with fewer side effects than conventional arthritis drugs. However, there isn’t enough good research to know whether their use is sensible. The manufacture of these kinds of supplements is not regulated and product quality, especially of chondroitin products, is not predictable.

So, does glucosamine and chondroitin work?

We don’t really know as there isn’t any convincing evidence that glucosamine or chondroitin help to ease the symptoms of osteoarthritis. There is some weak evidence that glucosamine, or a combination of glucosamine and chondroitin, might be helpful and no evidence that taking chondroitin on its own is helpful.

Glucosamine may help by reducing pain and stiffness rather like a non steroidal anti-inflammatory drug (NSAID) and some trials have shown that glucosamine, or glucosamine plus chondroitin, can help to control the symptoms of osteoarthritis. However, these trials have faults in them which make the results unreliable. So it is difficult to be sure whether these treatments work or not.

Just keep in mind that there isn’t any definite proof (or even good evidence) that either of these supplements is useful in treating osteoarthritis.

Products

In the US, glucosamine and chondroitin products are marketed as “dietary supplements”. Glucosamine is available in many forms, including glucosamine sulfate, glucosamine hydrochloride (HCl), and N-acetylglucosamine (NAG), and have various other contents. However, there appears to be no conclusive evidence that one form is better than another.

The safety of the substances

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the trials to date.

Do the experts agree?

The use of these agents is thought to be reasonable but more research is needed to place them in their proper roles. There is disagreement about how practical or sensible it is to use them now.

Is there a bottom line?

It is difficult to make a decision about using these agents because the information is far less convincing than desirable. Quality control of the products is also a significant problem, with the chemical makeup varying with different brands.

It’s not clear whether they actually do work at all but they could help the body make new joint cartilage and to repair damaged cartilage.

What should you do?

Get a concrete diagnosis from a competent physician.

Discuss the benefits and potential risks with your physician

 If you decide to try the compounds, ask your physician for guidance on

dosage/frequency etc.

 Get your doctor’s help, or the help of Consumer reports or Consumerlab.com, in

choosing a product.

Ignore all “miracle cure” claims for arthritis. Anything that seems too good to be

true, is.

Don’t buy products in response to junk mail, tv or other advertising, and check

carefully for price and good value. It won’t be cheap, even if it helps.

Do not trust any seller of dietary supplements, herbs, or homeopathic

remedies to give you impartial advice about whether you should use their products.

You want to see the evidence?

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evidence.

ConsumerLab is a very useful site, with analysis of all the evidence and also of the products. Some products don’t have any of the substance in them that they claim to have!

If you’d like to think about the issues and make an informed decision, the US Food and Drug Administration Centre for Food Safety and Applied Nutrition has issued a document Tips for the Savvy Supplement User: Making Informed Decisions And Evaluating Information which may be of interest.

Management & Treatment of Osteoarthritis

Treatment of OA concentrates on controlling the symptoms as there is no way to control the process, and pain is the measure used to check success or otherwise.

Treatment is progressed from less invasive and risky treatments up to surgery, depending on severity and areas of joint involvement.

This is a 10 point list:

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2. Physiotherapy is important in the management of OA. Strengthening of the quadriceps muscles has shown to be effective in reducing pain and improving function in knees. A study showed that aerobic and resisted exercise, combined with education and drugs, gave better results than education and drugs alone in people with knee OA and mild disability

3. Weight reduction reduces the risk of developing OA of the knees, and helps reduce pain and improve function in older women with knee OA. Routine diet management has a useful place here

4. Drugs are used to combat pain and paracetamol is the first choice, with non-steroidal anti-inflammatory drugs (NSAIDS) added if the pain does not respond. Medical advice is needed to choose the best drug or the one with the least side-effects.Scientific reviews have found paracetamol (acetaminophen) and anti-inflammatory drugs to be effective in controlling the pain of OA, although anti-inflammatories have not been shown to be more effective than paracetamol.There can be severe side effects on the gastrointestinal system from non-steroidal anti-inflammatory drugs and the situation should be discussed with your medical adviser

1. Application of creams to the joints can be helpful, such as NSAIDS or capsiacin, especially if only one or two joints are affected. There is limited evidence for the effectiveness of this treatment, and no guide as to which agent is any better than any other.

2. Injection of corticosteroids into the joint is a common treatment but there is little scientific evidence to back it up. Some people report long term improvement in their pain after injection but there is no way of telling which people will respond well to the treatment

3. Injection of hyaluronic acid is helpful in knee OA, but needs to be done weekly for three to five weeks

4. Strong painkillers such as narcotic drugs (morphine etc) may be helpful but the risks of side-effects, addiction and abuse are an issue

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6. Total knee replacement and total hip replacement (internal links in this site) are highly effective treatments for hip and knee OA, resulting in great improvements in the function and quality of life of these people. The success rate of TKR has risen to match that of hip replacement as a reliable operation

The Future for Osteoarthritis

Research into OA is very active and has increased the understanding of this condition over the last decade. New drugs are coming forward to control the pain symptoms or to alter the disease and its progression.

Some people with restricted areas of damage to the joint cartilage can have their own cartilage grown into a graft to replace the damaged region. This is known as Autologous Chondrocyte Implantation

Natural history of Osteoarthristis

It is difficult to give any exact opinion on how things will go with any particular joint or person, as the course of OA varies greatly.

Osteoarthritis usually takes years to develop to the level where it begins to interfere with the person’s life.

Typically, the symptoms bumble on with worse and better periods, with flare ups at times when the joint can be much worse for days or weeks.

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In the most commonly affected joints, the fingers tend to progress the most quickly, the knees the most slowly, with hips inbetween. Change in joint pain and bony destruction can be rapid in some cases, leading to a severe worsening in the person’s functional status.

Features of osteoarthritis on examination

Features of Osteoarthritis are divided into symptoms - what the person is complaining of, and signs - what the examiner can find.

Symptoms

 Joint pain

 Stiffness in the morning

 Instability or giving way of the joint

 Loss of normal function of the joint and the person as a whole

Signs

 Pain on movement

 Swelling of the joint

 Bony enlargement of the joint

 Limitation of range of movement

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 Joint deformity or poor alignment - eg bow leg or knock knee

Pain

Pain is the most common complaint and the thing which brings people to a doctor. It’s intensity and nature is described in hugely variable ways by different patients but it usually comes on gradually, is mild or moderate in level, is made worse by activity and improved by rest.

Activity pain usually begins soon after the activity itself and may continue for hours after the activity ceases. Many people complain of a vague ache or pain during activity while others describe sharp or stabbing pains associated with a particular activity.

If Osteoarthritis is severe there may be pain at rest (50% of sufferers or less) and at night (around 30% of sufferers). Severe and progressive osteoarthritis occurs at times, with a severely painful joint and significant disability.

Pain in joints with osteoarthritis could come from the membrane lining the joint, the joint capsule (fibrous bag around the joint), the ligaments around the joint, from muscle spasm and the underlying bone. Osteoarthritic joints are often tender at points around the margins and very sore if knocked or injured in any way.

However, pain in osteoarthritis is not simply related to the changes in the joint or surrounding tissues but is influenced by many factors. Although pain complaints fit well with x-ray changes of OA, the severity of pain does not reflect the severity of the changes. This means someone may have significant OA changes on x-ray but complain of little pain, while someone else may have little evidence of joint changes on x-ray but complains of severe pain.

Stiffness

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been still for a while, or a feeling of resistance as the joint is moved through its range.

A joint may have to be loosened up in the morning for a few minutes to half an hour. Longer periods of stiffness, or widespread stiffness through the body, is more characteristic of the arthritic diseases, the most common of which is rheumatoid arthritis.

Loss of joint movement

Joints often lose some of their range of movement when affected by osteoarthritis, with the ends of the movement reduced. Pain is often present when the joint reaches the end of its limited range. The reasons for this may be various: a thickening and tightening of the fibrous bag surrounding the joint, remodelling of the joint as the cartilage thins and the underlying bone becomes denser and bony outgrowths at the margins of the joint (osteophytes).

Instability

Giving way of a leg is a common complaint with OA of the knee or hip, with a feeling of insecurity, as if the leg cannot be trusted at times to support the weight of the body. There may be no actual signs of the joint being unstable but often there is weakness with muscle wasting. It may be that the muscles are weak or poorly co-ordinated as so the leg feels less trustworthy at times.

Bony enlargement

Osteoarthritis joints may have enlarged areas around them, which seem to be bony in nature in that they feel very firm and also tender. They may be made up of a mixture of soft tissue, cartilage and bony outgrowths.

Swelling and inflammation

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overproduction of the natural lubricating joint fluid. OA joints may feel warm at these times, and this may be due to a low grade inflammation occurring, with periods where the inflammation is more obvious with joint warmth and redness. These increased inflammatory symptoms may occur during flare ups of the joint pain and problems, typically lasting for a few weeks.

Joint destruction

When osteoarthritis gets severe it may be obvious that there is severe damage and destruction to the joints involved. As wear progresses in some joints, they may alter shape and become deformed. Examples are bow-leg and knock-knee in the knee joint, shortening of the leg in hip disease and the deformity and instability (wobbliness) which can occur in the end joints of the fingers.

Functional loss and handicap

Osteoarthritis causes a great burden to millions of people trying to live their lives in the world. Functional loss can be caused by pain, loss of movement or a decrease in muscle power. This can lead to disability, for example difficulty reaching the feet to dry them or put on socks, limited walking distances and problems with stairs. This in turn can lead to handicap, which is related more to the loss of independence, loss of role and depression which many people suffer.

Creaking and crunching

In osteoarthritis, patients often complain of crunching and cracking in their joints (technically called crepitus). A joint may give out loud cracks and crunches if the arthritis is severe. These noises may be due to the roughening and abnormality of the joint surfaces.

X-rays

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the underlying bone and sometimes obvious deformity of the joint. Blood tests are usually normal.

Outlook

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MEETING 4

Britain’s ageing population

The age structure of the British population is undergoing unprecedented change.

The changes in social policy and healthcare which started in victorian times have contributed to the great success of increasingly long lives for a large proportion of people.

The present and continuing changes have and will have increasingly strong effects on many aspects of society, including the provision of health care.

The Office for National Statistics figures show that the number of people aged 65 years and over increased from 7.4 million (13% of the population) in 1971 to 9.2 million (16%) in 1996 and is estimated to increase to 14.5 million (24%) in 2061.

People aged 65-74 could expect to live for 14.2 years if they were a man and 17.9 if a woman. Half of these remaining years are expected to be lived with some kind of disability.

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It is likely the number of people aged 65 and over will rise substantially over the next few decades. The frequency of conditions such as osteoarthritis rises with age so the number of hip replacement operations is also likely to rise.

Reference: Kay-Tee Khaw, How many, how old, how soon? BMJ 1999, volume 319, 1350-2.

Viscosupplementation for osteoarthritis of the knee

Osteoarthritis is the most common form of arthritis in the world, affecting huge numbers of people and is a major cause of disability. As industrialized populations become older and live longer, the effects of osteoarthritis (OA) will become more marked.

New treatments are continually being developed as the understanding of OA moves forward rapidly.

Introduction to viscosupplementation

The synovial fluid is the fluid secreted by the lining of the knee and other synovial joints (most of our joints are of the synovial type). This fluid provides a useful function in the life of our knees.

One of the main constituents of synovial fluid, hyaluronic acid, gives viscosity and elasticity to the fluid, allowing it to improve the way joints function.

In OA this viscosity and elasticity is reduced, and this may contribute to the abnormal functioning of the joint.

Viscosupplementation has been developed to replenish the hyaluronic acid part of the synovial fluid. This has shown some promise in improving the pain and abnormal function of osteoarthritic knees.

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Hyaluronic acid as a lubricant and shock absorber in the synovial fluid. It is not toxic when injected, has few side effects and has a rapid onset of action.

Reason for using this technique

The concentration and molecular weight of hyaluronic acid in osteoarthritic joint fluid is reduced. Normal viscosity of the synovial fluid is vital to joint lubrication and is thought to have protective effects on the joint cartilage.

It is suggested that the changes in the synovial fluid in OA joints makes the joint cartilage more likely to be injured by physical or chemical stresses.

The aim of treatment

Injecting the materials into the joint is intended to increase the concentration and molecular weight of the hyaluronic acid towards the normal. The aim is to make the joint chemistry resemble more closely that of normal synovial fluid.

How does it work?

The mechanism of action of this therapy is not clear. A substance introduced into the knee may have a cushioning effect, but is thought not to last very long in the knee. However, its effect of stimulating normal production of hyaluronic acid from the joint lining could have longer term effects, including inhibiting the joint’s pain nerves from firing.

Hyaluronic acid may increase joint lubrication, control swelling and may encourage the production of cartilage.

Research work

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Arthritis cost of treatment

Bobic (2003) showed the price of a course of injections costs £200-300 sterling, the average time of pain relief was seven months and 10% of people did not get any real pain relief. There were no significant complications.

Is the procedure safe?

Infection risk is very low if normal sterile technique is used. The treatment has no overall body effects so is an attractive treatment option for osteoarthritic knees. Overall the substances used are non-allergenic, non-toxic and do not cause inflammation.

Only Hyalgan TM has shown instances of anaphylactic shock-like reactions.

Treatment can be followed by a few days of redness, pain, warmth and swelling, with occasional more severe inflammatory reactions needed steroid injection.

It may be unwise to inject patients who are sensitive to hyaluran materials or bird proteins, who have an infected area around the injection site, have circulatory problems in the leg or if there is strong inflammation present.

Summary

OA costs enormous amounts of money and if this treatment reduces or puts off the need for arthroscopic surgery or total knee replacement, there could be a considerable cost saving. This treatment seems to be developing into an important treatment for OA joints.

V Bobic: Viscosupplementation for the osteoarthritis of the knee

ISAKOS Current Concepts 2003. Bobic paper

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This section tries to answer many of the questions people have about their back pain.

Am I damaging myself by keeping going? Should I rest for my back pain?

Do I need an operation? Do I need an x-ray? Do I need a scan? Is it serious?

Do I need to see my doctor? Have I got arthritis?

Am I damaging myself by keeping going?

In general the answer is no but there are a few things to be aware of. When the injury has just occurred it is likely there is tissue damage and inflammation. During this period it is useful to reduce the vigorousness and frequency of activities to allow the injury to heal itself.

However there is good scientific evidence that bed rest is possibly the worst treatment for low back pain episodes. Scaling down activities and gradually building them back up again as soon as possible to normal levels is the best treatment.

Even though the initial onset of low back pain may be due to tissue damage in many cases, once back pain has persisted longer than three months there is no evidence of ongoing tissue damage. In these cases avoiding activities and resting may be damaging in the long term.

However, the opposite approach of pushing yourself hard to get things done usually results in greatly increased pain and is also unhelpful.

Should I rest for my back pain?

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leading to more pain, more episodes over the years, more time off work and increased disability.

The advice now is never rest unless you absolutely have to, if forced to by the severity of the pain. 2 to 3 days is the maximum amount of bed rest recommended if the person has to lie down. If the pain is not bad enough to force you to lie down, don’t.

Do I need an operation?

Most people with back and leg pain are never going to have an operation as surgery is just a small part of the management of these conditions.

Discectomy is a treatment for severe and persistent leg pain, not back pain. Decompression is used in older (>60 years) people who complain of leg pain on walking.

Fusion is used to treat back pain but is complex and needs careful assessment and explanation. Most people with back pain do not have surgery, even if the pain is severe. See Spinal surgery.

Do I need an x-ray?

X-rays of the lumbar spine rarely show anything unexpected when the examination by the doctor has not thrown up any worrying features. Studies have shown the ratio of useful x-rays to non-useful ones to be 1 in a 100 to 1 in 2500.

The usefulness of xrays in normal back pain has not been demonstrated, especially since many of the abnormalities present are also present in people who do not have back pain. The doctor may order xrays in certain circumstances such as after a fall etc.

Xrays very rarely show the cause of back pain.

Do I need a scan?

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 If an operation is planned, to either check for a disc prolapse or to check the

condition of the discs in general

 If an unusual cause of back pain is suspected

Because of the high incidence of “false positive results”, ie changes on the scan which are of no relevance to the pain, the interpretation of scans is difficult.

An MRI scan often does not show the cause of back pain.

Is it serious?

Back or leg pain is rarely medically serious, even if the pain is severe. There are a few things to be aware of which may indicate a serious reason for back pain:

 The first episode of back pain comes under 20 years of age or over 55 years

 There is significant unexplained weight loss (for example more than a stone per

month)

 The person is unwell

 The pain is progressively worsening and not affected by changes in activity or

posture

 The pain is worse at night

 A traumatic onset, such as a fall from a height

 Previous medical history of cancer, steroid use, drug abuse, HIV

 Widespread or progressive leg weakness, numbness, pins and needles

 Numbness or pins and needles around the anus or genitals

 Difficulty with or incontinence of bladder or bowel

If you have any of these problems you should see your medical adviser without delay.

Do I need to see my doctor?

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Have I got arthritis?

The normal age-related type of arthritis is osteoathritis, and is not especially relevant to back pain. There are several arthritic diseases which may be important in the diagnosis of different types of back pain.

The symptoms of arthritis are different from normal back pain:

 Gradual onset of problems before 40 years of age

 Significant morning stiffness, taking more than an hour to go off

 The spine may be stiff to move in many directions, not just one

 Other body joints may be involved

 There may be iritis (eye inflammation), skin problems eg psoriasis, colitis (bowel

problems), urethral discharge

 A family history of this kind of condition is important

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MEETING 5

Physiotherapy Exercises

Some of the most important exercises physiotherapists commonly prescribe are:

 Simple back exercises  Simple knee exercises

 Simple neck exercises  Simple shoulder exercises

It is increasingly common for physiotherapists to ask patients to strengthen their core stablility and we have outlined for you some of the most important core stability exercises. One of the fun methods physiotherapists use to improve core stability is through the use of Gym balls.

As many patients are recovering from serious injuries, and some may not be keen on exercise, it is crucial to note the recent scientific evidence that Low Level Exercise Works.

As always with medical advice, it is essential before commencing a programme of activity to understand the Risks of Exercising and to consider first Exercise advice.

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Simple back exercises

One very powerful way of controlling your back pain is to do daily range of motion exercises, putting your back through full movement several times a day. This prevents stiffness developing and stretches all the attached muscles, making them less vulnerable to sudden demands.

Please note that exercises can make your pain worse as well as better so please consult the simple exercise guidance before getting on with them. If you have any doubts, please consult your physio, other manual therapist or medical practitioner.

These exercises are meant to maintain range of motion or regain loss of movement in the back region and to help control pain. Regular performance of movements can help with pain problems.

They are simple and not magical in any way. However, with regular performance, you should find your problems are improved. If you have long term back pain with some disability these exercises may help mobility but may not be very effective against pain.

Do each movement slowly five times, resting a short time in between each set of movements. Do two or three times a day although more often can be useful. You can increase the numbers over time as you get more confident.

One leg to chest

Lie on your back with your legs straight out. Bend one leg up, pulling your knee up towards your chest with your hands. Alternate sides.

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Knee rolling

Lie on your back with your knees bent up and feet flat on the surface.

Keep your knees together and roll them steadily from side to side. If you have a lot of mobility you may be able to get your leading knee to touch the surface.

Often you will not be able to allow a large movement initially as it may be uncomfortable, so keep a smooth and gentle motion going within your comfort zone.

There is very little rotation in the lumbar spine but nevertheless this movement is often uncomfortable in the low back and can be useful as part of your exercise programme.

Pelvic tilting

Lie on your back with your knees bent up and feet on the surface. Start by tilting your pelvis a little so your back arches a bit. This picture shows her arching her back rather a lot and you may not need to try and go this far in your own exercise.

I find that many people have real trouble in figuring out just what to do in this movement and just can’t get the hand of it. Adjusting the pelvic tilt in standing can be useful but if you can’t do it in lying you have no chance in standing. Starting the movement by going the opposite way, into back arch, can help get the idea into your head.

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up, this is a forward and back rocking motion and often tricky to get right. You should feel the small of your back has pushed down against the surface. If put your hand under your back when you arch slightly you will feel the pressure as you tilt correctly in the opposite direction.When you get good at this you can use it to control the amount of pelvic tilt you have in your back in standing and to perform the core stability exercises which are thought to play such an important part in back pain related problems these days.

Hip hitching

Lie on your back with your legs out straight. Shorten and lengthen each leg alternately, pulling up each side above the hip bones. Do this slowly and smoothly, it can be quite aggravating for the back if you go at it too hard and jerkily.

This exercise is really done from the waist, pulling the pelvis up at each side whilst keeping the knees straight. It’s easy to let the knees bend then this becomes a leg exercise and not a back one. It feels a bit strange and can be a little severe on the back joints so it’s good to go easy. Some people jerk it strongly and I recommend you develop a smooth, easy rhythm for best results.

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Both knees to chest

Lie on your back, bend one knee and hold on with the same hand then do the same with the other leg. Pull both legs up towards the chest, gently at first. NB If you have a recent disc problem this can make you worse. If in doubt, get advice.

This exercise can feel very stretchy at first as many of us do not flex our lumbar spines fully in normal life. You may not be able to get your knees up as far as she can but that doesn’t matter to start with. Go as far as you easily can and you will see improvement steadily with time.

Back arching

Lie on your front. Get up so you are resting on your forearms, as if you are lying on the beach and looking out to sea, then lie down again.

If you find this difficult you might need to start by just lying on your front for a short period of time for your back to get used to being in extension of some degree.

Your back and hips should be relaxed as you let them go and remain where they want. The only work you are doing is supporting your upper body weight with your arms and shoulders.

Standing exercises

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Forward bending

Yes! This is not a dangerous movement and is important to maintain as many of the normal things we do in life require it.

Slowly bend over as if you are trying to touch your toes, then return to the vertical. Don’t bounce, push or hold, just do a smooth movement.

Don’t worry if you do not get anywhere near your knees, it doesn’t matter at all. Regular use of this movement can be very useful to maintain a healthy back as it is one we tend to avoid, especially if we have had back pain problems in the past.

Side bending

Stand with your hands against the sides of your thighs. Slide one hand down the same thigh, bending to that side and avoiding any twisting, as if you are stuck between two panes of glass.

Do to one side, then give yourself a short rest before doing the other. I find it unpleasant if I go from one side to the other straight away. See how you feel. This can be quite a severe movement so go easy, allowing the range to increase slowly as you do it. It pushes the facet joints of the lumbar spine together and is a somewhat unnatural movement as it tends not to occur on its own.

Arching

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but go easily and you will find it easier with time. This can be a very useful movement to do if you have a disc related problem and can’t lie down to do prone back extensions (press-ups).

Simple knee exercises

One very powerful way of controlling your knee pain is to do daily range of motion exercises, putting your knee through full movement several times a day. This prevents stiffness developing and stretches all the attached muscles, making them less vulnerable to sudden demands.

Please note that exercises can make your pain worse as well as better so please consult the simple exercise guidance before getting on with them. If you have any doubts, please consult your physio, other manual therapist or medical practitioner.

These exercises are meant to maintain range of motion or regain loss of movement in the knee region and to help control pain. Regular performance of movements can help with pain problems.

They are simple and not magical in any way. However, with regular performance, you should find your problems are improved.

If you have long term knee pain with some disability these exercises may help mobility but may not be very effective against pain.

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Quadriceps tensing

The quadriceps (”four heads”) is the main muscle controlling the knee. For normal knee function it is essential that the quadriceps muscles remain strong and well co-ordinated. The stability of the knee largely depends on this muscle.

The quadriceps, along with the buttocks, are the main muscles which allow us to go up and down stairs, rise from a chair and walk normally.

The first image shows the knee muscles in a relaxed state, with a smooth outline over the thigh.

Lie with your leg out straight. Tense up the thigh muscles, trying to push to knee down and raise the heel. Hold that for a few seconds. Try not to tense up the buttock muscles, you should be able to see the muscles on the front of the thigh tensing up and the kneecap move.

You can see the difference here in the second picture, although it is not very obvious in most people. The ability to do this exercise is a basic requirement in the self-management of knee problems. Some people find

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Inner range contractions

I like this exercise, I think it’s one of the best for activating the quadriceps muscles. When you do this exercise, the correct muscles have got to be working.

Place a small object under your knee such as a rolled up towel, then keep the knee on the roll while you lift the heel. Try and get the knee completely straight without raising the knee from the roll. If you do this properly, the quadriceps (the most important stabilising muscle around the knee) must be contracting properly.

If this is difficult, start with a larger roll so you can get your heel up. As the roll gets smaller the exercise gets harder. You can progress your ability this way.

Straight leg raise

I’m not terribly fond of this exercise, as it stresses the hip and its muscles a lot, but it can be useful.

Keep your knee absolutely straight and lift the leg up six inches/18 cm off the surface.

NB if you have a hip replacement on the same side do NOT do this.

Knee bending

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Bend your knee as far as it can easily go, making sure you get to the end of the movement. Hold for a second or so then straighten and repeat.

Prone knee bends

Lie on your front. Keeping your thigh down, bend your knee as far as you easily can. This is more difficult because one of the knee muscles is tighter on your front.

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MEETING 6

Simple Neck Exercises

This article focusses on quick, simple and easy neck exercises. The pictures and text below make it easy.

Neck Range Of Motion Exercises, Neck Exercises

One very powerful way of controlling your neck pain is to do daily range of motion exercises, putting your neck through full movement several times a day. This prevents stiffness developing and stretches all the attached muscles, making them less vulnerable to sudden demands.

Please note that exercises can make your pain worse as well as better so please consult the simple exercise guidance before getting on with them. If you have any doubts, please consult your physio, other manual therapist or medical practitioner.

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long term neck pain with some disability these exercises may help mobility or allow you to tolerate more activity but may not be very effective against pain.

Do each movement slowly five times, resting a short time in between each set of movements. Do two or three times a day although more often can be useful. Work out how much you should do by slowly increasing the frequency until you are doing enough or start to have problems.

Neck flexion

This is the movement of bringing the head forward so that the chin hits the chest and your face is staring straight down at the floor. Do slowly five times.

This exercise stretches the structures at the back of the cervical spine, which are often kept in a tight position in normal day to day postures. They can then become shortened and stop the neck moving naturally.

To make this more difficult you can retract the neck slightly to start with (see below) and then flex the head forward, increasing the stretch on the neck.

Neck extension

This is the movement of allowing the head to go back until the face is looking directly at the ceiling. Don’t do this movement fast or forcefully as it forces all the small joints at the back of the neck into an extreme position. This won’t do them any harm but might increase your pain.

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NB If you feel dizzy when you do this leave it out. Dizziness, especially if you are older, might indicate that the blood vessels in your neck are being squeezed by the position.

Rotation

Turn your head slowly round to one side until it cannot easily go any further. Once you have done five to one side do the other. Do not go from one side to the other in the individual movements or roll your neck about.

Hold your neck at the end of the movement for a few seconds as this is the most valuable part of the movement to maintain or increase your movement.

NB If you feel dizzy when you do this leave it out. Dizziness, especially if you are older, might indicate that the blood vessels in your neck are being queezed the position.

Side flexions

Keep your head facing straight forward and try and tip your ear down towards the same shoulder. It’s difficult to do this well and without

rotating to one side. She’s doing pretty well in the picture, just lifting her chin up a little more than ideal.

This movement is quite severe on the neck joints so don’t go hard at the exercise. Don’t move from side to side in the movement as that stops you getting to the ends of the neck range and may aggravate your joints.

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This is one of the most useful neck movements as it counteracts the tendency we all have of allowing our heads to poke forwards in a poor posture. She’s showing the extreme position of “poking chin” here.

When we sit, which many of us do a lot of the time, we tend to slump and to keep our heads up so our eyes are horizontal we arch our necks backwards slightly

This gives a continual flexion (bending) posture to the lower neck and an extension (arching) posture to the upper neck. Over time the tissues can shorten and give us stiffness and pain. Typical pains are in the neck, upper shoulders, but this posture can also give you headaches.

Here’s the end point of the movement. Keep your face straight on during the whole movement, drawing the head back and the chin down slightly.

If you get it right, you will look funny, rather like a sergeant-major in an exaggerated military neck posture. If you do it in public people will either laugh or give you funny looks!

The whole movement is like the forward and back movement that chickens make. Hold the movement at the extreme of the backward posture for a few seconds.

Upper Neck Nodding

This movement particularly moves the upper cervical joints. In our bad postural habits we tend to poke our chins forward which puts our upper neck joints into extension (arching).

Figur

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Referensi

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Unduh sekarang (150 Halaman)
Related subjects : older people