Dupuytren’s contracture

This condition is due to inflammation involving the ulnar side of the palmar aponeurosis. There is thickening and contraction of the aponeurosis. As a result, the proximal phalanx and later the middle phalanx become flexed and cannot be straightened. The terminal phalanx remains unaffected. The ring finger anything little finger is most commonly involved.

SELF DIAGNOSABLE =Dupuytren’s contracture can cause one or more fingers to stay bent toward the palm. This can complicate everyday activities.

TREATMENT Treatment depends on severity. •using needles to break tissue that’s keeping the finger bent, enzyme injection to soften the tissue and surgery

Fracture of scaphoid

Fracture of scaphoid is quite common. The bone fractures through the waist at right angles to it’s long axis. The fracture is caused by a fall on the outstretched hand, or on the tips of the fingers.

•This causes tenderness and swellings in the anatomical snuffbox and pain on the longitudinal percussion of the thumb and index finger. The importance of the fracture lies in its liability to non-union, and avascular necrosis of the body of the bone with pain in anatomical snuffbox

•scaphoid has two nutrient arteries, one entering the palmar surface of the tubercle and the other the dorsal surface of the body.

•It may be treated on the lines of osteoarthritis.

•Dislocation of the lunate may be produced by a fall on the acutely dorsiflexed hand with the elbow joint flexed. The displaces the lunate anteriorly also leading to carpal tunnel syndrome like features

Microwave diathermy

• MWD-lies between radio waves and infrared
waves :1m to 1 cm
• 300MHz to 30GHz
Frequency(MHz) Wavelength(cm)
2450 12.245
915 32.79
433.9 69.14.

Behaviour of Microwaves
• Like electromagnetic radiation,
• reflection and refraction at interfaces,
• absorption and penetration depends on the nature of material.

Production of microwaves
• High frequency oscillating currents-
magnetron
• Physiologic effects of Microwaves-
• Raised metabolic rate,increased blood flow, decrease blood and tissue viscosity,collagen extensibility,pain relief.
• Fat is less heated,muscle is more heated and bone is least heated

• Distribution:ring pattern or oval pattern
• Therapeutic uses:
• 1.Pain relief-pain gate mechanism,increase
blood flow,decrease muscle spasm and sedative effect.
• 2.muscle spasm
• 3.accelerated healing:increase metabolic activity
• 4.softening of scar tissues
• 5.heating of muscle tissue.

Principles of application
• Preparation of patient
• Preparation of apparatus
• Small area-2-5 cm,large area-10 cm.

Dosage
• Time duration-20 minutes
• 200mW/cm2
• Dangers:Metals reflection ,concentration;
cardiac pacemakers,eyes,testes,.

Contraindications
• defective thermal sensation,
• defective blood supply,
• acute inflammation,
• recent haemorrhage,
• metal in the tissues,
• malignancy,
• cardiac pacemakers,
• intrauterine devices,
• eyes and testes. Indication of microwave diathermy. *Disorders of musculoskeletal condition. -Strains. – sprains. -capsular lesion. – degenerative joint disease. – Hematoma. – rheumatoid arthritis

Strengthening methods

•The art of training or strengthening muscles lies in creating the condition s under which they are called upon to work to full capacity against on ever- increasing resistance.

•Increase in strength andhyper-trophy occur in response to an increase in intra muscular tension set up by the factors which oppose their contraction.

•It is,therefore essential that these opposing factors,which constitute the resistance must be increased as the strength of the muscles improves, An increase in resistance which is too rapid results in overloading which prevents contraction and may damage the muscles, under loading will not increase strength,but may be sufficient to prevent wasting of muscles.

•At the beginning of treatment assessment of the strength of the muscles is essential.

•A suitable resistance is then selected,which includes consideration of the poundage of the resisting force,the leverage, the speed and the duration of the movement,As treatment continues,progression of one or all of these factors in made as muscles strength develops.

•Account must be taken of all work the muscles in question are called upon to do, whether it be exercise in the physiotherapy department, occupational therapy, specific home exercise work or the ordinary activities of everyday life.

•Re- education may be regarded as a continuous us process which attempted initiation of contraction, and extends until maximum function is achieved.

•The exact stages in this re-education process at which any particular muscles group begins is determined by the finding at the assessment made when treatment begins.

Mobilization

Mobilization:
 They are passive skilled manual therapy techniques
applied to joints and related soft tissues
 at varying speeds and amplitudes using
physiological or accessory motions for
therapeutic purposes.
 speeds and amplitudes could range from
 small-amplitude force applied at high
velocity
to a large-amplitude force applied at slow
velocity

Joint mobilization
 Joint mobilization refers to manual therapy techniques used
to modulate pain and
treat joint dysfunctions
regain range of motion (ROM)
 addressing the altered mechanics of the
joint.

The altered joint mechanics may be
due to

  1. pain
  2. muscle guarding
  3. joint effusion
  4. Contractures
  5. adhesions in the joint capsules
  6. Adhesions in supporting ligaments
  7. Malalignment.
  8. Subluxation of the bony surface.

Mobilization with Movement
 Mobilization with movement (MWM) is
accessory mobilization applied by the
therapist
an active physiological movement to end
range applied by the patient
 The technique is always applied in
a pain free direction
describe as correcting joint tracking
from positional fault

Manipulation
 Manipulation refer to :
a high-velocity thrust of small
amplitude performed at the limit of
available movement

Manipulation Under Anesthesia
 Manipulation Under Anesthesia
 is a medical procedure
 used to restore full ROM
 by breaking adhesions around a joint
 while the patient is anesthetized.
 The technique may be a rapid thrust or a passive stretch
 using physiological or accessory movements

Muscle Energy Technique:
Muscle energy technique:
 active contraction of deep muscles that attach near the joint  whose line of pull can cause the desired accessory motion.
 The therapist stabilize the segment on which the distal aspect of the muscle attaches.


 Physiological movements are the movements that patient can do voluntarily.
 e.g., the classic or traditional movement such as flexion and
abduction, rotation.
 term osteokinematics is used for these Accessory Movements.
 Accessory movements are the movements in the joint and
surrounding tissue
that are necessary for normal ROM
cannot be actively performed by the patient
 Terms related to accessories movements are. •components motion. •joints play.

Intermittent pneumatic compression

INTERMITTENT PNEUMATIC COMPRESSION= Intermittent pneumatic compression is a therapeutic technique used in medical device that include an air pump inflatable auxiliary sleeves,gloves or boots in a designed to improve venous circulation in the limb of particles who suffer edema or the risk for deep vein thrombosis. *Used to decrease edema. Edema. Pressure is created to reduce odema.

1) Nature of edema is first evaluated. •pitting. •Non pitting. IPC( intermittent pneumatic compression)can only be given in pitting odema. 2) odema is measured then= By volume method circumferential method( using measuring tape). 3)IPC( intermittent pneumatic compression) is given:- • pressure should be equal to 60 to 80 mm Hg( 32 mm Hg is pressure at which fluid gets back to vessels. • Treatment time 20 to 40 mins( can vary from 10 to 60 min.). • pressure and treatment time for upper limb and more for lower limb.

Method of Application. 1) suspect the part = No accessory. 2) First cottan= sterile dressing on wound if present sleeve is applied on body parts ,so that there is no damage to body parts. 3) put limb in it. 4) Hold time 20 to 30 sec. 5 ) Rest time 5 to 10 sec.

CONTRAINDICATIONS. •congestive heart failure. •Active phlebitis • wound infection. • cellulitis. •Deep vein thrombosis. INDICATION. •Severe chronic venous insufficiency ( stage C4b to C6). Peripheral arterial occlusive diseases ( PAOD).

Cryotherapy

CRYOTHERAPY
The word ‘cryos’ is of greek origin meaning cold and the word ‘therapy’ means treatment. Thus cryotherapy is treating the patient with the
help of application of cold.
*Cryotherapy is commonly used in the treatment of acute and subacute injury. *cryotherapy is the treatment of pathological lessions by the use of low temperature agents such as ice,frozen gel packs and vapocollant sprays.it has clinical application in therapeutic and diagnostics,so its widely used in rehabilitation and other areas of medicine.it exerts its therapeutic effects by influencing hemodynamic, neuromuscular and metabolic processes.


MECHANISM
The intial vasoconstriction of the superficial vessels is by axon reflex i.e neural phenomena.which causes decrease in lumen of vessels. This
is maintained by post hypothalamus and the vasomotor center of the medulla.
But the vasoconstriction is accompanied by the liberation of histamine like substances which
causes vasodilatation [supervised by neural mechanism]. This vasodilatation washes away
the histamine and thus again vasoconstriction occurs. This is the protective mechanism to
prevent freezing injury.


INDICATIONS
•Reduction of acute pain. •Acute and subacute inflammation. •Acute swelling. •myofacial trigger points. •muscle guarding. • muscles spasm. •Tendinitis. •Tenosynovitis. •Acute ligament sprain. • Acute muscle strain. • Bursitis. • small , Superficial 1st degree burn. •post exercise. •Delayed onset muscle soreness.

CONTRAINDICATION. •Impared circulation. •peripheral vascular disease. •Hypersensitivity to cold. •Skin anesthesia. • Open wound or skin condition(cold whirlpools and contrast baths). •Infection. • Cancerous growth. •Hysteric neuroses. •Hemorrhagic diathesis. • Active pulmonary tuberculosis.

PHYSIOLOGICAL EFFECT OF COLD.1)Haemo-dynamic effect/effect on circulatory system. When cold is applied to the body it causes are initial decrease blood flow due to vaso- construction persists if the duration of the cold application is limited to less than 15-20 min. 2)Neuromuscular effect cold has wide effect in neuromuscular function when applied it reduce the nerve conduction velocity increases the pain threshold,alteus the force generation by muscle and decrease spasticity and facilitates muscles contraction. 3)Neurovascular effect. •Decreases nerve conduction velocity= It has been established that the nerve conduction decreases in proportion to the degree of cooling through decreased nerve conduction velocity has been documented with 5 minute application of cold. After 15 min of cooling it take about 30 min or longer to recover cold can decreases the vol.of conduction in both sensory as well as motor nerve and has a greater effect on myelinated and small diameter fibres than reversible total nerve conduction block also occur of ice is applied over nerve trumps where it is superficial.

*METHOD OF APPLICATION
1)Ice massage-(alternatives:US\deep
kneading\electric stimulation\and lasers)Common areas found around cervical spine.
Shoulder girdle and low back.faulty posture and poor mechanics contribute it.Cryotherapy with
appropriate exercize program to be used the stroking of ice on body part can be performed by:_
a)Ice frozen in a plastic insulated cup, the upper part of which is out (best material used is (slyiofoam) to about 1 inch from the bottom.
b)lollipop with a tongue depression frozen in middle known as popsicle
c)Ice cube held in a towel.(round off the ends)method-
a)circular smooth rhythmical strokes over treatment area reducing size of circle as massage proceeds.water should be removed( from melting ice)with extra towels.bumping of bony prominence causes discomfort so should be avoided. B)longitudinal covering half of the next stroke that is one and half stroke.
Duration – To anesthesize the area 3-10 mins are required (though is dependent upon directly proportional to the size of the part, amount of fat , depth of the part) . 2-3 mins
around the pressure sore. Repeated 3-4 times.
Advantages:
Anesthezises in short time.
Small areas can be treated.
Easy to do.
Disadvantages:
Water drops Slightly more uncontorable than cold packs.
Cold packs
Three types-commercial
-chemical mixtures
-home made
A)commercial packs- silica gel or putty in a durable (plastic) pack.or sandy slury mixture.
2)polyvinyl alcohol in solution of sodium borate
3)petroleum distillate
Needs to refrigerated at 12 to 9 degree for first time for 24 hours and can be used for 20 mins.
It can be reused after 30 mins of refrigeration.
B)chemical mixtures- ideal for onfield use in a spirit event or emergency(can be used once only)
C)home made –frozen veg (peas are ideal for packs)
-frozen sanitary napkin
Method- place in a well wrung out of towel or some use a dry towel (avoid irritation and maintain hygiene)
Note- a mat or another thick towel/blanket should cover the superior surface prevents evaporation thus warming up from the ambient
air.
Check skin after 5 mins,if bluish remove it.
Advantages-easy to use/reapplyable
-Onfield uses/moulds to contours
can be used for ice repulsive subject
Disadvantages-less intense cold
-30 min gap before reuse
4)Ice towels-terry cloth towels and a ice bucket(containing shaved or crushed ice )is used. Ice shaving is caught in the nap of the towel.
Method-65percent water and 35% ice( crushed or shaved) mixed in a bucket. Towels are wrung out and applied to the part because ice shavings melt quickly towels needs to be changed every 30 secs to 2 mins .5-6 towels are initially dipped in the ice much.
Duration-10-15mins
Advantages-
moulds to body contour more even cooling chances of overcooling minimal can simultaneously exercise and elevate the part
Disadvantages
towels need to kept on changing therapist is not free wets the floor
multiple towels get wet.
5)ice packs-plastic bags with crushed /shaved ice
Method- bag is seated or tired and with a similar technique as with cold pack is used in application but the part should be applied (prior) with oil and a gutter can be made to drain off excess water.
Duration-5-15mins but for deeper muscles 20-
40 mins
Advantage-
Easily mouldable
More colder than cold pack
No special equipments required
Disadvantages-
Can cause frost bites
More tedious to apply.


CLASSIFICATION OF COLD INJURIES
1 degree damage-tissue appears red,inflamed with mild oedema
2degree damage-marked oedema,blisters or both
3degree damage-necrosis with a blue grey colour with formation of ice crystals
4 degree damage-gangrene and neurological complications Redness to application of ice-
O2 does not dissociate from Hb freely at lower temperatures,thus the veins have more oxygenated blood giving red colour to skin.
later on its due to reactive hyperemia which occurs 10-15mins after ice use.
Ice burns are painful red blotches which are uncomfortable and remain so for 3 days.
More severe injury i.e tenderness and thickening of subcutaneous tissue due to fat necrosis and persist for 3 weeks.
Treatment- rest and analgesics.

DEVELOPMENT OF NERVOUS SYSTEM


• A study of development of the nervous system helps to understand its complex organization and the occurrence of various congenital anomalies.
• The whole of the nervous system is derived from actoderm except its blood vessels and some neuroglial elements.

• The specific cell population of the early ectoderm,which gives rise to entire nervous system and special sense organ is termed neural ectoderm
• The neural ectoderm later differentiates into three structures: neural tube, neural crest cells, and
ectodermal placodes.
• The neural tube gives rise to the central nervous system (CNS), the neural crest cells form nearly all the
peripheral nervous system and ectodermal placodes contribute to the cranial sensory ganglia,hypophysis and inner ear. •Neural plate=ectoderm cell overlaying the notochord become tall columnar producing a thickened neural plate( in surrounding ectoderm that produces epidermis of skin. •Neural groove=The neural plate is transformed into a neural groove. •Neural tube=The dorsal margin of the neural groove merge medially and form neural composed of columnar neuroepithelial cell surrounding a neural cavity.

*Development of Spinal Cord.
• The spinal cord develops from the caudal elongated part of the neural tube. • The cells of the neural tube migrates to form the mantle layer of grey Matter which differentiates into:_ 1)An alar plate( sensory neurons) 2)A basal plate( motor neuron). 3)sulcus limitans.

DEVELOPMENT OF BRAIN
• The brain develops from the enlarged cranial part of the neural tube. At about the end of 4th week,
the enlarged cephalic part shows three distinct dilatations called primary brain vesicles Craniocaudally, these are: (a) prosencephalon(forebrain), (b) mesencephalon (mid-brain), and
(c) rhombencephalon (hindbrain). Their cavities form the ventricular system of the adult brain.
During the 5th week both prosencephalon and rhombencephalon subdivide into two vesicles
thus producing five secondary brain vesicles.

DEVELOPMENT OF VENTRICULAR
SYSTEM
• The cavities of brain vesicles form the ventricular system of adult brain:
• The hindbrain cavity becomes the fourth ventricle.
• The narrowed mesencephalic cavity becomes the cerebral aqueduct (aqueduct of Sylvius).
• The diencephalic cavity becomes the third ventricle.
• The twin telencephalic cavities become lateral ventricles.

ORGANIZATION AND FUNCTION OF NERVOUS SYSTEM.

Neuroanatomy is the study of nervous system.The nervous system is the most complex and widely investigate d and least understood system in the body. *Nervous system is also called master system of the body.

Function of nervous system includes:_. 1) Reception of sensory stimuli from internal to external environment. 2) coordination and control of voluntary action the body. 3) Assimilation of experiences, learning,memory and intelligency. 4)Integration of sensory information.

Nervous system consists of three functional types of neurons. • sensory= The sensory neuron detect stimuli and motor neurons send commands to the effector organ •motor. •Interneurons=capacity to analyze, integrate and store information.

Mechanisms of nervous system.

Division of nervous system. •Anatomical= Divided into two parts central nervous system(CNS) and peripheral nervous system (PNS). 1)CNS=consists of brain and spinal cord.The CNS is responsible for integrating,processing and coordinating sensory data and giving motor commands.it is responsible for memory, learning and emotions and intelligence. 2)PNS= includes all neural tissues outside the CNS such as 12 pair of cranial nerve, and 31 pair of spinal nerve and ganglia associated with cranial and spinal nerve.The PNS provide sensory information to the CNS and carries its motor command to the peripheral tissues and system.

•Functional= Functionally also the nervous system it divided into two parts. 1)The afferent division= Bring sensory information to the CNS. 2) The efferent division= carries motor commands to the muscles and glands.

NEURONS. A neurons also known as( neurone and nerve cell)is an electrically excitable cell that processes and transmits information by electrical and chemical signal.neurons are core components of the nervous system, which includes brain,spinal cord and peripheral ganglia.

STRUCTURE OF NEURONS. A neurons consist of three main parts:_the cell body ( soma) dendrites and axons. The cell body is the central region which is the most important parts of the neuron containing the necleus of the cell. • neurons receive signals via the dendrite and send outside signals down the axon.

CLASSIFICATION OF NEURONS. *BASED ON POLARITY. Unipolar=types of neuron in which only one protoplasmic process( neurite) extend from the cell body= In human mostly found in dorsal root ganglia. Pseudounipolar= contains an exon that has splits into two branches, one branch runs to the periphery and other run to the spinal cord. Bipolar=An exon and a single dendrite on opposite ends of the soma_ are specialized sensory neuron of the transmission of special senses, hence abundant in sensory pathways for smell and sight,taste hearing and vestibular. multipolar=An axon along with more than two dendrite= multipolar neurons constitute the majority of neurons in the brain_subdivided in to golgi I and II gogli type_ includes motor neuron and interneurons

FUNCTIONAL CLASSIFICATION. • sensory neurons=They carry impulse from the receptor organ to the CNS. Primary sensory neurons=The cell bodies of these neurons lie outside the CNS( except those of mesencephalic nucleus of fifth cranial nerve which lie within the CNS) secondary sensory neurons =The cell bodies of these neurons lie in the CNS. Tertiary sensory neuron=The cell bodies of these neurons lies in the thalamus.

*MOTOR NEURONS Types of motor neuron. In the somatic nervous system they are divided into two parts. 1) Upper motor neuron=Have their cell bodies located in the cerebral hemisphere,i.e motor area of the cerebral cortex. They form the descending pathways of the brain and synapse with the motor neurons Of the cranial nerve nuclei in the brainstem and motor neurons of the spinal nerve in the anterior horns of the spinal cord. The upper motor neurons are involved in the voluntary control of muscular activity. Lower motor neurons= have their cell bodies located in the brainstem and spinal cord. • The skeletal muscles are supplied by the motor neurons of the anterior horn in the spinal cord and in the motor neuclei of cranial nerve. These neurons from the final common pathway for determining the muscle action and are collectively known as lower motor neurons.

NEUROGLIA.
• The neuroglia are the interstitial or supporting
cells of the nervous system. They do not
contribute to the propagation of impulses or the
processing of the perceived information but
support the neurons both structurally and
functionally.
• Neuroglia in the central nervous system
• There are four main types of neuroglia (glial cells)
in the CNS: (a) astrocytes, (b) ependymal cells,
(c )oligodendrocytes, and (d) microglia

• Astrocytes are the largest and most numerous, and form the main
supporting tissue of the nervous system. They are star-shaped as the
name implies and possess many fine dendrite-like processes. At the ends
of processes there are small swellings called foot-processes.
•Ependymal cells line the ventricles of the brain and
central canal of the spinal cord. Ependymal cells
are of three types: (a) ependymocytes, (b) choroid
epithelial cells, and (c) tanycytes.

• Oligodendrocytes are smaller than astrocytes
and as the name implies have fewer
processes. They are found (a) in clusters
around the neurons of grey matter, and (b)
adjacent to and along the length of
myelinated nerve fibres in the white matter

– Microglias are the smallest of the glial cells, and are
capable of migrating through the surrounding neural
tissue. Microglia do not develop in the neural tissue.
They are derived from phagocytic white blood cells
(fetal monocytes) that migrate from the blood into the
nervous system before birth.
• The microglia enlarges and become phagocytic in
areas of inflammation and cell destruction. They
remove cell debris, wastes and pathogens that
invade the CNS by phagocytosis.

Biofeedback

Biofeedback is the process of gaining greater awareness of many physiological function of one’s own body, by using electronic or other instruments.

Procedure:_ Biofeedback session= A therapist attaches electrical sensors to different parts of your body.These sensors monitor your skin temperature,muscles tension heart rate and breathing.

*Types of biofeedback 1 ) Thermal biofeedback= Temperature of skin is used to known the blood flow of a particular area. • Used to detect in B.p.

2) Galvanic skin response= used to detect composition and inflammation. • microcurrents are sent in body b/w medium frequency and high frequency 5000 to 50,000.

• This current is absorbed and reflect in body.

3)Air flow biofeedback. •max amount of air expired can be measured. •peak expiratory rate,tidal volume can be measured.

4)EMG biofeedback. •measurement of muscle contraction can be done though this and exercise s can be suggested along with this.

5)EEG biofeedback. • Before ceisure of epilepsy,some electrical activity happening in the brain. •This activity can be recorded or detected by EEG biofeedback and patient gets feedback and any danger to patient before attack comes can be prevented.

6) Inclinometer. Used to measure range of motion.

* Display are two types. •Threshold type •progressive type. Threshold type= These will be sound or light beep only at a particular range of movement and then well known the exact range which can be increased and progressed on daily basis. Progressive type = more the progressive of movement more will be sound or light generated. The sound or light beeps from the beginning of movement no of sound and light beep increased. Progressive is 3 types. 1) Digital. 2)Analog. 3) progressively.

(INDICATION AND USES OF BIOFEEDBACK). • Relaxation of the body. •EMG biofeedback can be used to produce general or local relaxation. • Isolate a muscle action Eg as in VMO and vastus. •To strengthen the weak muscles and decreasing the trick movement. •To train specific muscle like to train bladder muscles. •ROM exercise. •Abnormal movement like dystonia. Biofeedback is used to manage.

physical and mental health issues:_. 1)chronic pain. 2) constipation. 3) Asthma. 4) Headache. 5) stroke. 6)High blood pressure. 7) tinnitus. 8)Irritable bowel disorder. 9) Anxiety or stress. 10) urinary incontinence.

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