Clinical Notes in Physiotherapy

✅ Scaphoid Fracture A scaphoid fracture is not always so obvious. Often a fracture here does not show up on standard roentgenograms. A key clinical sign in localized bony tenderness in the anatomic snuffbox on palpation. When this is found in a patient referred after a fall on the outstretched hand, the therapist should suspect a scaphoid fracture and should consult the physician. The incidence of avascular necrosis of the proximal fragment of the scaphoid is high with this fracture because the blood supply to the scaphoid often enters only from the distal aspect of the bone. The fracture, then, cuts off the blood supply to the proximal fragment. Strict, prolonged immobilization of the wrist and thumb is necessary to minimize the possibility of avascular necrosis and nonunion.

⚛ تست کلینیکی اختصاصی از وضعیت عصب گیری عضله سوپیناتور (Lap Test) عضله سوپیناتور یکی از عضلات کلیدی است که عصب دهی مجدد به این عضله قویا حاکی از آن است که عصب رادیال تا دیستال به قسمت های پروگزیمال ساعد بازسازی شده است. در مواردی که عصب گیری مجدد مورد شک است، مطابق با قانون خست، از یک تست بالینی برای تعیین عملکرد عضله سوپیناتور استفاده می شود. این تست بدین شکل انجام می شود که ساعد بیمار روی میز ساپورت بوده و فارغ از هر گونه مقاومت خارجی خیلی آرام ساعد را به سوپیناسیون می برد. به طور نرمال با تمرین کافی، این سوپیناسیون با توان خیلی کم بدون فعالیت بایسپس (یا با فعالیت خیلی کم آن) انجام می شود. اگر عضله سوپیناتور عصب گیری کرده و عملکرد داشته باشد فرد می تواند معمولا بدون انقباض همراه بایسپس، سوپیناسیون را انجام دهد. اما اگر هنوز عضله سوپیناتور فلج باشد حتی یک تلاش سوپیناسیون آهسته و کم توان باعث برجسته شدن تاندون بایسپس می گردد چرا که برای جبران فلج عضله سوپیناتور، منقبض خواهد شد. پاسخ تشدید شده بایسپس به یک کار سوپیناسیونی خیلی سطح پایین، تست مثبت درنظر گرفته می شود و یا بیانگر ضعف واضح عضله سوپیناتور است.

⚛ تمرین درمانی برای صافی کف پا در وضعیت طاقباز : 1- با حفظ انگشتان در فلکشن، در مچ پا حرکات دورسی فلکشن و اینورژن انجام دهد. 2- با حفظ اندام ها در وضعیت اکستنشن در کنار یکدیگر، بیمار تلاش کند که کف دو پا را رو به هم کند. در وضعیت نشسته : 3- اندام چپ را روی اندام راست قرار دهد و در پای چپ به صورت یک نیم دایره، دورسی فلکشن، اینورژن و پلنتار فلکشن انجام دهد و سپس استراحت کند (ایورژن انجام ندهد). این تمرین را برای پای راست تکرار کند. 4- در حالی که زانوها از همدیگر دور هستند، کف دو پا را در تماس با هم نگه دارد و سپس دو زانو را به هم نزدیک کند. 5- یک حوله روی زمین قرار داده و کف دو پا را با فاصله ای در حدود 15 سانتی متر از هم،روی آن گذاشته و سپس بیمار با انگشتان حوله را بگیرد و آنرا به داخل بکشد (با اداکشن) و حوله را بین دو پا جمع کند. 6- یک توپ کوچک را زیر قوس جلویی پا قرار داده و با انگشتان توپ را بگیرد. در وضعیت ایستاده : 7- در حالی که پاها رو به جلو است یا کمی به خارج مایل است (toe-out)، وزن بدن را با بالا کشیدن قوس ها به لبه خارجی پا منتقل کند. در وضعیت راه رفتن : 8- در حالی که پاها رو به جلو است، در امتداد خطی مستقیم روی زمین قدم بردارد و وزن بدن را از پاشنه به لبه خارجی پا و سپس به انگشتان انتقال دهد.

Intervention for Postural Syndrome Education is the key to the management of a postural syndrome. Spinal joint capsules, spinal ligaments, and muscles are strained at the end of their range of motion owing to prolonged static loading. The slouch-overcorrect exercise is given to teach patients how to find good posture in sitting. Intervention for postural syndrome must include a discussion of the long term consequences of poor posture, including the increased risk for future back and neck pain.

Intervention for Dysfunction Syndrome There are four types of dysfunction syndromes, which are named by the restricted direction or the direction in which symptoms are reproduced. They are flexion dysfunction, extension dysfunction, side gliding dysfunction, and adherent nerve root dysfunction. The appropriate intervention for a patient presenting with a dysfunction syndrome is progressive movement in the direction of restriction. The main goal of intervention is to improve motion by gradually eliminating the barriers to full motion. Patient education regarding the warning signs of overstretching, such as pain lasting more than 20 minutes after the completion of exercises, as well as postural education and correction, are an integral part of the plan of care for a patient with a dysfunction syndrome. The intervention of an extension dysfunction follows extension principle and the intervention for a flexion dysfunction follows flexion principle. The progression of intervention for an ANR is displayed in figure.

Intervention for Anterior Derangement Syndrome The intervention for an anterior derangement follows the flexion principle, which increases compressive forces anteriorly. Ten repetitions of the selected exercise must be performed every 1 to 2 hours. A progression of force is made when the patient's symptoms have improved, but are no longer progressing with the current exercise regimen. It is important to note that less than 7% of all derangements are anterior.

Intervention for Posterior Derangement Syndrome with Lateral Component Rotation mobilization in flexion : in hook-lying position, the patient rotates the knees to the side (usually toward the side of the pain). The hand closest to the patient fixes either the far shoulder or rib cage through the patient's clasped hands. The therapist's far hand pushes the knees downward, either sustaining the force or by applying intermittent pressure. Symptom response is monitored. The lower extremities are passively returned to the starting position (E).

Intervention for Posterior Derangement Syndrome with Lateral Component Some patients with a posterior derangement require the application of either frontal or transverse plane directed forces in order for a complete reduction to occur. These patients are said to have a lateral component to their derangements. When symptoms have centralized or become symmetrical, EIL in the pure sagittal plane should be retested to see if it is safe to perform, after which the treatment plan is progressed to pure extension-biased exercises. Rotation mobilization in extension : the clinician's hands are placed perpendicular to each other with hypothenar eminences over the area of the transverse processes of the spinal segment to be mobilized and shoulders over the hands. The mobilization is performed by alternating forces from one side of the spinal segment to the other. First, an anteromedially directed force is applied by shifting the shoulders forward over the extended arm. The shoulders are then shifted back to apply force through the opposite hypothenar eminence. Rhythmical application of forces is continued (D1). If application of force on one side centralizes the symptoms, a unilateral rotation mobilization is performed by placing one hand on top of the other (D2).

Intevention for Posterior Derangement Syndrome Extension in lying with clinician overpressure : The clinician places the heel of her hands on the selected transverse processes of the lumbar segment (F). Extension mobilization : the clinician places her hands perpendicular to each other over the transverse processes of the spinal segment. The clinician's shoulders must be directly over her hands and her elbows extended. Gradual rhythmic and symmetrical pressure is applied in a posteroanterior direction to end range. Symptom response is monitored at each segment. Mobilization is provided to the same segment 10 times before progressing to the next segment (G).

Intervention for Posterior Derangement Syndrome The intervention for a posterior derangement follows the extension principle. Most patients who present with a derangement falls into this subclassification. Prior to discharge, intervention for a patient with a posterior derangement must include restoration of pain-free flexion.

Intervention for Derangement Syndrome Reduction of a derangement is achieved and maintained by consistent application of the loading strategy that centralized the patient's symptoms during the examination. Ideally, exercises must be performed 10 times every 1 to 2 waking hours, or more frequently if symptoms recur. Assuming the mechanical classification given at examination is correct, patients should report a decrease in symptoms with centralization, increased mobility, and tolerance for progression of exercises. If centralization is not achieved within five sessions, it is unlikely that centralization will occur. A common error is that patients may not have achieved end range and and then are mistakenly believed to be noncentralizers. A return to provocative motions must be done gradually, with the goal of restoring any residual motion loss and with an awareness that any limitation in spinal motion is a risk factor for future derangement. Intervention is complete when the patient reports restoration of normal activities and pain-free movement in all directions.