Strain over lumbar area

   Lumbar strain is one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. It is classified as "acute" if it has been present for days to weeks. If the strain lasts longer than 3 months, it is referred to as "chronic."

Definition: 

              

               Lumbar strain,  muscle strains and sprains are the most common causes of 

low back pain. The back is prone to this strain because of its weight-bearing function and involvement in moving, twisting and bending. Lumbar muscle strain is caused when muscle fibers are abnormally stretched or torn.

Occurrence:

              Strains are defined as tears (partial or complete) of the muscle-tendon unit. Muscle strains and tears most frequently result from a violent muscular contraction during an excessively forceful muscular stretch.You can define acute and chronic strains are characterized by continued pain attributable to muscle injury. Low back pain is the second most common symptom that causes patients to seek medical attention in the outpatient setting. Approximately 70% of adults have an episode of LBP as a result of work or play.

Symptoms:

                 Common symptoms include pain, which is diffuse in the lumbar muscles, with some radiation to the buttocks. The pain could be exacerbated during standing and twisting motions, with active contractions and passive stretching of the involved muscle the pain vil increase.

                 Other symptoms are point tenderness, muscle spasm, possible swelling in and around the involved musculature, a possible lateral deviation in the spine with severe spasm, and a decreased range of motion. 

Physiotherapy Prevention:

                  In the acute phase of a lumbar strain Cold therapy should be applied (for a short period up to 48 h) to the affected area to limit the localized tissue inflammation and edema. Recent studies have found that continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than bed rest. TENS and ultrasound are often used to help control pain and decrease muscle spasm, mild stretching exercises along with limited activity.

Some stretching Activities:

Single or double knee to chest:

                   Lie down on your back with your knees bent and your heels on the floor. Pull your knee or knees as close as you can to your chest, and hold the pose for 20 seconds. Repeat this 3 to 5 times.

 Back stretch:

                    Lie on your back, hands above your head. Bend your knees and , keeping your feet on the floor, roll your knees to one side, slowly. Stay at one side for 20 seconds repeat 3 to 5 times.

• Kneeling lung (stretching iliopsoas)

• stretching piriformis

• stretching quadratus lumborum

                   Progression of strengthening exercises should begin once the pain and spasm are under control. The muscles requiring the most emphasis are the abdominals, especially the obliques, the trunk extensors and the gluteals. 

                    Additionally back muscle strengthening exercises, core muscle strengthening exercises , these will help to get recovery soon from lumbar strain.

Erb's Palsy

ERB'S PALSY(BRACHIAL PLEXUS BIRTH INJURY)

                                                    Erb's Palsy or Erb–Duchenne palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves. These form part of the brachial plexus, comprising the ventral rami of spinal nerves C5–C8 and thoracic nerve T1.

Causes:

                             They are usually due to trauma, for example falling on the shoulder, or traction on the arm at birth - in which case the name Erb Duchenne paralysis is given.

Specified features:

                            The arm hangs at the side with the elbow extended and the forearm pronated; the so-called waiter's tip or Erb's palsy. Like policemen tip getting position, So it's called as "policemen tip palsy"

PHYSICAL THERAPY  REHABILITATION:

                                If muscle having  less than 1 power means , Physios are using some of muscle activation activities are, MASSAGE, QUICK ICE, BRUSHING, ELECTRICAL MUSCLE STIMULATION, QUICK STRETCH etc..

If the muscles are having power more than 1 , we are using some of muscle strengthening  exercises ,

                                

1.Activities and exercises to promote recovery of movement and muscle strength 

2.Exercises to maintain range of movement in the joints to prevent stiffness and pain 

3.Exercises to promote increased awareness of the arm 

4.Provision of splints to prevent secondary complications and improve function 

Aerobic exercises and its impact

AEROBIC EXERCISES:

                       Aerobic exercise is sometimes known as "cardio"- exercise that requires pumping of oxygenated blood by the heart to deliver oxygen to working muscles. Aerobic exercise stimulates the heart rate and breathing rate to increase in a way that can be sustained for the exercise session. Health benefits. Besides strengthening your heart and lungs, aerobic exercise can help lower your cholesterol, reduce your risk of type 2 diabetes, improve your immune function, and lower your blood pressure. Physical benefits. Aerobic exercise burns up calories, which can in turn help you shed excess weight.

  

Benefits of Aerobics:

                 Regular aerobic exercise has significant cardiovascular benefits, including a reduction in incidence of and mortality from coronary artery disease--probably because of positive effects on blood lipid levels and blood pressure. Aerobic exercise can also be an important adjunct to a weight-loss program.

                 Aerobic exercises are brisk exercises, such as running or swimming, that make your heart and lungs work hard, increasing the amount of oxygen circulating through your blood. To lose weight with aerobics, you'll need to burn more calories than you consume and exercise regularly.

                 Truly any exercise is going to help you lose weight. Aerobic exercise will assist in weight loss due to the amount of calories that are burned. You may potentially burn more calories through intense aerobic exercise than what you burn during anaerobic exercise. However, anaerobic exercise will also help in weight loss.

Aerobic exercises are, Walking, Running, Swimming, Aquarobics, Cycling, Rowing, Boxing, Aerobic and Cardio classes etc

Myofacial pain syndrome

Myofascial pain syndrome is a chronic pain disorder. In this condition, pressure on sensitive points in your muscles (trigger points) causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain.

This syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension.

While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens. Treatment options include physical therapy and trigger point injections. Pain medications and relaxation techniques also can help.

Symptoms

Signs and symptoms of myofascial pain syndrome may include:

• Deep, aching pain in a muscle
• Pain that persists or worsens
• A tender knot in a muscle
• Difficulty sleeping due to pain

Causes

Sensitive areas of tight muscle fibers can form in your muscles after injuries or overuse. These sensitive areas are called trigger points. A trigger point in a muscle can cause strain and pain throughout the muscle. When this pain persists and worsens, doctors call it myofascial pain syndrome.

Risk factors

Myofascial pain syndrome is caused by a stimulus, such as muscle tightness, that sets off trigger points in your muscles. Factors that may increase your risk of muscle trigger points include:

• Muscle injury. An acute muscle injury or continual muscle stress may lead to the development of trigger points. For example, a spot within or near a strained muscle may become a trigger point. Repetitive motions and poor posture also may increase your risk.
• Stress and anxiety. People who frequently experience stress and anxiety may be more likely to develop trigger points in their muscles. One theory holds that these people may be more likely to clench their muscles, a form of repeated strain that leaves muscles susceptible to trigger points.

Complications

Complications associated with myofascial pain syndrome may include:

Sleep problems. Signs and symptoms of myofascial pain syndrome may make it difficult to sleep at night. You may have trouble finding a comfortable sleep position. And if you move at night, you might hit a trigger point and awaken.

Fibromyalgia. Some research suggests that myofascial pain syndrome may develop into fibromyalgia in some people. Fibromyalgia is a chronic condition that features widespread pain. It's believed that the brains of people with fibromyalgia become more sensitive to pain signals over time. Some doctors believe myofascial pain syndrome may play a role in starting this process.

Diagnosis

During the physical exam, your doctor may apply gentle finger pressure to the painful area, feeling for tense areas. Certain ways of pressing on the trigger point can elicit specific responses. For instance, you may experience a muscle twitch.

Muscle pain has many possible causes. Your doctor may recommend other tests and procedures to rule out other causes of muscle pain.

Treatment

Treatment for myofascial pain syndrome typically includes medications, trigger point injections or physical therapy. No conclusive evidence supports using one therapy over another, but exercise is considered an important component of any treatment program. Discuss your options and treatment preferences with your doctor. You may need to try more than one approach to find pain relief.

• Medications

  Medications used for myofascial pain syndrome include:
  • Pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) may help some people. Or your doctor may prescribe stronger pain relievers. Some are available in patches that you place on your skin.
  • Antidepressants. Many types of antidepressants can help relieve pain. For some people with myofascial pain syndrome, amitriptyline appears to reduce pain and improve sleep.
  • Sedatives. Clonazepam (Klonopin) helps treat the anxiety and poor sleep that sometimes occur with myofascial pain syndrome. It must be used carefully because it can cause sleepiness and can be habit-forming.

  Therapy

  A physical therapist can devise a plan to help relieve your pain based on your signs and symptoms. Physical therapy to relieve myofascial pain syndrome may involve:
  • Stretching. A physical therapist may lead you through gentle stretching exercises to help ease the pain in your affected muscle. If you feel trigger point pain when stretching, the physical therapist may spray a numbing solution on your skin.
  • Posture training. Improving your posture can help relieve myofascial pain, particularly in your neck. Exercises that strengthen the muscles surrounding your trigger point will help you avoid overworking any one muscle.
  • Massage. A physical therapist may massage your affected muscle to help relieve your pain. The physical therapist may use long hand strokes along your muscle or place pressure on specific areas of your muscle to release tension.
  • Heat. Applying heat, via a hot pack or a hot shower, can help relieve muscle tension and reduce pain.
  • Ultrasound. This type of therapy uses sound waves to increase blood circulation and warmth, which may promote healing in muscles affected by myofascial pain syndrome.

  Needle procedures

  Injecting a numbing agent or a steroid into a trigger point can help relieve pain. In some people, just the act of inserting the needle into the trigger point helps break up the muscle tension. Called dry needling, this technique involves inserting a needle into several places in and around the trigger point. Acupuncture also appears to be helpful for some people who have myofascial pain syndrome

Effectiveness of Mckenzie Approach in Back pain

The McKenzie assessment consists of taking a patient history and performing a physical exam. Both are used to gauge the degree of impairment as well as identify any red flags that might be contrary to exercise-based treatment (e.g. fracture, tumor, infections, or systemic inflammatory disease).

During the McKenzie physical examination, patients are taken through provocative loading strategies (movements) that help classify the patient and determine the best treatment approach. The movements are intended to either increase or decrease symptoms. For example, patients may be asked to perform single and/or repeated flexion or extension movements forward and backward

The McKenzie method is a classification system and a classification-based treatment for patients with low back pain. A acronym for the McKenzie method is mechanical diagnosis and therapy (MTD). The McKenzie method was developed in 1981 by Robin McKenzie, a physical therapist from New Zealand.

The McKenzie method exists of 3 steps: evaluation, treatment and prevention. The evaluation is received using repeated movements and sustained positions. With the aim to elicit a pattern of pain responses, called centralization, the symptoms of the lower limbs and lower back are classified into 3 subgroups: derangement syndrome, dysfunction syndrome and postural syndrome. The choice of exercises in the McKenzie method is based upon the direction (flexion, extension or lateral shift of the spine). The aims of the therapy are: reducing pain, centralization of symptoms (symptoms migrating into the middle line of the body) and the complete recovery of pain. The prevention step consists of educating and encouraging the patient to exercise regularly and self-care. All exercises for the lumbar spine are repeated a number of times to end-range on spinal symptoms in one direction. When you do only 1 repetition, this will cause pain. When you repeat it several times the pain will decrease. Also after movement termination the changes in pain intensity can persist, which leads to a treatment modality. A single direction of repeated movements or sustained postures leads to sequential and lasting abolition of all distal referred symptoms and subsequent abolition of any remaining spinal pain.

Classification:

McKenzie described in 1981 for the first time the mechanical classification in the McKenzie system. The patients are classified into four groups according to the mechanical and symptomatic response to repeated movements and sustained positions. Each syndrome demands a different management approach. In the paragraph below you will find the four categories of the McKenzie classification with their descriptions

Posture syndrome:

Refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures.

The pain arises during static positioning of the spine: for example sustained slouched sitting.

The pain disappears when the patient is moved out of the static position.

The treatment includes: patient education, correction of the posture by improving posture by restoring lumbar lordosis, avoiding provocative postures and avoid prolonged tensile stress on normal structure.

Dysfunction syndrome:

• Refers to pain which is a result of mechanical deformation of structurally impaired tissues like scar tissue or adhered or adaptively shortened tissue.
• The pain arises at the end range of a restricted movement.
• The treatment includes:

Mobilizing exercises in the direction of the dysfunction or in the direction that reproduces the pain. The aim is to remodel that tissue, which limits the movement, through exercises so that it becomes pain-free over 

Derangement syndrome;

Is the most prevalent treatment classification. Refers to pain which is caused by a disturbance in the normal resting position of the affected joint surfaces.This syndrome is classified in two groups.

1. Irreducible derangement:

The criteria for derangement are present.No strategy is capable to produce a permanent change in symptoms.

2. Reducible derangement:

Shows one direction of repeated movement which decreases or centralizes referred symptoms = preferred direction.

Shows also an opposite repeated movement characterized by production or increase or distal movement of the symptoms.

The treatment includes: examination of the patient’s symptomatic and mechanical response to repeated movements or sustained positions because the chosen treatment depends on the clinically induced directional preference.

Others:

Contains minority of patients who do not fit within one of the three mechanical syndromes but who demonstrate symptoms and signs of other pathology like:

Spinal stenosis

Hip disorders

Sacroiliac disorders

Low back pain in pregnancy

Zygapophyseal disorders

Spondylolysis and spondylolisthesis

Post-surgical problems. 

Management:

Unlike other exercises for treating low back pain meant for muscle strengthening, stability and restoring range of motion, the McKenzie method exercises are meant to directly diminish or even eliminate the patients symptoms. This effect is accomplished by providing corrective mechanical directional movements in end range. The McKenzie method educates patients regarding movement and position strategies can reduce pain. A cautious progression of repeated forces and loads is used in this method.  The exercises may be uncomfortable at first, but after some repetitions the symptoms will decrease. 

• Principles:
• Kyphotic antalgic management: extension principle
• Acute coronal antalgic management: lateral flexion-then-extension principle
• Acute lordotic antalgic management: Flexion principle.

Example:

1. Lying prone:

The patient takes place at the treatment table in prone position. The arms have to be parallel with the thorax, with the hands next to the pelvis. The head is turned to one side. This position creates automatically a lordosis of the lumbar spine. Patients with posterior derangement should be careful when arising from the position to standing. It is important that, while arising, the restored lordosis is maintained. In any kind of derangement it is important to perform the exercise long enough (5-10 minutes) for the fluid to alter its position anteriorly. In minor derangement, prone lying may reduce the derangement without any other procedures being required.

 Although this position may be painful, the pain does not indicate the procedure is undesirable if it is felt centrally. In major derangement, for example patients with lumbar kyfosis, it is possible that the patients cannot tolerate the prone position unless they are lying over a few pillows. In case of dysfunction the loss of extension may be enough to prevent lying prone because the soft tissue shortening has reduced the range of motion and extension stress produces pain.

2. Extension in lying:

The patient lies on his abdomen while the hands are placed near the shoulders. The hands are placed with the palms down. Now the patient makes a press-up movement with straight arms. The Pelvis stays near the table while the patient presses the thorax upwards. After this movement the patient returns to his starting position and repeats this exercise 10 times. The first couple of exercises have to be done easily, but after a few times the movement has to be made to the maximum extension range that is possible. The aim of this exercise is to make the lumbar spine relax after the maximum extension, in the relaxation phase. The maximum degree of extension is obtained with this exercise. It is possible that there occurs central low back pain described as a strain pain, but it will gradually wear off. An intermittent extension stress is influencing the contents and surrounding structures of the lumbar segments, having a pumping as well as a stretching effect. This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction.

3. Extension in standing:

The patient stands up straight with his feet apart, to remain a stable position. The hands are placed on the lumbar region, in the area of the spina iliaca posterior superior. His hands fixate the pelvis while the patient leans backwards. The patient has to lean backwards as far as possible. This exercise has to be repeated ten times. It has similar effects on derangement and dysfunction as extension in lying. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint. The procedure is important in the prevention of the onset of low back pain during or after prolonged sitting and is very effective when performed before pain is actually felt.

4. Rotation mobilization in extension:

The patient lies in a prone position on the treatment table with his arms parallel with the trunk and the head turned to one side. The therapist stands next to the patient and places the heels of the hands on the lumbar region. One will fixate the processus transverses of the vertebra on top of the vertebra you want to rotate. The other hand will make a rotation of the vertebra beneath in the opposite direction. This is more a technique than an exercise, but has to be repeated also ten times. In derangement rotation mobilization in extension has to be performed first to bring about centralization of nuclear material in the disc. Followed by symmetrical extension mobilization to restore the nucleus to its more anterior position. In derangement mechanical deformation is extremely undesirable. In dysfunction an increase of deformation with certain limits is desirable.

5. Self Treatment Exercises:

• Rest position for cold pack
• Sphinx-movement
• standing back extension
• Pelvic side shift

This exercise is called a “mirror exercise” and can be helpful when you have a “blocked” back and you’re leaning to one side because of it. The patient has to lean with his upper body against the wall, while his feet take same distance from the wall. Now the patient has to move his pelvis against the wall and back to the beginning position. This exercise has to be repeated 8-10 times.

Effectiveness:

For acute pain:

1. The McKenzie Method is not clinically superior to all interventions in treating acute LBP but is more effective at reducing pain intensity when compared to manual therapy and exercise combined.

For chronic pain:

1. The McKenzie Method was more effective at reducing pain and disability than “other” interventions,
2. McKenzie Method was more effective at reducing disability but not pain when compared to exercise alone,
3. McKenzie Method was not more effective than a combined exercise, manual therapy and education intervention.

As always take these findings with a pinch of salt. The effects of the McKenzie Method could be as a result of the fact large groups of patients may not fall into their subgroups and would have benefited from any exercise anyway.  The McKenzie Method is a mechanical-based system and does not account for psychological aspects of pain or alternative theories of pain. It lumps you into a category, disregards psychological aspects or more nuanced aspects of treatments. Still this doesn’t mean McKenzie isn’t a viable option for treatment. Just bare this in mind. Other treatments and assessment tools / strategies have proven as or more effective.