Rehabilitative exercises for Ankle sprain:

Introduction

Ankle sprains are common injuries that can result in lifelong problems. Some people with repeated or severe sprains can develop long-term joint pain and weakness. Treating a sprained ankle can help prevent ongoing ankle problems.

Rehabilitation (rehab) exercises are critical to ensure that the ankle heals completely and re-injury does not occur.

• You can begin healing by walking or bearing some weight, while using crutches if needed, if you can do so without too much pain.
• Start rehab with range-of-motion exercises in the first 72 hours after your injury. Continue with further rehab, including stretching, strength training, and balance exercises, over the next several weeks to months.
• You can do rehab exercises at home or even at the office to strengthen your ankle.

How to do rehabilitation exercises for an ankle sprain

Start each exercise slowly and use your pain level to guide you in doing these exercises. Ease off the exercise if you have more than mild pain. Following are some examples of typical rehabilitation (rehab) exercises.

Keep in mind that the timing and type of rehab exercises recommended for you may vary according to your doctor's or physical therapist's preferences.

Range-of-motion exercises

Range-of-motion exercises begin right after your injury. Try doing these exercises then putting ice on your ankle, up to 5 times a day. These are easy to do while you are at a desk or watching TV.

Try the following simple Range of motion exercises:

• Trace the alphabet with your toe, which encourages ankle movement in all directions. Trace the alphabet 1 to 3 times.
• Sit in a chair with your foot flat on the floor. Slowly move your knee side to side while keeping your foot pressed flat. Continue for 2 to 3 minutes.

Towel curls: While sitting, place your foot on a towel on the floor and scrunch the towel toward you with your toes. Then, also using your toes, push the towel away from you. Make this exercise more challenging by placing a weighted object, such as a soup can, on the other end of the towel.

Stretching exercises

Start exercises to stretch your Achilles Tendon as soon as you can do so without pain. The Achilles tendon connects the calf muscles on the back of the lower leg to the bone at the base of the heel. Try the towel stretch if you need to sit down, or try the calf stretch if you can stand.

• Towel stretch. Sit with your leg straight in front of you. Place a rolled towel under the ball of your foot, holding the towel at both ends. Gently pull the towel toward you while keeping your knee straight. Hold this position for 15 to 30 seconds, and repeat 2 to 4 times. In moderate to severe ankle sprains, it may be too painful at first to pull your toes far enough to feel a stretch in your calf. Use caution, and let pain be your guide.
• Calf stretch: Stand facing a wall with your hands on the wall at about eye level. Put the leg you want to stretch about a step behind your other leg. Keeping your back heel on the floor, bend your front knee until you feel a stretch in the back leg. Hold the stretch for 15 to 30 seconds. Repeat 2 to 4 times. Repeat the exercise with the back knee bent a little, still keeping your back heel on the floor. This will stretch a different part of the calf muscles.

Strengthening exercises

Talk to your doctor or physical therapist about the timing of strengthening exercises. Typically you can start them when you are able to stand without increased pain or swelling.

Do 8 to 12 repetitions of these exercises once or twice daily for 2 to 4 weeks, depending on the severity of your injury.

• Start by sitting with your foot flat on the floor and pushing it outward against an immovable object such as the wall or heavy furniture. Hold for about 6 seconds, then relax. After you feel comfortable with this, try using rubber tubing looped around the outside of your feet for resistance. Push your foot out to the side against the tubing, then count to 10 as you slowly bring your foot back to the middle.
• While still sitting, put your feet together flat on the floor. Press your injured foot inward against your other foot. Hold for about 6 seconds, then relax.
• Next, place the heel of your other foot on top of the injured one. Push down with the top heel while trying to push up with your injured foot. Hold for about 6 seconds, then relax.

Balance and control exercises

You can usually start balance and control exercises. when you are able to stand without pain. But talk to your doctor or physical therapist about the exact timing. Also, don't try these exercises if you could not have done them easily before your injury. If you think you would have felt unsteady doing these exercises when your ankle was healthy, you are at risk of falling when you try them with an injured ankle.

Practice your balance exercise at least once a day, repeating it about 6 times in each session.

1. Stand on just your injured foot while holding your arms out to your sides with your eyes open. If you feel unsteady, stand in a doorway so you can put your hands on the door frame to help you. Balance for a long as you can, working up to 60 seconds. When you can do this for 60 seconds, try exercise number 2.
2. Stand on your injured foot only and hold your arms across your chest with your eyes open. When you can do this for 60 seconds, try exercise number 3.
3. Stand on your injured foot only, hold your arms out to the sides, and close your eyes. If you feel unsteady, stand in a doorway so you can put your hands on the door frame to help you. When you can do this for 60 seconds, try exercise number 4.
4. Stand on your injured foot only, hold your arms across your chest, and close your eyes. Balance for a long as you can, working up to 60 seconds.

Stretching exercises should be continued on a daily basis and especially before and after physical activities to prevent reinjury. Even after your ankle feels better, continue with strengthening exercises and balance and control exercises several times a week to keep your ankles strong.

some of useful exercise videos:

Adult Neurogenesis ( new neurons generation)

What is adult neurogenesis?

"Adult neurogenesis" refers to the ability of the central nervous system (brain and spinal cord) to generate new neurons in adulthood called adult generated neurons. This is as differentiated from "neurogenesis" typically used to describe the processes of neuronal generation that occur during the prenatal (embryonic and fetal) period extending in to the early years of postnatal life.

Back in the 1800s and the first half of the 20th century, scientists and scholars believed that development of new neurons only occurred early in life and would cease at some point during development, so that no new neurons could be formed in the brain or spinal cord after this 'critical age'.  Some scientists back then disputed this as fact but had no means of disproving the widely accepted notion, the non-availability of advanced equipment back then and less advanced scientific investigation and laboratoty techniques meant this notion would go unchallenged for a very long time.

Definition:

Adult neurogenesis is the process of generating new neurons which integrate into existing circuits after fetal and early postnatal development has ceased. In most mammalian species, adult neurogenesis only appears to occur in the olfactory bulb and the hippocampus

What happen in neurological diseases?

Immense interest has been generated around this area, now that adult neurogenesis is known to be a fact, focus has shifted towards determining the factors that affect adult neurogenesis (increase or decrease it rate of occurrence) and the functions of these adult generated neurons. Interestingly it has been shown that such factors as physical exercise, living in an environmentally enriched area and mentally challenging tasks among other things improve the rate of production of new neurons in the adult hippocampus as well as increase the longevity of these newly generated neurons. In the same vein, scientists have managed to demonstrate that laboratory animals in which the rates of neurogenesis had been increased by such means as physical exercise performed better at tasks such as learning a new skill or spatial navigation in a novel (new) environment. Incidentally, elevated levels of adult hippocampal neurogenesis have been observed in adults with neurological insults and diseases such as stroke (CVA), Alzheimer's disease, Parkinson's disease and dementia amongst others. These diseases are characterised by death and destruction of neurons and the elevated levels of neurogenesis are hypothesized to be the body's own way of trying to replace the neurons that would have been lost. 

Physiotherapist role in Adult neurogenesis:

Considering that physical exercise and environmental enrichment will improve the levels of adult neurogenesis, physiotherapists can augment the body's own regenerative capacities by working with patients with neurological diseases to promote activities that enhance hippocampal neurogenesis.

1. Promote a healthy lifestyle - eat healthy, avoid the use of drugs. The use of drugs such as methamphetamine(reduces the rate of neurogenesis) and decreases cognitive functions 

2. Develop an exercise regime as part of the treatment programme for neuro patients. 

So everyone come to know, physiotherapy helps in a lot of ways to rehabilitatate neurological patients in all ways( also in neurogenesis). 

Benefits of dance in Parkinson's disease

Parkinson Disease is a progressive neurodegenerative disease. Common symptoms of PD are resting tremor, bradykinesia, rigidity, mask face, and difficulties with gait. Gait difficulties include short and shuffling steps, festination and/or freezing of gait, difficulty turning or walking backward, and impaired ability to perform dual tasks when walking.  Individuals with PD are also at an increased risk of falls.

Dance address each of the previously mentioned key areas in the following ways, 

• The use of music to accompany dance movement can act as an external cue to facilitate movement.
• The use of specific movement strategies when teaching the dance steps.
• The need to control dynamic balance and respond to perturbations when interacting with other participants facilitates balance exercises.
• Dance helps enhance strength and flexibility. It may also improve cardiovascular functioning if done at a sufficient intensity

 Some of benefits are,

Motor benefits

Dance is shown to benefit individuals with Parkinson's disease by enhancing motor function through stretching, stepping and balance. Individuals who participated in a dance intervention ranging from 90 minutes of dance per week for 8 weeks, to 2 hours, two times per week for 2 years, showed improvements in various outcome measures, when compared to a regular exercise group. The motor improvements could be due to repetition, direction change, and step sequencing that are inherent in dance and transfer into effective, regular gait patterns.Furthermore, basal ganglia may be activated during rhythmic movements, and enhanced by the auditory cues in the music accompanying dance.

Cognitive benefits:

The changing visual and auditory stimuli, unique to dance, facilitate cognitive improvements when compared to regular exercise programs for PD patients. A dance class creates an environment where individuals must control continuously changing patterns of movement to match the instructor. Dance has been shown to reduce time taken to correctly complete the MRT (Mental Rotation Task) as dance aids in imagery formation and judgement. The attention required to anticipate movements, and respond to changes in music or instruction is unique to dance and can enhance the activity of the basal ganglia loops and frontal lobes. This is supported by greater improvement in FAB (frontal assessment battery). When compared to traditional rehabilitation (balance exercises, gait training) there were moderate improvements in cognitive test scores at the 8 week follow up, supporting dance therapy as being able to impact higher cortical functions in the long term.

Mental health benefits:

Mental health benefits for individuals with Parkinson's disease are exclusive to dance when compared to control and regular exercise treatment. Improvement shown in mood, motivation and enjoyment can be related to feelings of unity. There are improved AP (apathy scale) and SDS (self-rating depression scale) scores after dance intervention in patients with PD. It has been suggested that dance therapy can decrease fear of falling through practicing position changes in a controlled environment. Overall, health related quality of life and emotional well-being has been increased through dance for people living with PD.

Other benefits:

When compared to regular exercise and control groups, dance for PD yields greater gains in UPDRS (Unified Parkinson's Disease Rating Scale).  Personal, cultural, and social preference need to be considered to improve adherence to treatment program.

Herniated Disc or Slipped Disc - major reason back pain

What is Herniated Disc?

Each disc of the spine is designed much like a jelly donut. As the disc degenerates from age or injury, the softer central portion can rupture (herniate) through the surrounding outer ring (annulus fibrosus). This abnormal rupture of the central portion of the disc is referred to as a disc herniation. This is commonly referred to as a "slipped disc."

The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumber vertebrae.The lower back is also critically involved in our body's movements throughout the day, as we twist the torso in rotating side to side and as we hinge the back in flexion and extension while bending or lifting. Sometimes people are telling as "muscle catch" or there was  a sound like "click". So therapists or doctors only can clearly diagnose the condition through a lot of investigations

                                                            Symptoms

The symptoms of a herniated disc depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. Disc herniation can cause local pain at the level of the spine affected.

If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body and is referred to as Sciatica. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness, weakness, and tingling in the leg. The pain often is worsened upon standing and decreases with lying down. This is often referred as pinched nerve

If the disc herniation occurs in the cervical spine, the pain may shoot down one arm and cause a stiff neck or muscle spasm in the neck.

If the disc herniation is extremely large, it can press on spinal nerves on both sides of the body. This can result in severe pain down one or both lower extremities. There can be marked muscle weakness of the lower extremities and even incontinence of bowel and bladder. This complication is medically referred to as cauda equina syndrome.

Special Investigations for Lumbar disc herniation:

Usually we are looking for, how orthopaedicians or therapists diagnose the condition through their knowledge, without using special equipments. They are using some physical examination, patient history, on time examination, special tests etc .. to find out the condition. After that they are confirming through special investigations by use of special equipments( MRI,CT,X RAY, Etc). Here I gonna discuss about some physical examinations, usually they are using to rule out the condition.

Straight Leg Raise (SLR);  
The patient is in supine position and the examiner raises the leg (on the symptomatic side). The knee stays fully extended. When the angle at the hip in which the SLR is reached differs in comparison to the other leg, or when pain is produced during the test, the test is considered to be positive.

Slump test: the sitting patient (with convex back) bends his head forward and stretches his leg out with the toes pointing upward. The purpose is to stretch the neural structures within the vertebral canal and foramen. If the pain is reappear, test is positive

Lasègue’s test: it’s an extension of the SLR: the therapist lowers the leg to an extent of five to ten degrees. Then, the foot is passively dorsiflexed. The test is considered to be positive when the ipsilateral leg pain (sciatica below the knee) occurs upon elevation.

Crossed Lasegue test (XSLR): This test is considered to be positive when the pain (sciatica) can be reproduced upon passive extension of the contra-lateral leg.

Scoliosis: the therapist is going to evaluate this parameter using visual inspection. Scoliosis might be a potential indicator of lumbar disc herniation. Research has proven that the diagnostic performance of this test is really poor. The sensitivity and specificity are really low.

Muscle weakness or paresis: the examiner measures strength during ankle dorsiflexion or extension of the big toe (without or against resistance). 
Dorsal flexion impaired --> L4 radiculopathy
Toe extension impaired --> L5 radiculopathy
If the possible range at the symptomatic side differs from the non-symptomatic side, then the test is considered to be positive.

Reflexes: weakness or absence of the Achilles tendon reflex possibly refers to S1 radiculopathy.

Forward flexion test: the purpose is to bend forward in standing position. There is no consensus regarding the criteria that have to be considered in order to determine if the radiant pain is caused by disc herniation. Some studies use limitation of forward flexion as main criteria, while others use back/leg pain as the primary indicator.

Hyperextension test: the patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pain deteriorates.

Manual testing and sensory testing: looks for hypoaesthesia, hypoalgesia, tingling or numbness. One example of testing: the patient closes his eyes and the examiner strikes the skin bilaterally and simultaneously. The patient is asked if he feels any differences between the left and right side. The test is considered to be positive when there is a dermatomal distribution. Although, the diagnostic performance of sensitivity and specificity is poor. 

                       Physiotherapy Intervention:

Physiotherapists can help in you in lot ways to recover from the back pain by doing some of their therapies like Shockwave, Ultasound, TENS, and IFT etc ,as well as by their special manipulation and particular exercises for this herniated disc. PT may include deep tissue massage, hot/cold therapies, hydrotherapy, and exercise. Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief, but they also teach you how to condition your body to prevent further injury

useful youtube videos:

Stretching: There is low-quality evidence found to suggest that adding hyperextension to an intensive exercise programme might not be more effective than intensive exercise alone for functional status or pain outcomes. There were also no clinically relevant or statistically significant differences found in disability and pain between combined strength training and stretching, and strength training alone.

Behavioural graded activity programme: A global perceived recovery was better after a standard physiotherapy programme than after a behavioural graded activity programme in the short term, however no differences were noted in the long term.

Ultrasound and shock wave therapies: Ultrasound is used to penetrate the tissues and transmitting heat deep into the tissues. The aim of ultrasound is to increase local metabolism and blood circulation, enhance the flexibility of connective tissue, and accelerate tissue regeneration, potentially reducing pain and stiffness, while improving mobility. Shock wave applies vibration at a low frequency to the tissues (10, 50, 100, or 250 Hz). This causes an oscillatory pressure to decrease pain. The available evidence does not support the effectiveness of both therapy strategies for treating disc herniation.

Transcutaneous electrical nerve stimulation (TENS): TENS uses an electrical current to stimulate the patients muscles. Electrodes on the skin send a tiny electrical current to key points on the nerve pathway. It is generally believed to trigger the release of endorphins, which are the body's natural pain killers and reduce muscle spasms. For this reason, TENS therapy contribute to pain relief and improvement of function and mobility of the lumbosacral spine.

Manipulative treatment: Manipulative treatment on lumbar disc herniation appears to be safe, effective, and it seems to be better than other therapies. However high-quality evidence is needed to be further investigated.

Core strengthening exercises: A strong core is important to the health of the spine. The core (abdominal) muscles help the back muscles support the spine. When your core muscles are weak, it puts extra pressure on your back muscles. So it is important to teach core stabilizing exercises to strengthen your back. It is also very important to train the endurance of these muscles. A core stability program decreases pain level, improves functional status, increases health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients. Individual high-quality trials found moderate evidence that stabilisation exercises are more effective than no treatment.