OSTEOARTHROSIS GENU- REHABILITATION MEDICINE APPROACH

Impairment, Disability, and Handicap

Other terms associated with rehabilitation include impairment, disability, and handicap. Impairment is the residual limitation resulting from disease, injury, or a congenital defect. Disability is the inability to perform some key life function. Handicap is the interaction of a disability with the environment.

Report from my office

Mrs. Emma was sent to me with working diagnosis: bilateral knee osteoarthritis. Using rehabilitation terminology, knee osteoarthrosis (OA genu) was her impairment. No limitation to perform activity of daily living (eating, bathing, grooming, toileting), means no disability. Chief complaint: very painful when walking (Visual Analog Scale/ VAS > 6), Handicap : yes.

Program : Goal : pain reduction

Regiment: Diode laser, output 90mW; 60 J , 3 times, every other day

Knee support

Discussion : Low Level Laser given to reduce pain.

Another modality, such as TENS, would not be helpful if VAS for pain > 6

Knee support : to reduce weight bearing , pain reducing is the result

Resulted: mobility: minimally pain while walking after 3^rd cold laser ;

no more handicap

Rehabilitation working diagnosis: Impairment : yes :OA Genu

Disability : no

Handicap : no

Program : Impairment: - glucosamine-chondroitine; Quadriiceps isometric exrecise

Knee support for Mrs. Emma - bilateral









Knee support check out

Smiling happily !!!

ANKLE SPRAINS - REHABILITATION

FROM : SKYLARK MEDICAL CLINIC

Ankle Sprains

Ankle sprains are one of the most common sports medicine injuries.
The ankle is stabilized by 3 ligaments on the outside - the anterior talofibular, calconeal fibular and posterior talofibular ligaments (see figure-1st panel, and by a fan-like ligament in the inside-the deltoid ligaments)

Inversion injuries (turning the ankle inward, strain the outer ligaments, while eversion injuries will sprain the inner deltoid ligament. Sprains are classified by degree of severity.

1st degree sprains involve stretching of the ligaments but not tears. There is minimal swelling and instability. Usually the patient may resume sports within a few weeks. This is most common in ankle injury.
2nd degree injuries involve tearing of ligaments with more swelling and bruising. This may take 3-8 weeks to return to sports.
3rd degree injuries involve severe tears of the ligament (yet surgery is rarely required). Because the ligaments are torn it may take 8-12 weeks to heal. Laxity and instability can result of this injury. Many injuries with incomplete tears fall between 2nd and 3rd degree tears.

Treatment of Ankle Sprains
The first thing to do is accurately diagnosing an ankle sprain and not missing other serious fractures that require other treatment.Any injury that is very painful or unable to walk on should be suspected as a fracture and be seen by a doctor. The severity of the injury should dictate the treatment. Even a severe ankle sprain should be kept splinted and on crutches (even if no fracture is seen on the x-ray) since this treatment will also help them heal

Approach to Rehabilitation
Stage 1 - Inflammation (3 days) It is important to rest and splint the ankle. PRICES or Protection, Rest, Ice, Compression, Elevation and Support, will help decrease the pain and swelling associated with the acute injury. An anti-inflammatory drug may be used as well. That will treat both the inflammation and the pain.
Stage 2 - Early mobilization and strengthening (up to 1week) This involves walking on injury (assisted with crutches for partial support if needed). Taping or a brace will also give support. Early exercises to maintain range of motion are important.
Stage 3 - Rehabilitation This involves improving ankle strength, flexibility, and balance. Physiotherapy or athletic therapy is important (this may begin on the 2nd week)
Stage 4 - Late Rehabilitation It is important to ensure that the ankle is adequately strong enough to allow return to sport.

Some advocate 'over-rehabilitation' which refers to the continuing of stretching and exercise programs at home to ensure that this same injury will not reoccur. Often making the athlete stronger than they were before the injury.

Forms of Treatment

Crutches - should be used whenever the injury is very painful to walk on. Gradually crutches may be used less as the injury heals, by allowing more weight to rest on the foot.

Athletic Taping - supportive athletic tape is applied to the ankle to give support. The tape must be applied by an experienced therapist and not left on overnight as it can interfere with circulation

Ankle Braces - commercial over-the-counter braces give similar support to taping but may be easily applied by the patient and are reusable. They may also be used continually to prevent future ankle injuries.

Ankle braces such as "aircast" or equivalent are useful in limiting the injured ankle motion to an up and down plane (dorsiflexion/plantar flexion) but preventing any rolling over. This allows a quicker return to normal activities without re-injuring the injured ankle.

Medications
As mentioned earlier, anti-inflammatories are used at the onset to control inflammation and pain. They are also of benefit later during rehabilitation.
Analgesics such as Tylenol (acetaminophen) give pain control but not ant-inflammation. Glucosamine is a herbal agent that although slower in onset, has anti-inflammatory effects.
Corticosteroid injections are sometimes used in chronic injuries that still have significant pain and swelling but are not used for fresh injuries.

Efficacy of different therapy regimens of low-power laser in painful osteoarthritis of the knee: a double blind and randomized-controlled trial

Efficacy of different therapy regimens of low-power laser in painful osteoarthritis of the knee: a double blind and randomized-controlled trial

Gur A; Cosut A; Sarac AJ; Cevic R; Nas K; Uvar A

Physical Medicine and Rehabilitation ; School of Medicine , Dicle University, Diyarbakir , Turkey.

alig@dicle.edu.tr

BACKGROUND MEDICINE OBJECTIVES: A prospective , double blind, randomized, and controlled trial was conducted in patients with knee osteoarthritis (OA) to evaluate the efficacy of infrared low-power Gallium-Arsenide (Ga-As) laser therapy (LPLT) and compared two different laser therapy regimens.

STUDY DESIGN/ MATERIALS AND METHODS: Ninety patients were randomly assigned to three treatment groups by one of the nontreating authors by drawing 1 of 90 envelops labeled ‘A’ (Group I : actual LPLT consisted of 5 minutes, 3 J total dose +exercise ; 30 patients ), ‘B’ (Group II: actual LPLT consisted of 3 minutes , 2 J total dose + exercise ; 30 patients); and ‘C’ (Group III: placebo laser group + exercise ; 30 patients). All patients received a total of 10 treatments , and exercise therapy program was continued during study (14 weeks). Subjects, physician, and data analysis was complete. All patients were evaluated with respect teek 0o pain, degree of active knee flexion, duration of morning stiffness, painless walking distance and duration , and the Western Ontario and Mc Master University osteoarthritis Index (WOMAC) at week 0,6,1, and 14.

RESULTS: Statistically significant improvements were indicated in respect to all parameters such as pain , function, and Quality of Life (QoL), measures in the post-therapy period compared to pre-therapy in both active laser groups (p< style=""> and in parameters such as pain, and WOMAC of the Group II , were more statistically significant when compared with placebo laser group (p<>

CONCLUSIONS: Our study demonstrated that applications of LPLT in different dose and duration have not affected results and both therapy regiment were a safe and effective method in treatment of knee OA.Copyright 2003 Wiley- Liss, Inc.

PMID: 14677160 (PubMed – indexed for MEDLINE)

ANKLE SPRAINS

This week I share two cases of mine. Ankle sprains and osteoartritis genu.

Story from my clinic

Mrs Dianiati a lady pulmonologyst from a famous hospital in JakartaIndonesia , slipped her ankle while went around a big mall in south Jakarta. Mrs Dianiati did not realized that her left was not already touch the floor, she felt with her left ankle twist to the middle. It is a classic story about ankle sprain. The owner of the groceries do not understand how important to make different color between different high of the floor.

It was so painful, she could not rise immediately. For few minutes she seated on the floor , her lower extremity, below the knee, began edema suddenly.

Roentgen took the day after (Tuesday), bony intack, so the diagnose was ankle sprain. I asked her to visit my clinic, laser administered, diode laser 90 mW; 12 J/cm2 , with probe mode , totally 10 points.

I met her on Wednesday at Cipto Mangunkusumo, edema was gone, just swollen around her ankle. Mobility independently, used sandals, one crutch as cane, but the pain still annoying. Saturday afternoon (3^rd March 2007), I gave her diode again but this time for her pain.

(I wrote this report Sunday, 4^th oh March 2007.)

Discussion : At her first visited , the laser given to relive the edema, and second visit for the pain.

Ussually the recovery will take four weeks, but at the first week, she already ambulation with minimal dependent. Edema decrease because effect emitted energy laser to the microcirculation, and influenced on pain due to effect to the C-fiber activity and bradychinine. (I enclose diagram represent the proces initiated by the energy emitted). The dose and the mode the laser delivery take important place to get best result. It is a therapeutic window must be understand, and also the mode to reach the site of the damage.

Low-level laser therapy in ankle sprains as randomized clinical trial

de Bie RA; de Vet HC; Lensen TF; van den Wildenberg FA; Kootstra G; Knipschild PG

Departement of Epidemiology , Mastrich University , The Netherlands

OBJECTIVE : The test the efficacy of low-level laser therapy on lateral ankle sprains as an adition to standardized treatment regiment, a trial was conducted in which high laser (5 J/ cm2), low-dose laser (0.5/cm2),and placebo laser therapy (0J/cm2) att skin laser level were compared .

DESIGN: Randomized , double-blind, controlled clinical trial with a follow-up of 1 year. Patients, therapist, assessors, and analyst were blinded to the assigned treatment.

SETTING: An ambulatory care setting.

PATIENTS: After informed consent and verification of exclusion criteria, 217 patients with acute lateral ankle srains were randomized to three groups from September 1, 1993 , through Desember 31, 1995.

INERVENTIOS: Twelve treatments of 904 nm laser therapy in 4 weeks as an adjunct to a standardized treatment regiment of 4 weeks of brace therapy combined ith standardized home exercise and edvice. The laser therapy device used was a Ga- As laser , with 25-watt peak power and 5,0000 or 500 Hz frequency, a pulse duration of 200nsec, and an irradiated area of 1cm2.

PRIMARY OUTCOME MEASURES : Pain and function as reported by the patient

RESULTS: Intervention –to- treat analysis of the short term results showed no statistically significant difference on the primary outcome measure, pain (p=.02) and at some points for hindrancein activities in daily life and pressere pain, as well as subjective recovery (p+.05). intention-to-treat analysis showed that total days absenteeism from work and sports were remarkably lower in the placebo group than in the laser groups, rangimg from 3.7 to 5.3 and 5 to 8 days, respectively. The total number of relapsesat 1 year in the low-dose laser group (n=22) was significantly higher (p=.04) than in the other two groups (high laser, n=13; placebo, n=13). Subgroup analysis to correct for possible confounders did not alter these findings.

CONCLUSIONS: Neither high- nor low dose laser therapy is effective in the treatment of lateral ankle sprains.

Arch Phys Med Rehabil. 1998 Nov;79(11):1415-20

Carpal Tunnel Syndrome

Introduction

A friend of mine, a dentist, came to me, numbness on her right hand as the chief complaint. That is a very specific injury to whom who uses hand, especially the wrist, rhythmic and for a long time. It usually occurs in people who work as a dentist (like my friend), somebody who works a lot using computer, or in Indonesia, during fasting month, housewives suffer from Carpal Tunnel Syndrome (CTS) due to their repeated work of making “sambal” using “cobek”. Apparently, CTS is one of ladies’ disease.

Published data in Minnesota shows the ratio of CTS incidence between male : female = 5 : 14. In Cipto Mangunkusumo Hospital, the number of CTS cases found was 238 in the year of 2001 and 149 cases in 2002. The patients’ age ranges between 25 – 35 years old. In Washington, the chief complaint reported was tingling and pain .

Pathogenesis:

CTS is caused by impingment of the median nerve inside the carpal tunnel. As tension inside the tunnel increases, perineural edema occurs, and causes damage to the nerve. This event will release serotonin and prostaglandin, and impair microcirculation. This is the mechanism which stimulate the pain.

Laser therapy:

I gave her diode laser (15 mW for 15 minutes) with trans-cutaneous application. The day after her first visit, she told me that after the treatment she felt an “uncomfortable sensation” in her injured hand. I decided to decrease the dosage of laser therapy to 10mW for 15 minutes. She felt comfortable with this regiment and could work as usual. Orthose also given to fixate the wrist at zero degree position.

Research

A research on CTS has been conducted at the Physical Medicine and Rehabilitation Department in Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The hypothesis was, “Application of plaster of Paris & and Low Level Laser Therapy (LLLT) are more effective than plaster of Paris only for pain reduction in Carpal Tunnel Syndrome”. Is there any additional effect to plaster of Paris fixation by LLLT compared with fixation only in reducing Carpal Tunnel Syndrome pain? It was the question tried to be answered.

There were two groups, LLLT combined with plaster of Paris, and the other as control only using plaster of Paris.

The subjects were homogenous among those groups. It was conducted for a period of two weeks, and Visual Analog Scale (VAS) was used as outcome assessment for pain.

Conclusion: Application of plaster of Paris and Low Level Laser Therapy has an additional effect for pain reduction in comparison to plaster of Paris only

Discussion:

The effect of Low Level Laser Therapy as anti inflammatory and pain reliever worked in this case of CTS.

Acknowledgement:
This story is dedicated to Mrs. Hermina., a friend of mine who is such a beautiful dentist.

(Hi, Mrs Hermina, , your visit to my office reminded me to share this kind of problem to others. Thank you)