physiotherapy

scoliosis

2008-09-16T02:16:00.000-07:00

Scoliosis and Spinal Deformities:A Guide for Patients

If you or a member of your family has a spinal deformity you probably have questions and concerns. The doctors and nurses in the Children's Hospital Spinal Deformities Program have prepared this booklet to help answer your questions. In it we describe spinal deformities and explain both non-operative and surgical treatment.

Your orthopaedic surgeon and nurse are ready to answer your questions and to help you understand your particular spinal abnormality and treatment. This booklet is not meant to substitute for discussions with the doctor or nurse. No question is too simple to ask. Please write down any additional questions you have and bring them when you come for your next appointment. We welcome your questions.

What is the spine?
The spine is made up of many individual bones called vertebrae, joined together by muscles and ligaments. Flat, soft intervertebral discs separate and cushion each vertebra from the next. Because the vertebrae are separate, the spine is flexible and can bend. Together the vertebrae, discs, muscles, and ligaments make up the vertebral column or spine. Different regions of the spine are named differently. The cervical spine refers to the neck, the thoracic spine to the chest, and the lumbar and sacral spines to the low back.

What are normal spinal curves?
Just as the shapes of peoples' bodies differ, the normal spine varies in size and shape. You may have been told to "stand up straight," but no one's spine is perfectly straight. The healthy spine has front-to-back curves. It's only when these curves become too large that they present a potential problem.

When the backward curve in the upper spine is too great, the condition is called thoracic hyper-kyphosis, round back, Scheuermann's disease, or sometimes simply kyphosis. When there is not enough backward curve in the upper spine, the condition is called hypo-kyphosis. When the inward curve in the lower back is too great, the condition is called hyper-lordosis or swayback.

What is scoliosis?
Although the spine does curve from front to back it should not curve sideways very much. A side-to-side curve is called scoliosis and may take the shape of an "S" (double curve) or a long "C" (single curve).

Scoliosis is more than just a curve to the side. The scoliotic spine is also rotated or twisted, like the stripes on a barber pole. As the spine twists it pulls the ribs along with it, so that one side of the chest becomes higher than the other, or the shape of the breastbone may change. You may have noticed that one of your shoulders is higher than the other or that your clothes hang unevenly at the waist because one hip is higher than the other. To better understand this, compare the drawings of the normal spine and the scoliotic spine. Many people with scoliosis also have hypo-kyphosis. Because of all the possible combinations of curvatures, scoliosis can be very different in different people.

What causes abnormal spinal curves?

There are many different causes of abnormal spinal curves. Some babies are born with spinal defects that cause the spine to grow unevenly, a condition called congenital scoliosis or congenital kyphosis. Some children have nerve or muscle diseases, injuries or other illnesses that cause spinal deformities, for example cerebral palsy, or myelomeningocele.

Sometimes, however, the back just doesn't grow as straight as it should, and no one knows why. This most common type of scoliosis is called "idiopathic" scoliosis and has no known cause. There is no known prevention. This means that if you have scoliosis, nothing you did caused it, and you could have done nothing to prevent it.

Scientists are studying idiopathic scoliosis, hoping to discover its cause. They have many clues but no real answers yet. They do know it tends to run in families and that girls are eight times more likely to have it than boys. Scoliosis isn't rare, it affects about one in every ten people. Many people have mild scoliosis but are unaware of it and need no treatment for it.

Observation: Keeping watch on curves
Idiopathic scoliosis doesn't happen all at once, it develops gradually over time, and may worsen rapidly during rapid growth in the pre-teen and teen years. Some mild curves never worsen with growth and need no treatment. Some curves worsen only a little and need no treatment. Early detection of abnormal spinal curves by school screening programs and pediatricians is intended to find scoliosis early enough to begin brace treatment and avoid surgery. Once an abnormal spine curve has been detected, it is important to monitor the curve during growth.

The years before and during adolescence are a time of rapid growth and your curve can worsen quickly. Your doctor will decide on your treatment plan and follow-up based upon your x-rays and physical exam. Even though your curve may not bother you now, it needs to be watched all through your growth. Your doctor will show you the curve on your x-rays to help you understand how he measures the degree of curvature and its change.

Why treat scoliosis? Avoiding future problems:
Scoliosis rarely seems a problem to the child or adolescent who has a curve. Why then do we bother to monitor and treat curves? Adults with moderate or severe scoliosis can have progressively worsening curves which cause cosmetic disfigurement, back pain and in the worst cases, difficulty breathing. Treatment after the curve has already become severe in adulthood is much less successful than treatment during childhood or adolescence. By finding progressive curves early, we hope to keep them from becoming problems in adulthood.

Treatment without surgery: Exercises and braces
The treatment of scoliosis depends on the location and degree (severity) of curvature. Slight curves (curves measuring less than 20 degrees), usually require no treatment, but must be watched carefully for worsening during growth. If your curve shows significant worsening or is already greater than 30 degrees, and you are still growing, your doctor will probably recommend a bracing program.

The scoliosis brace is designed especially for you and your particular curve. It holds your spine in a straighter position while you are growing to try to partly correct your curve or prevent it from increasing. A bracing program may help you avoid surgery. You will need to wear your brace almost all the time until the end of growth. Almost all braces can be hidden beneath normal clothing, and you can continue to do all athletic activities. Usually there are other adolescents in your school who wear braces, but since you can't see their brace you don't know it!

Your doctor works with a team of professionals who help you adjust to this treatment since a bracing program can be difficult and you may need help in organizing your activities and school day. The team offers both support and experience in guiding you through the process. The team includes your doctor, orthotist (a specialist who makes braces), a physical therapist, and a nurse. Your doctor and the orthotist decide which brace design is right for you. The braces are made of firm plastic and fit closely over the hips, and are worn under clothes. A few have metal pieces extending to the chin, but these are usually only necessary to treat hyperkyphosis and are usually worn part time.

The physical therapist evaluates your posture, muscle strength and flexibility and gives you a home exercise program which is designed specifically for you. This program helps to stretch and strengthen your muscles so you are more comfortable in your brace. Each time you visit the clinic, you see the physical therapist.

The nurse helps you and your parents with all your questions and your appointments. She teaches you how to care for yourself and your brace, gives you a schedule to follow, and helps you plan your day-to-day activities. If you are interested she will also help you meet others who wear braces. Following a brace program may sound like a lot of work and effort, but if your curve can be controlled with a brace and you can avoid surgery, it will be worth it!

Surgery

Some curves do not respond to bracing despite everyone's best efforts, and some curves are just too large to begin with (greater than 40-45 degrees). If you have this type of curve, you will probably need surgery. If your doctor recommends surgery, you'll want to think about it seriously and ask many questions.

The goal of the surgery is a usually a solid fusion (solidification) of the curved part of the spine. A fusion is achieved by operating on the spine, adding bone chips and allowing the vertebral bones and bone chips to slowly heal together to form a solid mass of bone called a fusion. The bone chips (bone graft) may come from your hip (iliac crest) or from the hospital's bone bank. Often, the spine is partially straightened with metal rods and hooks or wires (instrumentation). The rods or sometimes a brace or cast hold the spine in place until your fusion has a chance to heal. Once the fusion has healed (usually 3 to 12 months) the abnormal section of the spine cannot curve more. The rods, hooks or wires can usually be left in your back without causing any problems.

Posterior Fusion
Posterior fusion with instrumentation is the most common operation done for idiopathic scoliosis. In the posterior fusion the spine is operated on from behind with an incision straight down the back. Various types of rods, hooks, wires or screws are used to partially straighten the spine and hold it fast while the bone fusion occurs. For most of these operations on idiopathic scoliosis, no brace or cast is used postoperatively. In congenital scoliosis or spondylolisthesis the posterior fusion may be done without instrumentation, and a cast or brace is needed postoperatively.
Anterior Fusion
In the anterior fusion, the spine is operated on from the front, or side. Anterior fusion is used in some special instances of idiopathic scoliosis when a lot of growth remains, and commonly in congenital scoliosis, kyphosis, or myelomeningocele. An incision is made along a rib and/or down the front of the abdomen to obtain access to the front of the spine. Bone graft from the hip, rib or bone bank is used for the fusion. Screws and washers attached to a rod may be used to straighten the spine. Fusions of this type may require a postoperative brace. Some anterior fusions can be done with minimal incisions and an instrument called a thoracoscope. Rather than needing a large incision, the surgeon can operate through smaller incisions with a telescope and camera.
Anterior and Posterior Fusion
Some special cases of spinal deformity require both an anterior (front) and posterior (back) operation. Usually these can be done on the same day, but sometimes must be done at separate operations spaced 1-2 weeks apart.
Further Information about Surgery:
A separate booklet: GETTING READY FOR SPINAL SURGERY is available and describes the surgical experience in more detail.

Glossary of Terms
Anterior Fusion: Fusion performed on the front of the spine, usually by replacing intervertebral discs with bone chips.

Bone Age: An X-ray of the left hand and wrist is compared to the average appearance of the bones at different ages. An estimate of remaining growth is obtained.

Bone Bank Bone: Bone graft obtained from donors.

Bone Graft: Pieces of bone used to create a fusion, obtained from the patient's iliac crest, rib, or from the bone bank.

Boston Brace: A type of spinal orthosis (brace) developed at the Children's Hospital, Boston. The Boston Brace System starts with prefabricated, symmetric spinal orthotic modules of different sizes. Individual braces are customized to fit a particular patient's body shape and spinal curvature. The brace or orthosis is designed according to a 'brace blueprint' drawn from the spinal X-ray. The Boston Bracing System is commonly used throughout the United States and Europe.

Brace: A semi-rigid plastic (and sometimes metal and leather) device which pushes on the muscles and ribs adjacent to the spinal column. The brace (also called an orthosis) is designed to lessen the abnormal spinal curvature while worn.

C-D Rods: Drs. Cotrel and Dubousset designed this popular form of spinal instrumentation, which was the first type of rod system to use multiple hooks on one rod which could be turned in either direction. C-D, TSRH, and other similar systems are popular because they offer more strength of fixation, more points of attachment to the spine and can help preserve or restore normal spinal contours of thoracic kyphosis and lumbar lordosis.

Disc: The intervertebral disc is a strong, rubbery and gelatin - like structure which normally separates the individual vertebral bodies and allows movement between them. Discs are usually removed from the portion of the spine undergoing anterior fusion and replaced with bone chips to create a fusion.

Fusion: A continuous mass of bone which solidifies and immobilizes the desired part of the spine. A fusion is created by adding bone graft to the surfaces of vertebra and then immobilizing that part of the spine with instrumentation or with a cast. A solid fusion cannot bend or curve more as time passes.

Harrington Rod: Designed by Dr. Harrington, the Harrington rod was the first modern means of spinal instrumentation which reliably produced correction and immobilization.

Hook: A hook is that portion of the spinal instrumentation which grasps the vertebra.

Incision: The cut made through the skin for the purposes of operation.

Instrumentation: The metal rods, hooks, screws, etc. which are attached to the spine to change spinal shape and immobilize the spine while fusion occurs.

ISIS, Quantec, or Ortelius: A computerized system used to document the three-dimensional contour of the spine using light beams and a scanning device.

Inclinometer or Scoliometer:: A simple device using a level to measure the 'rib hump'. Useful for detecting and screening for scoliosis.

Kyphosis: Curvature of the spine with the convexity pointing toward the back. It is normal to have some kyphosis in the thoracic (chest area) spinal column. Sometimes there is too much kyphosis in the thoracic spine, called "hyperkyphosis," Scheurmann's kyphosis, or "round back." When there is not enough kyphosis in the thoracic spine (as is usually the case with idiopathic scoliosis), it is called thoracic hypokyphosis.

Lordosis: Curvature of the spine with the convexity toward the front. It is normal to have lordosis in the cervical (neck) and lumbar (waist area) portions of the spine.

Luqué Rods, Wires: Named for Dr. Luqué, these spinal rods use sublaminar wires (wires looped around the back part or each vertebra) for attachment. Luqué type instrumentation is commonly used in paralytic scoliosis such as that seen in cerebral palsy.

Milwaukee Brace: The Milwaukee Brace was the first modern spinal orthosis used for scoliosis, and in its modified form, is still used for Scheurmann's kyphosis and some spinal curves.

Moiré Photograph: Moiré photography uses light projected through a grid and then photographed to record the three-dimensional shape of the back.
Orthosis: A spinal brace.

Posterior Fusion: A fusion performed on the posterior or back surface of the spine.

Rib Hump: The prominence formed by ribs on the convexity of a curve, caused by rotation of the spine and attached ribs.

Risser Sign: The top of the pelvis bone matures in predictable stages referred to as Risser stages. These give some indication of growth remaining in the spine.

Scoliosis: Lateral (sideways) curvature of the spine greater than 15 degrees. (Fifteen degrees or less of sideways curvature in adults is probably normal and should probably not be called scoliosis.)

Skeletal Maturity: When the bones (and spine) are finished growing, skeletal maturity has been reached.

Spinal Column: The spinal column is composed of individual vertebral bones, ligaments, and discs. It surrounds the spinal cord.

Spinal Cord: The spinal cord travels through the spinal column and consists of nerves which carry and receive signals to and from the arms, legs, and many internal organs.

Sublaminar Wires: See Luque' Instrumentation

TLSO (Thoraco-Lumbar-Sacral-Orthosis): A brace or spinal orthosis which does not extend above the shoulders.

TSRH Rods: Similar to C-D rods, named after the Texas Scottish Rite Hospital.

Vertebra: Individual bones which comprise the spinal column.

RHEUMATOID ARTHRITIS

2008-07-31T01:53:00.000-07:00

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body

CAUSES

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research

SYMPTOMS

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. A rare, serious complication, usually with long-standing rheumatoid disease, is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

DIAGNOSIS

first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and x-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.
The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.
Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.
A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.
Joint x-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints.
The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid, in the laboratory, can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

TREATMENT

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.
Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine (Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.
The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.

Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.
Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues.
Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals. For more information, please read the Total Hip Replacement and Total Knee Replacement articles.

PHYSIOTHERAPY

Rheumatoid arthritis (RA) is a chronic and painful clinical condition that leads to progressive joint damage, disability, deterioration in quality of life, and shortened life expectancy. Even mild inflammation may result in irreversible damage and permanent disability. The clinical course according to symptoms may be either intermittent or progressive in patients with RA. In most patients, the clinical course is progressive, and structural damage develops in the first 2 years. The aim of RA management is to achieve pain relief and prevent joint damage and functional loss. Physiotherapy and rehabilitation applications significantly augment medical therapy by improving the management of RA and reducing handicaps in daily living for patients with RA. In this review, the application of physiotherapy modalities is examined, including the use of cold/heat applications, electrical stimulation, and hydrotherapy. Rehabilitation treatment techniques for patients with RA such as joint protection strategies, massage, exercise, and patient education are also presented.
Introduction
RA is a chronic and progressive disease leading to considerable physical functional loss and disability. Currently, there is no curative therapy for RA; therefore, patients are subjected to various life-long treatment modalities. Thus, an important component of successful management of the disease is educating patients and informing them about the planned treatment modalities. Objectives of physiotherapy and rehabilitation applications in patients with RA are to prevent disability, to increase functional capacity, to provide pain relief, and to provide patient education.[1]
Before starting therapy, the physiotherapy needs of patients are determined in accordance with their incapacity, disability, and handicaps. Physical assessment should include these components:
Functional assessment (ie, transfer status, analysis of gait, activities of daily living);
Range of joint motion (ROM) (for all joints);
Muscle strength test (manual or by isokinetic equipment);
Postural assessment; and
Evaluation of respiratory function.
It should be remembered that presence of inflammation, instability, and contractures may affect the results of these evaluations and tests. Scales such as Arthritis Impact Measurement Scale I and II, Health Assessment Questionnaire, and Functional Independence Measure may be used for functional assessment.[2-4]

MUSCULAR DYSTROPHY

2008-07-14T23:23:00.000-07:00

MUSCULAR DYSTROPHY

Muscular dystrophy (MD) is a genetic disorder that gradually weakens the body's muscles. It's caused by incorrect or missing genetic information that prevents the body from making the proteins it needs to build and maintain healthy muscles.
A child who is diagnosed with MD gradually loses the ability to do things like walk, sit upright, breathe easily, and move the arms and hands. This increasing weakness can lead to other health problems.
There are several major forms of muscular dystrophy, which can affect a child's muscles in different levels of severity. In some cases, MD starts causing muscle problems in infancy, while in others, symptoms don't appear until adulthood.

SYMPTOMS OF MUSCULAR DYSTROPHY

A child who has MD may start to stumble, waddle, have difficulty going up stairs, and toe walk (walk on the toes without the heels hitting the floor). A child may start to struggle to get up from a sitting position or have a hard time pushing things, like a wagon or a tricycle. It is also common for a young child with MD to develop enlarged calf muscles, a condition called calf pseudohypertrophy, as muscle tissue is destroyed and replaced by fat.

DIAGNOSIS

When a doctor first suspects that a child has muscular dystrophy, he or she probably will do a physical exam, take a family history, and ask about any problems - particularly those affecting the muscles - that the child might be experiencing.
In addition, the doctor may perform a series of tests to determine what type of MD a child may have and to rule out any other diseases that may be causing a problem. This might include a blood test to measure levels of serum creatine kinase, an enzyme that's released into the bloodstream when muscle fibers are deteriorating. Elevated levels of this enzyme indicate that something is causing muscle damage.
The doctor also may do a blood test to check a child's DNA for gene abnormalities, or a muscle biopsy to examine a muscle tissue sample for patterns of deterioration and abnormal levels of dystrophin, a protein that helps muscle cells keep their shape and length. Without dystrophin, the muscles break down.

TYPES OF MUSCULAR DYSTROPHY

The different types of muscular dystrophy affect different sets of muscles and result in different degrees of muscle weakness.

DUCHENNE muscular dystrophy is the most common and the most severe form of the disease. It affects about 1 out of every 3,500 boys. (Girls can carry the gene that causes the disease, but they usually have no symptoms.) This form of MD occurs because of a problem with the gene that makes dystrophin. Without this protein, the muscles break down and a child becomes weaker.
In cases of Duchenne muscular dystrophy, symptoms usually begin to appear around age 5, as the pelvic muscles begin to weaken. Most kids with this form of MD need to use a wheelchair by age 12. Over time, their muscles weaken in the shoulders, back, arms, and legs. Eventually, the respiratory muscles are affected, and a ventilator is required to assist breathing. Kids who have Duchenne muscular dystrophy typically have a life span of about 20 years.

BECKERS muscular dystrophy is similar to Duchenne, but it is less common and progresses more slowly. This form of MD affects approximately 1 in 30,000 boys. It too is caused by insufficient production of dystrophin

MYOTONIC dystrophy, also known as Steinert's disease, is the most common adult form of muscular dystrophy, although half of all cases are diagnosed in people who are younger than 20 years old. It is caused by a portion of a particular gene that is larger than it should be. The symptoms can appear at any time during a child's life

LIMB-GIRDLE muscular dystrophy affects boys and girls equally. Typically, symptoms begin when kids are between 8 and 15 years old. This form of MD progresses slowly, affecting the pelvic, shoulder, and back muscles. The severity of muscle weakness varies from person to person. Some kids develop only mild weakness while others develop severe disabilities and as adults need a wheelchair to get around.

FASCIOSCAPULOHUMERAL muscular dystrophy can affect both boys and girls, and the symptoms usually first appear during the teen years. This form of muscular dystrophy tends to progress slowly.

CARING THE KID

If your child is diagnosed with muscular dystrophy, a team of medical specialists will work with you and your family. That team will likely include: a neurologist, orthopedist, pulmonologist, physical and occupational therapist, nurse practitioner, cardiologist, registered dietician, and a social worker.
Muscular dystrophy is often degenerative, so kids may pass through different stages as the disease progresses and require different kinds of treatment. During the early stages, physical therapy, joint bracing, and the medication prednisone are often used. During the later stages, doctors may use assistive devices such as:
physical therapy and bracing to improve your child's flexibility
power wheelchairs and scooters to improve your child's mobility
a ventilator to support your child's breathing
robotics to help your child perform routine daily tasks

2008-07-14T01:58:00.000-07:00

Osteomyelitis is a bone infection usually caused by bacteria, including mycobacteria, but is sometimes caused by fungi.
Bacteria or fungi can infect bones by spreading through the bloodstream, spreading from nearby tissue, or directly invading the bone.
People have pain in one part of the bone, fever, and weight loss.
Blood tests and x-rays are done, and doctors remove a sample of bone for tests.
Antibiotics are given for weeks, and surgery may be needed.

Osteomyelitis occurs most commonly in young children and in older people, but all age groups are at risk. Osteomyelitis is also more likely to occur in people with serious medical conditions.
When a bone becomes infected, the soft, inner part (bone marrow) often swells. As the swollen tissue presses against the rigid outer wall of the bone, the blood vessels in the bone marrow may become compressed, which reduces or cuts off the blood supply to the bone. Without an adequate blood supply, parts of the bone may die. These areas of dead bone are difficult to cure of infection because it is difficult for the body's natural infection-fighting cells and antibiotics to reach them. The infection can also spread outward from the bone to form collections of pus (abscesses) in adjacent soft tissues, such as the muscle.

CAUSES
Bones, which usually are well protected from infection, can become infected through three routes:
The bloodstream (which may carry an infection from another part of the body to the bones)
Direct invasion (infection)
Infections in adjacent bone or soft tissues

When organisms that cause osteomyelitis spread through the bloodstream, infection usually occurs in the ends of leg and arm bones in children and in the spine (vertebrae) in adults, particularly in older people. Infections of the vertebrae are referred to as vertebral osteomyelitis. People who undergo kidney dialysis and those who inject drugs using nonsterile needles are particularly susceptible to vertebral osteomyelitis.
Bacteria or fungal spores may infect the bone directly through open fractures, during bone surgery, or from contaminated objects that pierce the bone. Staphylococcus aureus is the bacteria most commonly responsible. Mycobacterium tuberculosis (the main cause of tuberculosis) can infect the vertebrae to cause osteomyelitis

DIAGNOSIS
Symptoms and findings during a physical examination may suggest osteomyelitis. For example, doctors may suspect osteomyelitis in a person who has persistent pain in part of a bone with or without a fever and feels tired much of the time.

Elevations in the erythrocyte sedimentation rate (ESR—a test that measures the rate at which red blood cells settle to the bottom of a test tube containing blood), and an elevated level of C-reactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation) usually occur. Also, blood tests often indicate elevated levels of white blood cells. However, these blood tests are not sufficient to diagnose osteomyelitis

PROGNOSIS AND PREVENTION

Prognosis and Prevention
The prognosis for people with osteomyelitis is usually good with early and proper treatment. However, sometimes, chronic osteomyelitis develops, and a bone abscess may recur weeks to months or years later.

TREATMENT

Treatment
For children and adults who have recently developed bone infections through the bloodstream, antibiotics are the most effective treatment. If the bacteria causing the infection cannot be identified, then antibiotics that are effective against Staphylococcus aureus and many types of bacteria (broad-spectrum antibiotics are used. Depending on the severity of the infection, antibiotics may be given by vein (intravenously) for about 4 to 8 weeks but then may be given by mouth later. Some people need months of antibiotic treatment.

OSTEOARTHRITIS

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*Osteoarthritis is the most common form of arthritis.
* It is caused by the breakdown of cartilage. Cartilage is the tough elastic material that covers and protects the ends of bones. Bits of cartilage may break off and cause pain and swelling in the joint between bones. This pain and swelling is called inflammation.
*Over time the cartilage may wear away entirely, and the bones will rub together.
*Osteoarthritis can affect any joint but usually affects hips, knees, hands and spine.
Osteoarthritis is a disease that affects joints in the body. It can involve any joint, but usually concerns hands and weight-bearing joints such as hips, knees, feet and spine.
It affects men and women in equal numbers.
Most people develop osteoarthritis after the age of 45, but it can occur at any age.

WARNING SIGNS OF OSTEOARTHRITIS

Pain, stiffness and swelling around a joint that lasts longer than two weeks.

The joints that are usually affected are the hips, knees, feet and spine. Finger and thumb joints might also be affected.

If you are experiencing persistent joint pain, visit your family doctor.

CAUSES OF OSTEOARTHRITIS

The exact cause is unknown.

The chances of getting osteoarthritis seem to increase with age.

Some people with osteoarthritis have other family members with it.

Being overweight can increase your risk of getting osteoarthritis.

Excess weight puts stress on joints such as hips and knees.

Injury to a joint or repeated overuse of it can also damage the cartilage and lead to osteoarthritis.

Other types of arthritis can also damage joints and lead to osteoarthritis.

Excess WeightExcess weight puts extra stress on the weight-bearing joints, especially the knees and hips. The good news is losing weight, even just 10 pounds (4.5 kilograms), can help prevent osteoarthritis in your knees. Even if you have osteoarthritis in your knees, losing weight can make you feel better. Less body weight means less stress on Wear and Tear?
Osteoarthritis used to be thought of as the inevitable result of “wear and tear” on the joints. Research now shows that normal wear does not actually cause “tear.” Normal activity and exercise is good rather than bad for joints and does not cause osteoarthritis your knees

MEDICINE:ANALGESICS

Acetaminophen is often the first medication chosen to treat osteoarthritis. It can relieve pain but does not reduce inflammation

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a type of medication that helps reduce the pain and swelling of the joints and decrease stiffness. However, they do not prevent further joint damage.
Medicine: Corticosteroids
Cortisone may be injected into the joint to relieve severe inflammation. Cortisone is a steroid that reduces inflammation and swelling

EXERCISES

Regular exercise is known to be very effective for relieving the pain and stiffness of osteoarthritis and may help slow the progression of the disease. Exercise also helps you reach or maintain a healthy weight, which reduces the stress on your joints. Here are some good reasons to exercise if you have arthritis:

Exercise strengthens the muscles that support your joints, which helps protect the joints from further damage and can reduce the pain of arthritis.

Exercise improves the flexibility of your joints; the more flexible your joints are, the more easily you can move them without pain.

Exercise can make you feel better mentally and emotionally by relieving stress and elevating your mood.

Exercise can spark your energy and generally improve the quality of your life.

The exercise program that will work best for you is one that fits your lifestyle and physical abilities. Doctors generally recommend a combination of stretching exercises, mild strengthening exercises (such as lifting weights), and low-impact aerobic exercises (such as swimming, walking, or bicycling).

Make exercise a part of your life If your exercise routine is comfortable and enjoyable for you, it will become a habit that will be easy to keep up. It doesn't have to be a formal exercise program. Just fitting more activity into your daily routine, such as taking the stairs instead of the elevator and walking or riding your bike instead of driving, can provide many benefits. You will get the most out of your exercise program if you plan workouts for those times of the day when your pain is least severe and your joints most flexible.

For many people, pain and stiffness are often worse in the morning than at other times. If this is the case for you, try exercising after you have taken a hot shower, which can help loosen your joints.

Begin and end each exercise session with a warm-up and cooldown by walking around slowly for 5 minutes before and after.

at a rate at which you can speak comfortably.

STRETCHING EXERCISES, which are also called range-of-motion exercises, are good for helping to reduce stiffness in your joints and improve their flexibility. Stretching exercises include anything that requires regular movement of a joint to its fullest capacity.
For example, holding your arms out to your sides and circling them in a windmill fashion stretches your shoulder joint.

Some forms of water exercise use warm water to loosen joints and help them stretch. Doing stretching exercises for a few minutes every day can significantly improve the movement in your joints.

STRENGTHENING EXERCISES help maintain or build the muscles around your joints, which helps keep the joints stable. Stronger muscles also improve the joint's movement.
Lifting light weights, such as 1- to 2-pound dumbbells, every other day is often enough to make a difference. (Muscles need a day off in between to rest and rebuild.). You will need to be carefully instructed in this type of exercise to avoid injury and further damage to your joints.

Some forms of water exercise include strengthening exercises. Fitness exercises Fitness exercises, also called aerobic exercises, increase your endurance, strengthen your heart and lungs, and give you energy.

Try to exercise aerobically for at least 60 to 90 minutes each week.

Brisk walking, swimming, and bicycling are good fitness exercises if you have arthritis because they allow for smooth rather than jerky movements. You should avoid high-impact exercises—such as jogging, tennis, or step aerobics—because they can put too much pressure on your joints and can worsen your symptoms.Swimming is especially good if you have arthritis in your knees or hips because the water supports your weight, which reduces stress on those joints.

Walking is also a good exercise for relieving the pain and stiffness of arthritis.

HEAT AND COLD

The use of heat and cold are time-honored techniques for relieving the pain, stiffness, and occasional swelling that can result from osteoarthritis. Some people get better results with heat; others prefer cold.

Do not apply either heat or cold for longer than 20 minutes at a time. Your skin should be allowed to return to normal temperature between applications. And do not combine either heat or cold with rubbing or the use of creams. This combination can cause burns.Heat

Heat is usually used to relax muscles and sometimes to warm them up before exercising.
You can heat up your sore joints with heating pads or hot packs or by sitting in a hot tub or heated pool.

For many people who have arthritis, a hot shower in the morning is all they need to loosen their stiff joints. Cold Applying cold to a sore joint reduces the pain by numbing the area

Use ice or reusable cold packs. Never apply ice directly to your skin because it can burn the skin; wrap ice and cold packs in a towel.

Although applying cold can be helpful for short-term pain relief, you have to be careful because the lack of feeling may cause you to overuse the sore joint or muscle.

NUTRITION AND DIET

Obesity causes strain on the weight bearing joints and induces osteoarthritis. Balanced diet with adequate supplementation of calcium in the diet can be helpful to patients. It is also advisable to avoid foods rich in fat. These are the general principles of diet therapy. However the diet regime of patients can be individualized depending on the clinical scenario.

BUTTOCK EXERCISE

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Gluteus Maximus muscle strengthening (buttock exercise)
To strengthen this muscle, lie on the stomach with the hips and legs off the end of a table or bench. Tighten the buttock on one side and extend the leg up toward the ceiling while maintaining a neutral spine. Movements should be slow. Initially, it is common to only be able to perform a few repetitions at a time.

*

Hold 5 seconds
*

4-10 repetitions per side
*

1 time per day
*

4-5 days per week

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LOW BACK PAIN RELIEF

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Strengthening exercise program for low back pain relief

Transversus Abdominis muscle strengthening (abdominal exercise)
Many people think of performing abdominal crunches or situps to strengthen the abdominal muscles. While “six pack abs” look nice to some, it is more important to work the Transversus Abdominis (TVA) through abdominal exercise to achieve spinal stability. When retraining the TVA, it is important to maintain a neutral lumbar spine (don’t try pushing the back all the way into the floor). The back is most often in a neutral spine position, so it makes less sense to strengthen the back in a flexed or extended position. Lie on one’s back with the knees bent. Knees and feet should be shoulder width apart. Draw the belly button toward the spine while maintaining a neutral spine. Upon exhalation, reach toward the ceiling as if trying to grab a trapeze overhead. Then raise the head and shoulders off the floor, just to the point where the shoulder blades are barely touching the floor, and hold 1-2 seconds. Inhale upon return and repeat at the end of the next exhalation. Continue until it is not possible to maintain a neutral spine or when fatigued.

* Hold 1-2 seconds

* Repeat until fatigued

* 1 time per day * 4-5 days per week

McKenzie therapy for low back pain

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McKenzie therapy for mechanical low back pain McKenzie Method assessment and treatment Of the many frustrations back pain patients face, the lack of a standardized or uniform treatment approach is high on the list. Especially for those patients with longer-lasting symptoms of sub-acute pain (lasting between six and twelve weeks) or longer than twelve weeks (chronic back pain), treatment approaches are very inconsistent. While the McKenzie Method is successful with treating acute low back pain, it is also very helpful for those patients with sub-acute and chronic back pain. One of the benefits of the McKenzie Method (or McKenzie Therapy) is that it is a standardized approach to both the assessment and treatment of low back pain and/or leg pain (sciatica). The McKenzie Method is not simply a set of exercises; it is a defined algorithm that serves to classify the spinal problem so that it can be adequately treated.
The McKenzie Method is grounded in finding a cause and effect relationship between the positions the patient usually assumes while sitting, standing or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient’s pain response. The approach then uses that information to develop an exercise protocol designed to centralize or alleviate the pain.
While there are certainly other forms and schools of physical therapy, this article discusses the components of the McKenzie assessment and classification system, and summarizes the experience of a typical patient whose pain classification reflects that he or she would benefit from McKenzie exercises.
McKenzie Method assessmentWhen a patient’s pain symptoms can be made better or worse by adopting various, differentiated active positions, it is said that a patient has a directional preference of movement for treatment. The identification of a directional preference through mechanical means is the hallmark of the McKenzie Method (which is often referred to Mechanical Diagnosis and Therapy or MDT). The patient’s beneficial ‘directional preference’ also is the direction of movement that causes pain symptoms to move more centrally (toward the mid-back or neck),
Correct assessment or mechanical diagnosis is the key to prescribing effective exercises. Without the aid of a good assessment, there are no McKenzie exercises; there are just exercises, the efficacy of which is questionable. 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 may be asked to perform single and/or repeated flexion or extension movements forward and backward. These movements are done to ‘end range’ —the point at which the patient’s range is limited for any reason—and are done in both standing and lying positions. Lateral flexion movements may also be performed.
McKenzie therapy classifications The Mechanical Diagnosis and Therapy system has three broad treatment classifications: postural, dysfunction and derangement syndromes.
A postural syndrome is the result of prolonged postures or positions that can affect joint surfaces, muscles or tendons. Pain may be local and reproducible when end range positions, such as slouching, are maintained for sustained periods of time. Repeated movements do not change symptoms in postural syndrome patients, and response (i.e. pain relief) is usually immediate. It is valuable to have the patient perform poor postural positions followed by the symptom-abolishing positions in order for them to ‘understand’ what is leading to their discomfort and train patients to avoid them.
The dysfunction classification is so named because it implies some sort of adaptive shortening, scarring or adherence of connective tissue causing discomfort. A dysfunction may be intermittent or chronic, but its hallmark is a consistent movement loss and pain at the end range of movement. When the patient moves away from end range their pain is decreased. Successful treatment takes time because it focuses on tissue remodeling which requires constant attention. Patient education is critical for this syndrome, because the patient will need to understand that remodeling tissue can be slow and often uncomfortable because the exercises prescribed are intended to challenge any adhesions or tissue scarring that has occurred.
The derangement classification is the most common syndrome that presents clinically. Its hallmark is its sensitivity to certain movements and its preference for particular movement patterns. When certain movements are performed, such as a flexion and/or extension (bending or straightening) the symptoms (e.g. low back pain) become either more central (e.g. just in the low back) or less intense. It is not uncommon for a patient to experience rapid reduction of their symptoms immediately during the assessment. That is to say, if their symptoms were pain in their right thigh, the pain may be moved more centrally to their buttock, or in some cases be completely aMcKenzie therapy for mechanical low back pain
McKenzie Method assessment and treatment McKenzie therapy for mechanical low back pain
McKenzie Method assessment and treatment bolished. Treatment for the patient with derangement syndrome, as with the postural and dysfunction syndromes, is directly guided by the patient’s response to these provocative assessment movements.
While not all patients are successfully treated by Mechanical Diagnosis and Therapy exercise, it could be strongly argued that all patients with neck pain or low back pain may be successfully assessed by the Mechanical Diagnosis and Therapy method. Failure to find a mechanical component to the patient’s pain is a significant finding, in that it is as important to know for whom McKenzie exercises will be successful and those for whom they will not.

Isthmic Spondylolisthesis

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Exercise for sciatica from isthmic spondylolisthesis

Sciatica can be caused by isthmic spondylolisthesis if the condition results in nerve root irritation or impingement. In most cases, if isthmic spondylolisthesis affects or pinches a nerve root it will affect the L5 nerve root. For more information on this condition, see Overview of isthmic spondylolisthesis.

When treating sciatica resulting from isthmic spondylolisthesis with exercise, the spine specialist will typically recommend an exercise program that is a hybrid of:

Flexion based exercises (as when treating spinal stenosis), and
Stabilization program (as when treating degenerative disc disease).

The goal of this type of exercise program is to teach the lumbar spine to remain stable in a flexed position. Therefore, the exercises for scia

tica caused by isthmic spondylolisthesis are a combination of both programs.

Sciatica exercises for isthmic spondylolisthesis

These sciatica exercises often require specific hands-on instruction because they offer much less benefit if done incorrectly, and the exercises tend to be much more difficult to do than they appear.

Three exercises that are commonly prescribed for sciatic pain from isthmic spondylolisthesis include: Hook-lying march. As another form of stabilization exercise, Curl-ups. Strengthening the abdominals with the curl-upsthe hook-lying march.

water therapy

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Water therapy exercise program

Water therapy pain relief

Water therapy exercise programs (sometimes called pool therapy, hydrotherapy, or aquatic therapy) consist of a variety of aquatic-based treatments and exercises that are designed for back pain relief, to condition and strengthen muscles. Water therapy exercise offers many of the same benefits associated with a land-based exercise program, including development of a treatment plan that is carefully tailored to the individual. Water therapy exercise is especially helpful in cases where a land-based exercise program is not possible due to pain, decreased bone density, disability or other factors. As such, water therapy is a versatile exercise and is particularly good for people with conditions such as:

Osteoarthritis
Advanced osteoporosis (with susceptibility to and/or pain from fracture)
Muscle strain or tears

Benefits of water during exercise therapy

The physical properties of water make it a highly desirable medium in which to exercise to treat back pain and other musculoskeletal injuries. Some of the most important properties of water that make exercise easier are:

Buoyancy: water counteracts gravity and helps to support the weight of the patient in a controlled fashion as the patient is immersed. This can aid the development of improved balance and strength.
Viscosity: water provides resistance by means of gentle friction, allowing strengthening and conditioning of an injury, while reducing the risk of further injury due to loss of balance.
Hydrostatic pressure: there are powerful effects produced by hydrostatic pressure that improve heart and lung function, making aquatic exercise a very useful way to maintain and strengthen heart and lung function. This pressure effect also aids in improving muscle blood flow.

Together, these properties allow development of an exercise regimen that minimizes the weight placed on the spine (axial load) and risk of injury due to unintended movements during exercises. For example, individuals with osteoarthritis in the neck (cervical spine) and shoulder could practice arm circles or shoulder rolls in water to improve their range of motion and strength. Because the water provides both mild resistance and support through buoyancy, the person would most likely not experience the pain caused when a tired arm drops suddenly, as it can do at the end of land-based exercises.

Moreover, the perception of pain may be diminished as a result of many factors including the relaxing sounds as well as the warmth of the water during water therapy exercise, making it a different and often very pleasurable experience. Finally, the buoyancy of water permits a greater range of positions due to the virtual elimination of gravitational forces, particularly for exercises that require lifting the legs, the heaviest limb of the body for most people. Exercises such as range of motion stretches for hip flexors and abductors are generally much easier to try out first in water because the leg is supported somewhat as the individual learns the right positioning. Buoyancy when doing water therapy exercises can be increased with the use of floats.

Limitations to consider during water therapy exercise

For many back pain patients, water-based exercises should only be performed under the guidance of a qualified health professional. Water therapy exercise should usually be avoided if a person has any of the following:

Fever
Severe heart failure
Incontinence
Infection

Individuals with severely limited endurance or range of motion may not be able to safely navigate a tiled (and slippery) pool apron to participate in a water therapy exercise program. Rubber mats are often used to increase traction to reduce this risk.

The perception of objects (like the instructor demonstrating exercises) in water is also affected by refraction, leading to difficulty in learning specific motor skills in patients with limited eyesight, or impaired sense of body position or balance due to stroke or other injury. Also, the water temperature may be too warm to accommodate some conditions. Therapy is generally conducted in pools or tanks with water that is between 90 to 94 degrees (Fahrenheit), almost as warm as bath water, so blood circulation is increased. Consequently, patients with any of the conditions listed above should avoid or limit their water therapy exercise, or make sure the pool or tank used is cooler so that their conditions are not exacerbated.

Finally, for patients with low bone density or osteoporosis, the buoyancy provided by the water may not be as beneficial for building bone as weight bearing land-based exercises although the added strength and balance achieved through an aquatic exercise program may facilitate a safe return to land-based exercise.

Water therapy exercises muscles and joints, as well as the back

Some of the basic techniques for pool therapy exercises are as follows (they can be modified for varying degrees of difficulty):

Knee-to-chest exercise. This movement is performed with one hand on the side of the pool or with back to the wall. Alternating between legs stretches the lower back, as well as the gluteus (buttocks), quadriceps (front thigh) and hamstring (back thigh) muscles.
Leg raise exercise. This movement is performed with one leg outstretched and the supporting leg slightly bent while one hand holds onto the side of the pool. It strengthens and stretches the muscles in the leg, hip and lower back.
Wall-facing leg stretch exercise. In this stretching exercise individuals assume a “Superman” position with hands resting on side of pool and the body and legs outstretched into and supported by water. This extends all regions of and joints in the back as well as stretching shoulder muscles.
Pool walking exercise. Walking both forward and backward in chest-high water works the leg muscles while exerting no impact of the knees or hips, particularly important for people who have arthritis in those joints. The walking exercise can be made more demanding with the addition of hand floats or light weights, so a stroll in the pool becomes an aquatic version of power walking.
Quadruped activity and exercise. This exercise works legs and arms and is performed while floating on one’s back (sometimes achieved with a therapist supporting the trunk or using a flotation jacket). The individual makes paddling motions with his/her arms and legs.

Combined water therapy for back exercise with land-based methods

Water therapy for back exercise can be a short-term exercise option if back pain or a back injury makes land-based exercise too difficult. Or it can be adopted as part of an ongoing exercise program if land-based methods worsen symptoms or if the person prefers water exercises. If their functional status or competitive goals require it, people may transition to exercise in a dry environment once they are successfully performing exercises in water.

Some people may find mixed use of wet and dry exercise therapy environments most beneficial.

OBESITY

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People gain weight when the body takes in more calories than it burns off. The amount of weight gain that leads to obesity doesn't happen in a few weeks or months. Because being obese is more than just being a few pounds overweight, people who are obese have usually been getting more calories than they need for years.
many problems have solved by the treatment.
Genes - small parts of the DNA that people inherit from their parents and that determine traits like hair or eye color - can play an important role in this weight gain. Some of your genes tell your body how to metabolize food and how to use extra calories or stored fat. Some people burn calories faster or slower than others do because of their genes.

Obesity can run in families, but just how much is due to genes is hard to determine. Many families eat the same foods, have the same habits (like snacking in front of the TV), and tend to think alike when it comes to weight issues (like urging children to eat a lot at dinner so they can grow "big and strong"). All of these situations can contribute to weight gain, so it can be difficult to figure out if a person is born with a tendency to be obese or overweight or learns eating and exercise habits that lead to weight gain. In most cases, weight problems arise from a combination of habits and genetic factors. Certain illnesses, like thyroid gland problems or unusual genetic disorders, are uncommon causes for people gaining weight. the obesity leads to several incurable diseases

Arthritis

2007-07-16T01:33:00.000-07:00

Actemra (tocilizumab), a biologic drug being developed to treat rheumatoid arthritis by Roche Pharmaceuticals, has produced successful results in the third Phase III trial conducted. Actemra is a first-in-class humanized anti-interleukin-6 receptor monoclonal antibody. There were 498 patients in the trial known as Actemra RADIATE (Rheumatoid Arthritis Study in Anti-TNF Failures). The RADIATE trial studied Actemra in moderate to severe rheumatoid arthritis patients who failed to respond to anti-tumor necrosis factor treatments (anti-TNF drugs) e.g., Enbrel, Remicade, and Humira.