M AART 1975 F I S I O T E R A P I E Non - A rticular Rheum atism By W. A. M cD O N A L D SC O T T M .B ., Ch.B.(Aberd), M .R .C .P.(Lond.) W h e n S h a k e s p e a r e in M id s u m m e r N i g h t ’s D r e a m s a i d : “ T h e n o r th - e a s t w in d — A w a k ’d th e sle e p ie r h e u m e , a n d so by c h a n c e D i d g ra c e o u r h o llo w p a r tin g w ith a t e a r e ” , he w a s sa y in g a s m u c h a s w a s k n o w n a b o u t r h e u m a tis m th ree h u n d r e d a n d fifty y e a rs a g o . W e c a n a d d little m o r e to d a y in sp ite o f m a s siv e a d v a n c e s in th e w h o le field o f m e d ic in e , a l t h o u g h in th e “ c l i m a t r o n ” o f th e U n iv e r s ity o f P e n n s y lv a n ia , “ w e a th e r ” c a n b e a r r a n g e d by a d ju s tm e n ts o f t e m p e r a tu r e , h u m id ity , a i r e le c tric ity a n d b a ro m e tric p r e s s u re : in th is w a y p a tie n ts w ith r h e u m a tic d ise ase u n d e r d o u b le - b lin d c o n d itio n s w e re f o u n d t o h a v e v s e n i n g o f th e ir s y m p to m s w ith “ a c h a n g e in t h e w e a th e r L /11”" N o n - a r t ic u la r r h e u m a tis m c o v e r s a w id e r a n g e o f a c h e s a n d p a in s fe lt in t h e s o ft tis s u e s b u t n o t a s s o c ia te d w ith a r th ritis . T h e m u sc le s a n d f ib ro u s s tr u c tu r e s o f th e b o d y C ongenital Talipes (continued from page 5) Conclusion C o n g e n ita l ta lip e s e q u i n o - v a r u s is a s e rio u s f o o t d e ­ d e fo rm ity , a n d r e q u ire s p r o lo n g e d a n d s t r e n u o u s tr e a tm e n t. It is o f te n v ery d iffic u lt to c o r re c t a d e q u a te ly , a n d m a y s h o w a v ic io u s te n d e n c y to r e la p se t h r o u g h o u t g ro w th . H o w e v e r, w ith e a r ly g e n tle m a n ip u la tio n a n d c o n tin u o u s sp lin tin g , s o f t tis s u e re le a se a s y o u n g a s th r e e m o n th s o f ag e , a n d c o n s t a n t a f te r- c a r e u n til g r o w th h a s c e a s e d , a s a tis f a c to ry b u t n e v e r n o r m a l f o o t c a n b e o b t a i n e d . REFERENCES B row ne, D e n is : T a lip e s e q u in o - v a r u s . L a n c e t I I , 9 6 9 , 1934. B ro w n e, D e n is : M o d e r n M e th o d s o f T r e a t m e n t o f th e C lu b f o o t. B r itis h M e d ic a l J o u r n a l , 2, 570, 1937. B row ne, D e n i s : S p lin tin g f o r C o n tr o lle d M o v e m e n t. R e ­ p rin te d f r o m C lin ic a l O r th o p a e d ic s , N o . 8 , 1956. D w y er, F . C . : T r e a t m e n t o f R e la p s e d C lu b F o o t b y th e In se rtio n o f a w e d g e in to th e C a lc a n e u m . J o u r n a l o f B o n e # J o i n t S u rg e ry , 45B , 67, 1963. ( n n s , D . : R e la p s e d C lu b F o o t . J o u r n a l o f B o n e & J o i n t iu T g e ry , 43B , 722, 1961. F rip p , A . T . : P ro b le m o f R e la p s e d C lu b F o o t . J o u r n a l o f Bone & J o i n t S u rg e ry , 4 3B , 626, 1961. K ite, J . H . : T r e a tm e n t o f C o n g e n ita l C lu b F e e t. J o u r n a l o f A m e ric a n M e d ic a l A s s o c ia tio n , 99 -2 , 1156, 1932. K ite, J . H . : P rin c ip le s I n v o lv e d in th e T r e a t m e n t o f C o n ­ ge n ita l C lu b f o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 21, 595, 1939. K ite, J. H . : T r e a t m e n t o f C o n g e n ita l C lu b fe e t. O f fp r in t fro m A m e ric a n A c a d e m y o f O r th o p a e d ic S u rg e o n s . I n s tr u c tio n a l C o u rse L e c tu re s , V o l. V 1948. K u h lm a n n , R . F ., & B ell, J. F . : C lin ic a l E v a lu a tio n o f O p e ra tiv e P ro c e d u re s f o r C o n g e n ita l T a lip e s E q u in o - v a r u s . J o u r n a l o f B o n e & J o i n t S u rg e ry , 3 9 A , 265, 1957. S inger, M .: T ib ia lis p o s te r io r tr a n s f e r in C o n g e n ita l C lu b F o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 4 3B , 717, 1961. S in g er, M ., & F r i p p , A . T . : T ib ia lis a n t e r i o r tr a n s f e r in C o n g e n ita l C lu b f o o t. J o u r n a l o f B o n e & J o i n t S u rg e ry , 40B , 252, 1958. S o u th w o o d , R . T . : S o u th A u s tr a lia n C lin ic s, N o . 4 V o l. 5, 1971. W iley, A . M .: A n A n a to m ic a l & E x p e rim e n ta l S tu d y o f M u scle G r o w th . J o u r n a l o f B o n e & J o i n t S u rg e ry , 4 1 B, 821, 1959. m a y b e a ffe c te d b y p o s tu r a l s tr a in , b y ex c e s siv e u se , b y p s y c h o lo g ic a l o r c lim a tic stre s s a n d b y p h y sic a l in ju ry . T h is le a d s t o p a in , te n d e r n e s s a n d stiffn e ss w ith a s s o c ia te d m u sc le s p a s m in m a n y . T h e p re c ise p a th o lo g y o f th e s e c o n d itio n s re m a in s o b s c u re . F ib ro s itis o r m u s c u la r r h e u m a tis m is p r o b a b ly th e c o m m o n e s t o f a ll f o rm s . I t is c a lle d p sy c h o g e n ic r h e u m a tis m in A m e r ic a , su g g e stin g t h a t p sy c h o lo g ic a l stre ss is a lw a y s a c a u s e , w h ic h is d iffic u lt t o p ro v e . I f w e c o n s id e r r h e u m a tis m a s a n e x p r e s s io n o f th e r e s u lt o f stre s s o n a p a r t i c u l a r te m ­ p e r a m e n t — th e “ r h e u m a tic y ” ty p e — th o s e w h o s e m u s c u lo ­ sk e le ta l sy s te m re p re s e n ts a t a r g e t o r g a n in t h a t in d iv id u a l — th e n th e r e m u s t b e a p s y c h o lo g ic a l c o m p o n e n t, a t le a st. I n su c h a p e rs o n th e r e is o f te n a h is t o r y fro m c h ild h o o d , s ta r tin g w ith “ g ro w in g p a i n s ” a n d c o n tin u in g th r o u g h a d o le s c e n c e a n d a d u lt life w ith e p is o d e s o f r h e u m a tic n a tu r e . T h e d ia g n o s in g o f n o n - a r t i c u l a r r h e u m a tis m m u s t b e te m p e r e d w ith c a u tio n , b u t in th e f a c e o f o b v io u s g o o d g e n e ra l h e a lth , a n o r m a l b l o o d s e d im e n ta tio n r a te , a n o r m a l o r ra is e d s e ru m u r ic a c id a n d n e g a tiv e L a te x s c re e n in g te st f o r r h e u m a to id a r t h r i t i s , it is re a s o n a b le t o m a k e it. A lth o u g h th e r e a r e se v e ra l r e a s o n a b ly c le a r - c u t sy n d r o m e s , so f t- tis s u e r h e u m a tis m is m o r e e a sily re v ie w e d r e g io n by re g io n . NECK T h e d iffu s e a c h in g p a in o f r h e u m a tis m is d iffic u lt to lo c a lis e a n d th is h a s b e e n c h e c k e d e x p e r im e n ta lly w ith h y p e r to n ic sa lin e . E a c h s p in a l se g m e n t h a s a c h a r a c te r is tic r e fe rra l a r e a . A n i n je c tio n in to th e n e c k a t C 2 w ill p r o d u c e a c h in g in th e b a c k o f th e n e c k a n d h e a d r a d i a t i n g o fte n t o t h e f o re h e a d . A t C 4, p a in is fe lt in th e s id e o f t h e n e c k . A t C 5, p a in is fe lt in th e s id e o f t h e n e c k a n d t h e p o in t o f th e s h o u ld e r. A t C„, p a in te n d s t o s p r e a d d o w n t h e o u te r sid e o f t h e a r m . A t C , a n d T j , p a in s p r e a d s d o w n t h e in n e r sid e o f t h e a r m . I n a ll th e s e a r e a s , t h e s k in a n d su p e rfic ia l m u sc le s a r e t e n d e r t o to u c h a n d s p o ts n o r m a lly s e n s itiv e t o p re s s u re b e c o m e e s p e c ia lly so . T h is is t h e c o m m o n p ic tu r e o f f ib ro s itis o f n e c k a n d s h o u ld e rs — th e w o r d t h a t in c o r re c tly s u g g e sts a n in fla m ­ m a to r y s ta te . T h e “ n o d u le s ” a r e m u s c le b u n d le s w h ic h c a n b e fe lt, a n d t h e i r d is p e rs a l su g g e sts th e r e lie f o f s p a s m o f th e s e b u n d le s . LOW BACK P A IN (Lumbago, Sciatica, “ Slipped D isc ” ) A c u te e p is o d e s a g a i n s t a b a c k g r o u n d o f a “ b a d b a c k ” a r e p e r h a p s t h e c o m m o n e s t o f a ll th e p r o b le m s o f n o n - a r t i c u l a r r h e u m a tis m . A l th o u g h th e g r e a t m a jo r ity a r e f o r p r a c tic a l p u r p o s e s m u s c u lo -s k e le ta l th e p o s s ib ility o f u n d e r ­ ly in g p a th o lo g y m u s t b e re m e m b e re d . P h y sic a l, l a b o r a t o r y a n d ra d io lo g ic a l in v e s tig a tio n s s h o u ld b e k e p t t o a m in im u m a n d re s p o n s e to th e r a p y u s e d a s c o n f irm a tio n o f d ia g n o s is . I t is r a r e t o fin d t h e a b s e n c e o f p sy c h o lo g ic a l f a c to rs , th e m o s t i m p o r t a n t b e in g a lo ss o f c o n fid e n c e in th e b a c k w h ic h h e lp s t o p e r p e tu a te s y m p to m s . A m y th o lo g y h a s g r o w n u p a b o u t th e “ s lip p e d d is c ” a n d t h e in e v ita b ility o f t r o u b le if th e r e is ra d io lo g ic a l e v id e n c e o f d e g e n e r a te d isc s. I t se e m s t h a t t h e r e d u c tio n in size o f t h e s h o c k a b s o r b e r b e tw e e n tw o v e r te b ra l b o d ie s is c o n s id e re d c ritic a l in th e p r o d u c t i o n o f p a in a n d y e t th e m o s t m o d e r n tr e a t m e n t o f d isc o ly sis p r o ­ d u c e s c h e m ic a l d e s tr u c tio n o f t h e d is c w ith re lie f o f p a in . U n le s s th e r e is m e c h a n ic a l p r e s s u re o n n e r v e r o o ts o r s p in a l c o r d b y d is p la c e m e n t o f t h e d isc , t h e r e d u c tio n o f siz e is u n im p o r ta n t. T r e a t m e n t o f t h e p a t i e n t a s a p e r s o n a lity c o m b in e d w ith t r e a t m e n t o f trig g e r p o in ts in t h e b a c k w ill o fte n p r o d u c e re g re ssio n o f s y m p to m s a n d g r a d u a l r e h a b ilita tio n . I n g e n e r a l, t h e s u p p o r t o f a c o r s e t o r sim ila r a p p lia n c e w ith o u t p o sitiv e f o r m s o f th e r a p y c a n b e in e ffe c tu a l a n d e x tre m e ly u n c o m f o r ta b le in a h o t c lim a te . U PPER LIM B T h e p a in f u l s h o u ld e r, a c o m m o n f e a tu r e o f r h e u m a to id a r t h r i t i s , is e v e n m o r e c o m m o n a s a n e x p re s s io n o f n o n - R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 P H Y S I O T H E R A P Y M ARCH, 1975 a r t i c u l a r r h e u m a tis m . A s a j o i n t , t h e r a n g e o f m o v e m e n t is g r e a te r t h a n in a n y o t h e r in t h e b o d y a n d th e v a rie ty o f d is tu r b a n c e s e q u a lly g r e a t. G e n e r a lly th e r e is p a in c o m b in e d w ith a d e g re e o f im p a ir e d m o v e m e n t o r a c tio n . M o s t c o m m o n ly th e s y m p to m s a r is e f r o m t h e p e r i a r tic u la r s t r u c tu r e s a n d th e r e a r e f o u r m a in s y n d r o m e s : (1) S u b a c r o m ia l b u r s itis , a s s o c ia te d o c c a s io n a lly w ith c a lc a r e o u s te n d in itis . (2) A d h e s iv e c a p s u litis . (3) B ic ip ita l te n o s y n o v itis . (4) M u s c u lo - te n d in o u s c u f f lesio n s. S u b a c r o m ia l b u rs itis m a y p r e s e n t d r a m a tic a lly w ith se v e re p a i n w h e n ca lc ific d e p o s its r u p t u r e , b u t m o r e c o m m o n ly p r o d u c e s a c o n s t a n t a c h e a s s o c ia te d w ith a p a in fu l a r c . P a in o n a b d u c t i o n , m a y b e lo c a lis e d a t t h e tip o f th e s h o u ld e r b y p r e s s u re o n t h e s u p r a s p i n a t u s te n d o n . T h e p e r s is te n t p a in o f “ te n n is e lb o w ” w ith its c h a r a c te r is tic p o i n t o f te n d e r n e s s n e a r th e r a d ia l h e a d is e x tre m e ly c o m m o n . T h e m o d e r n c o n c e p t o f t h e “ e n th e s is ” , t h e ju n c t i o n a l p o in t o f m u sc le o r t e n d o n a n d b o n e , w h e re th e r e a r e m a n y n e rv e e n d in g s , h a s o ffe re d a c le a r e r p ic tu r e o f th is a n d s im ila r c o n ­ d itio n s . T h e m e d ic a l s y n d r o m e o f “ g o lf e r ’s e lb o w ” is less c o m m o n , b u t e q u a lly p e r s is te n t. T h e c a r p a l t u n n e l s y n d r o m e se e n ty p ic a lly in m id d le -a g e d w o m e n is a c o m m o n c a u s e o f p a in , o f te n se v e re a n d w o rs e a t n ig h t. T h e p a in m a y r a d i a t e in to t h e w h o le a r m f r o m th e h a n d . N e u r o lo g ic a l sig n s a r e in f r e q u e n t a n d if p r e s e n t re la te t o t h e m e d ia n n e rv e . D e Q u e r v a i n ’s d ise a se o r te n o s y n o v itis o f th e lo n g e x te n s o r o f th u m b p r o d u c e s p a i n in th e w ris t a n d f o r e a r m a n d th e r e m a y b e v isib le s w e llin g . R e s is ta n c e t o e x te n s io n o f th e t h u m b r e p ro d u c e s t h e p a in . I n b o th s y n ­ d r o m e s — c a r p a l t u n n e l a n d D e Q u e r v a i n ’s — t h e p o s s i­ b ility o f u n d e r ly in g r h e u m a t o i d a r t h r i t i s s h o u ld b e c o n ­ sid e re d . LO W ER LIM B M o s t c a u s e s o f s o ft tiss u e r h e u m a tis m in t h e lo w e r lim b a r e a s s o c ia te d w ith c o n d itio n s in th e lu m b a r s p in e a n d s a c r o ­ ilia c j o i n t s . R e fe r r e d p a i n m a y m is le a d in g ly su g g e st k n e e o r h ip - jo in t d ise a se . B u r s itis r e la te d t o t h e isc h ia l tu b e r o s itie s a n d g r e a te r t r o c h a n t e r o f t h e fe m u r, m a y p r o d u c e p a i n lo cally . S tra in s o f lig a m e n ts a t t h e k n e e j o i n t c o m m o n ly p r o d u c e p a i n a n d o b e s ity is a f a c t o r in m a n y o f th e s e p a tie n ts . T h e re is o n e p r o b le m in t h e o b e s e w h ic h c a n b e e x tre m e ly d iffic u lt t o h a n d le — th e p a n n ic u litie s o f m e d ic a l f a t p a d s . P a in in t h e leg s o n w a lk in g m a y a p p e a r t o b e r h e u m a tic w h e n th e r e a l c a u s e is isc h a e m ic d ise a se , a n d a b s e n t o r i n a d e q u a t e p u lse s w ill c la rify th e p ic tu re . T h e p a in f u l f o o t m a y b e a s s o c ia te d w ith ■ p o o r m u sc le s, p o s tu r a l f a u lts a n d b a d f o o tw e a r , sin g ly o r in' a s s o c ia tio n . M e ta ta r s a lg ia is c o m m o n in la t e r life : it is d u e t o f la tte n in g o f th e e x te r io r a r c h w ith p a in f u l c a llo s itie s b e n e a th th e h e a d s o f th e 2 n d a n d 3 rd m e ta ta r s a ls . H a llu x v a lg u s is a ls o p r e s e n t in m o s t cases. P a in in t h e heel c a n b e r e m a r k a b ly d isa b lin g . P la n t a r f a s c iitis is t h e u s u a l c a u s e a n d m a y b e a s s o c ia te d w ith r h e u m a t o i d a r t h r i t i s , a n k y lo s in g s p o n d y litis o r R e it e r ’s d is­ e a s e . M o s t c o m m o n ly h o w e v e r it is a lo c a l c o n d itio n p r o b a b ly d u e to lo n g - te rm t r a u m a . T h e p l a n t a r s p u r o n t h e c a lc a n e o u s is f r e q u e n tly f o u n d b u t su r g ic a l r e m o v a l is ra re ly n e c e s s a ry . I n S o u th A fric a , th e h ig h in c id e n c e o f h y p e r u ric a e m ia as a r e s u lt o f m e ta b o lic a n o m a lie s in c re a s e s t h e lik e lih o o d o f r h e u m a tic r e a c tio n p r e s u m a b ly b e c a u s e o f th e a d d e d i r r i t a ­ ti o n o f u r ic a c id c r y s ta ls o r u r a te s lu d g e t o t h e p r o v o c a tiv e stre s s. I t is i m p o r t a n t t o e s ta b lis h th is b e f o re p h y s io th e r a p y h a s b e e n in itia te d , a s t h e r e s p o n s e to s u c h th e r a p y is c o m m o n ly p o o r . M A N A G E M E N T O F N O N -A R TIC U LA R R H E U M A T ISM T h e m a n a g e m e n t d e p e n d s c r itic a lly o n a d e q u a t e r e ­ a s s u r a n c e c o m b in e d w ith p h y s ic a l t r e a t m e n t d e p e n d in g o n t h e c o n d itio n . T h e lo c a l in s tilla tio n o f lo c a l a n a e s th e tic c o m b in e d w ith a s te ro id is t h e m o s t e ffe c tiv e s h o r t- te r m m e a s u re . P h y s io ­ th e r a p y is e x tr e m e ly i m p o r t a n t b u t th e b u r d e n c a r r ie d by d e p a r t m e n t s w o u ld b e tr e m e n d o u s ly lig h te n e d b y g r e a te r use b y d o c to r s o f th e d ire c t a p p r o a c h m e n tio n e d . T h e u se o f a n a lg e s ic s is a d v is a b le b u t th e s tr o n g e r a n ti- in f la m m a to r y a n a lg e s ic d r u g s s h o u ld b e a v o id e d in v iew o f th e i r p o ss ib ly s e rio u s sid e effe cts. I n a te n s e , w r o u g h t- u p p e r s o n , th e u se o f a m u sc le r e la x a n t — D ia z e p a m o r C h l o r d ia z e p o x id e — m a y b e a s e ffe c tiv e a s a n a n a lg e s ic a n d m o r e c o m f o rtin g . T h e in c id e n c e o f n o n - a r t i c u l a r r h e u m a t i s m w ill re m a in h ig h , b u t t h e d is a b ility w h ic h is a s s o c ia te d w ith it c o u ld be r e d u c e d b y g r e a te r a w a re n e s s o f th e p r o v o c a tiv e f a c to r s a n d b y t h e u se o f p h y sic a l m e th o d s in a d d itio n t o d r u g th e ra p y . Non - A rticular Rheum atism The place of Physiotherapy by S . H . M . BLACKW OO D M .C .S .P . Dip T.P. N o n - a r t i c u l a r r h e u m a tis m is a c o n v e n ie n t te r m f o r all th o s e a c h e s a n d p a in s w h ic h c a n n o t b e p la c e d in a specific c a te g o r y , a n d y e t a p re c ise d ia g n o s is is e s s e n tia l f o r th e ir s a tis f a c to ry m a n a g e m e n t. F o r t u n a te ly th is r e s p o n s ib ility d o e s n o t r e s t w ith th e p h y s io th e r a p is t, a n d t h e p u r p o s e o f th is p a p e r is t o d isc u s s th e r o l e o f P h y s io th e r a p y a n d its a p p lic a tio n in th e t r e a tm e n t o f n o n - a r tic u la r d is o r d e r s . T h e m o s t lo g ic a l w a y t o c o n s id e r th e s e is o n to p o - g r a p h ic a l b asis b e c a u s e th is is th e w a y in w h ic h p a tie n ts p r e s e n t e.g . “ 1 h a v e a p a i n in m y s h o u l d e r .” S y m p to m s m a y b e o f lo c a l o rig in , r e fe rr e d f r o m a m o r e c e n tr a l site , o r m a n if e s ta tio n s o f a g e n e ra lis e d c o n n e c tiv e tis s u e d is o r d e r . W h a te v e r th e o rig in p a in a rise s f r o m a le s io n , th e r e fo r e tr e a t m e n t s h o u ld re a c h th e le s io n a n d s h o u ld e x e r t a b e n e fic ia l e ffe c t o n th e lesio n . P a tie n ts a r e in d iv id u a ls , th e r e fo r e t r e a t m e n t ' w h ic h is b e n e fic ia l to o n e m a y a c h ie v e n o th in g in a n o t h e r o r e v e n m a k e s y m p to m s w o rse in a th ir d . O f te n a c o m b in a tio n o f te c h n iq u e s p ro v e s th e m o s t b e n e fic ia l. N o n - a r t i c u l a r m e a n s all s o f t tiss u e s t r u c tu r e s in t h e b o d y i.e. m u sc le s, te n d o n s , lig a m e n ts , b u r s a e , c o n n e c tiv e tissp^- T h e first tr e a t m e n t is o f g r e a t i m p o rta n c e . O n th is o c c a s f '< ■: r a p p o r t m u s t b e e s ta b lis h e d b e tw e e n p a t i e n t a n d p h y s ic ^ t h e r a p is t, tim e m u s t b e g iv e n to t a k i n g a g o o d h is to r y a n d g iv in g a th o r o u g h e x a m in a tio n a n d in itia l a s s e s s m e n t o n w h ic h t r e a t m e n t m a y b e b a s e d . T h is c a n n o t b e r u s h e d , it is f re q u e n tly t h e firs t tr e a t m e n t w h ic h is th e c r u c ia l f a c t o r in t h e o u tc o m e o f t h e p a tie n ts p r o g re s s. TH E S H O U L D E R I n th e n o r m a l p ro c e s s o f a g e in g t h e m a j o r i m p a c t u su a lly fa lls o n t h e s t r u c t u r e o f w h ic h s u s ta in s t h e g r e a te s t s tre s s. I n th e c a s e o f t h e s h o u ld e r th is is t h e r o t a t o r cu ff. P a i n is o fte n re fe rr e d to th e o u t e r a s p e c t o f t h e u p p e r a r m a n d t r e a tm e n t s h o u ld b e d ir e c te d to t h e w h o le s h o u ld e r a r e a . S h o r t W a v e D ia th e r m y a n d I n f r a R e d R a y s a r e u se fu l a n a lg e s ic s a n d c a n b e a p p lie d w ith a n y te c h n iq u e t h a t t h e p h y s io th e r a p is t fin d s g iv e s th e p a t i e n t m o s t c o m f o r t. I n s o m e ca s e s h e a t in a n y fo rm m a y a g g r a v a te s y m p to m s a s m a y a ls o th e a p p lic a tio n o f ic e — e i th e r m a y b e f o u n d t o b e b e n e fic ia l. U l t r a - S o u n d , e s p e c ia lly p u lse d U l tr a - S o u n d se e m s to h e lp , p o ss ib ly b y r e d u c in g r e s id u a l in f la m m a to r y e x u d a te . I t is p r o b a b l e t h a t th e m o s t effe ctiv e p a r t o f a n y t r e a t m e n t is t h a t in v o lv in g t h e p h y s io ­ th e r a p i s t ’s h a n d s b y th e u se o f m a s s a g e o r t h e m o b ilis in g a n d m a n ip u la tiv e te c h n iq u e s . B ic ip ita l te n d in itis f o r e x a m p le R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) re s p o n d s v e ry w ell t o d e e p fric tio n s o v e r t h e site o f p a in , n ia in ta in e d f o r a s lo n g a s t h e p a t i e n t is a b le t o to le r a te it, a n d t o a c c e s s o ry m o b ilis a tio n s o f t h e s h o u ld e r j o in t. R a n g e o f m o v e m e n t s h o u ld b e m a in ta in e d , b u t n o t in c r e a s e d , b y th e p r a c tic e o f e x e rc ise b y t h e p a tie n t. T h e s e s h o u ld b e c o n tr o lle d is o m e tr ic e x e rc ise s in t h e firs t in s ta n c e , c a re fu lly p ro g re s sin g o v e r a lo n g p e r io d . V ig o r o u s u n g u a r d e d e x e rc ise s p e rfo rm e d t o o e a rly m a y p r o v e r e tro g r e s s iv e a n d n e c e s s ita te a p e rio d o f c o m p le te re st f o r t h e jo i n t . G r e a t p a tie n c e m u s t be o b s e rv e d by b o t h p h y s io th e r a p is t a n d p a tie n t in th e m a n a g e m e n t o f a n y d is o r d e r in t h e r e g io n o f t h e s h o u ld e r jo in t. C a p s u litis o f t h e s h o u ld e r, t h e t r u e “ f ro z e n s h o u l d e r ” h as a n a t u r a l h is to r y o f its o w n , t h e d u r a t i o n o f w h ic h c a n n o t be fo re c a s t w ith c e r ta in ty a n d t r e a t m e n t is s y m p to m a tic a n d p a llia tiv e . A n y le s io n in t h e r e g io n o f t h e s h o u ld e r m a y p ro d u c e s y m p to m s in t h e n e c k a n d it is a d v is a b le t o in c lu d e th e c e rv ic a l s p in e in t h e t r e a t m e n t p r o g ra m m e . THE ELBOW T h e m o s t c o m m o n le s io n a t t h e e lb o w is a te n d in itis e ith e r t h e o r ig in o f th e e x te n s o r m u sc le s o f t h e f o r e a r m a t th e ' t e r a I e p ic o n d y le o f t h e h u m e r u s o r t h e o r ig in o f t h e fle x o r l y o u p f ro m th e m e d ia l e p ic o n d y le — “ t e n n i s ” a n d “ g o lf e rs ” e lb o w re sp e c tiv e ly . I n th e a c u t e p h a s e s o m e f o r m o f h e a t a n d u ltr a s o u n d g iv e relief. D e e p fric tio n s a c r o s s t h e t e n d o n a ffo rd m a s s a g e a n a lg e s ia , a n d t h i n o u t s c a r tiss u e . M a n i p u la ­ tio n , if s k ilfu lly p e r fo r m e d , m a y g iv e g o o d re su lts . M o r e th a n 4 -6 tr e a t m e n t s s h o u ld n o t b e g iv e n . I f s y m p to m s h a v e n o t r e s p o n d e d in th is tim e t h e p a t i e n t s h o u ld b e re fe rre d b ack t o t h e s p e c ia lis t fo r h y d r o c o r tis o n e in je c tio n . T h e r e is m o re t h a n o n e ty p e o f b o th te n n is a n d g o lfe rs e lb o w a n d a n a c c u r a te d ia g n o s is is e s s e n tia l f o r g o o d re su lts . O p e r a tio n m ay b e re q u ire d . THE W RIST A N D H A N D T e n o s y n o v itis is m o s t c o m m o n ly a s s o c ia te d w ith a n u n d e rly in g c o n d itio n su c h a s r h e u m a t o i d d is e a s e b u t m a y o c c u r s p o n ta n e o u s ly d u e t o o v e ru s e . D e e p tr a n s v e r s e fric tio n s , ro llin g t h e te n d o n s h e a th to - a n d - f r o o v e r th e te n d o n se rv e s t o s m o o th t h e g lid in g s u rfa c e s a n d c a n h a v e d r a m a tic re su lts . U ltr a - S o u n d m a y r e d u c e th ic k e n in g in th e te n d o n s h e a th a n d S h o r t W a v e D ia th e r m y is a g o o d a n a lg e sic . C a r p a l t u n n e l s y n d r o m e in its e a r lie s t sta g e s w h e n sw e llin g m ig h t se em t o be r e v e rs ib le m a y r e s p o n d v ery w ell t o t r e a t ­ m e n t w ith U l t r a - S o u n d a n d S h o rtw a v e D ia th e r m y . W h e re th e re is n o r e a s o n a b le c h a n c e o f r e s o lu tio n , s u rg ic a l d e ­ c o m p re s s io n is in d ic a te d a n d p h y s io th e r a p y is d ir e c te d p o s t- o p e ra tiv e ly to r e g a in in g fu ll f u n c tio n o f t h e h a n d . f ^HE LO W ER LIM B P a tie n ts m a y p r e s e n t w ith p a in in h ip , k n e e o r f o o t, a n d n o t o n ly in te n d in o u s a r e a s in r e la tio n t o t h e j o i n t s b u t a ls o in t h e b u lk o f s t r o n g m u sc le s su c h a s G a s tr o c n e m iu s , H a m s trin g s , o f Q u a d r ic e p s . P a i n o f r h e u m a t i c o rig in se em s o n t h e w h o le t o r e s p o n d b e s t t o s o m e f o r m o f h e a t. D e e p f ric tio n s a c r o s s te n d o n o r lig a m e n t o r t h e fib re s o f m u sc le belly se e m t o m o b ilis e a n d fre e a d h e s io n s . I n v e ry t e n d e r a re a s U l t r a - S o u n d b rin g s re lie f. M o b ilis in g a n d m a n ip u la tiv e te c h n iq u e s p e r fo r m e d o n t h e k n e e o r t h e f o r e f o o t m a y giv e d r a m a tic r e lie f in a fe w m o m e n ts . M a n u a l s t r e tc h in g o f so ft s tr u c tu r e s relie v e s t e n s io n in c o n n e c tiv e tiss u e . THE BACK A N D NECK E a c h fo rm s a v a s t s u b je c t o n its o w n a n d c a n n o t b e d e a lt w ith in d e ta il h e re . E x tre m e ly c a r e f u l in itia l e x a m in a tio n a n d a s s e s sm e n t o f t h e p a t i e n t a s a w h o le is a n e c e s sity . R a d io ­ g ra p h s s h o u ld b e a s k e d f o r a n d s c ru tin is e d b e f o re tr e a t m e n t o f a n y d r a s tic n a t u r e is g iv e n . U n t o l d d a m a g e m a y b e c a u s e d b y ill-a d v is e d t r a c t i o n o r c lu m sy m a n i p u la tio n s . W h e re tr a c tio n is c o n c e r n e d , e s p e c ia lly o f t h e n e c k , it is a d v is a b le t o feel t h e w a y b y a p p ly in g n o r m a l t r a c t i o n in t h e first in s ta n c e , s o a s t o a s se s s t h e r e a c tio n o f t h e p a t i e n t a n d th e IVIAART 1975 9 t e n s io n o f m u sc le s a n d lig a m e n ts . S o o th in g e ffle u ra g e a n d firm k n e a d in g h e lp b o th in g e n e ra l r e la x a tio n o f t h e p a t i e n t a n d in t h e lo c a lise d a r e a s b e in g tr e a t e d . G r a d e d m o b ilis in g te c h n iq u e s re le a se te n s io n s in lig a m e n ts a n d c o n n e c tiv e tis s u e a n d d e e p f ric tio n s “ ir o n o u t ” n o d u le s in m u s c le . O n c e a d e g re e o f r e la x a tio n h a s b e e n a c h ie v e d d is c re e t m a n ip u la ­ tio n s m a y b e p e r fo r m e d . A n y p a in o r b ru is in g in flic te d by th e s e m o v e m e n ts m a y be re lie v e d b y t h e u se o f U l t r a - S o u n d , so m e f o r m o f h e a t o f ice. I t is a d v is a b le t o g iv e t r a c t i o n w h ile t h e r e is still t e n s io n in t h e m u sc le s so t h a t th e ir p r o ­ te c tiv e f u n c tio n is p r e s e n t. S tre tc h in g in its e lf w ill p r o d u c e r e la x a tio n . I n c o n c lu s io n it m u s t b e m e n tio n e d t h a t in d e a lin g w ith , t h e p a t i e n t su ffe rin g f ro m n o n - a r t i c u l a r d is o r d e r s a n u m b e r o f r e la te d c o n t r i b u to r y f a c to r s s h o u ld b e t a k e n in to c o n ­ s id e r a tio n . F o r e x a m p le p e r s o n a l r e la tio n s h ip s a n d p o s s ib le d is s a tis f a c tio n a t w o r k ; m e c h a n ic a l stre s s s u c h a s re p e titiv e f a c to ry w o r k w h ic h p u ts c o n s t a n t s tr a in o n o n e j o i n t o r lim b ; p o s tu r a l stre s s s u c h a s t h e in c o r r e c t h e ig h t o f a ty p is ts c h a ir in r e la tio n t o t h e ty p e w r ite r ; p s y c h o lo g ic a l a n d e m o tio n a l stre s se s su c h a s a fe e lin g o f in a d e q u a c y a t w o r k o r in s e c u rity a t h o m e . A d v ic e c a n b e g iv e n o n t h e o v e r ­ c o m in g o f so m e o f th e s e s tre s s e d , e s p e c ia lly t h e m e c h a n ic a l o n e s . M a n y o f th e s e p a tie n ts a r e in s e d e n ta ry o r r e p e titiv e o c c u p a tio n s a n d s h o u ld b e e n c o u r a g e d t o p a r tic ip a te in s o m e f o rm o f s p o r t ; t a k e p a r t in g r o u p e x c e rc is e s, s u c h a s y o g a ; o r sim p ly t o t a k e r e g u la r e x e rc ise a t h o m e in t h e f o r m o f r u n n i n g sp e cific e x e rc ise s a im e d a t t h e d i s o r d e r , o r r e ­ c r e a tio n a l a c tiv ity su c h a s g a r d e n in g . SU M M A R Y A lm o s t a n y f o r m o f p a llia tiv e t r e a t m e n t m a y b e u s e d by t h e p h y s io th e r a p is t t o i n d u c e a s t a te o f r e la x a t i o n in t h e p a t i e n t a n d in t h e p a r t t o b e tr e a t e d . T h is s e e m s t o b e a m a t t e r o f in d iv id u a l c h o ic e d e p e n d e n t o n th e p h y s i o t h e r a p i s t ’s e x p e rie n c e a n d t h e p a t i e n t ’s p re fe re n c e . T h e m o s t i m p o r t a n t p a r t o f a n y t r e a t m e n t is t h a t w h ic h r e a c h e s a n d h a s a b e n e fic ia l effe c t o n t h e le sio n . I t se e m s t h a t in a la rg e m a jo r ity o f c a s e s th is is t h e u se o f th e p h y s io th e r a p is t’s h a n d s in g iv in g a g o o d d e e p m a s sa g e , e s p e c ia lly lo c a lise d f ric tio n s in m o b ilis in g w ith a c c u r a te te c h n iq u e s a n d c a r e f u l g r a d in g ; a n d in c o n tr o lle d m a n ip u la ­ tio n s . To All Members S.A.S.P. Please rem em b er to send in y o u r com pleted Q uestionnaires Before March 31st 1975. F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )