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Demonstrating the Modified Schober Test 3

By Dr Irwin Lim, Rheumatologist

We see a lot of patients with inflammatory back pain in our clinics. Some of these patients have Spondyloarthritis or the prototype condition, Ankylosing Spondylitis.

Given our expertise in this area, we’ve decided to create a range of videos highlighting some of the examination techniques used to help make a diagnosis. You can find these on our Youtube channel.

Rachael Butterworth, our Spondyloarthritis physiotherapist demonstrates on our model, Errol while Dr Roberto Russo facilitates.

This video is an example, and highlights the Modified Schober Test, a test commonly used to help measure the lumbar spine flexibility (or lack of).

 

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

Arthritis requires an integrated approach. We call this, Connected Care.  Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

 

 

 

Posted on: 12-7-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Back & Neck, Physiotherapy

Dry Needling 2

Dry Needling

By Errol Lim, Physiotherapist

Dry needling has become more topical in recent years when talking physiotherapy treatment. Physios are always looking for new techniques and methods of treatment that can improve patient outcomes. The quicker we can get someone better, the better we feel, the better we “look” and more importantly, the better our PATIENTS feel. The problem for most people is the fear of the needle.

1. Is dry needling better than other physiotherapy techniques?

Dry needling is just one of a multitude of treatment options, our physiotherapists have in order to get desired outcomes with their patients. As a treatment modality, it is no better or no worse when compared to other modalities. It would only seem better if a patient has had numerous other types of physiotherapy treatment and it so happens that dry needling gave them the best result. Like many things in this world, there is no hard and fast rule about when to use dry needling as every patient is different. The art for a physiotherapist is then to know when dry needling can be most effective.

2. So, when does a physiotherapist decide to use dry needling?

Dry needling is most effective for patients who have sensitivity (or do not like) to other treatment modalities such as massage or trigger pressure therapy. These techniques can often cause pain upon a physiotherapist applying pressure to the patient’s skin/body. Hence, dry needling allows a physiotherapist to release tension or trigger points in muscles without the discomfort of finger/hand pressure. Typically, patients with conditions such as fibromyalgia or other arthritic conditions as well as patients with severe pain such as lower back disc and whiplash injuries may benefit.

In other patients, dry needling can have a better effect than massage as the needle is able to reach deeper fibres of a particular muscle group. The only way to know this is to have both treatments. The physio will then be able to make this decision with the patient. Many athletes tend to fall into this group as they are always looking for ways to recover quicker from training and competition.

Hope this post helps to alleviate some fears when it comes to deciding whether dry needling is a suitable treatment technique when performed by physiotherapists. If you still have some apprehension, let us know and hopefully we can help you through this decision making process.

Errol Lim is a physiotherapist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.


Posted on: 07-28-2011
Posted in: Physiotherapy

The Painful Thumb: Arthritis at the base 0

By Ray Jongs, Hand Physiotherapist

There are many causes of pain at the base of the thumb.

But commonly, the thumb starts to become painful because of wear and tear of some of the small joints – osteoarthritis.

Our thumbs are fascinating and unique because we can place our thumbs in such a way as to hold and manipulate things easily. Our thumbs move into this position of ‘opposition’ to other fingers through rotation at the base of the thumb, between a very small bone (the trapezium), and the longer bone (the metacarpal).

Unfortunately, wear and tear of the base of the thumb may involve more than this joint of opposition, and possibly involve a more extensive process that includes the wrist (midcarpal joint).

In this way, ‘no pain, no gain’ could lead to a hastening of the arthritis.

Education for joint ‘protection’ is essential in the management of arthritis to the base of the thumb.

A hand physiotherapist will be able to advise on the common and specific activities that cause or exacerbate pain at the base of the thumb in daily activities. Following the assessment of each of the joints at the base of the thumb, a hand physiotherapist can also manufacture a splint to be used in daily activities. The splints are generally limited to the thumb and hand, or may extend to include the wrist; the splints can be inconvenient, but their purpose is to restrict motion of an irritable joint temporarily, and it is hoped the inconvenience can be justified.

Hand physiotherapists will also issue exercises for the thumb. Targeted stretches for the thumb, and gently progressed strengthening are usually supervised to ensure that the thumb and hand return to an optimum level of function.

Essentially, hand physiotherapy offers a tailored program of joint protection, splinting and exercises for the thumb.

As the arthritis at the base of the thumb is also associated with arthritis of other small joints of the hand, the tailored program can easily incorporated these principles for the overall benefit of the patient, in conjunction with the medical management for the arthritis.

Ray Jongs is a hand physiotherapist. He works at Royal North Shore Hospital and at BJC Health. BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.


Posted on: 07-4-2011
Posted in: Physiotherapy

Real Stories…Real People, a positive chain of events for Ankylosing Spondylitis 1

By Irwin Lim, Rheumatologist

In November 2010, I pitched the concept of a seminar directed at physiotherapists.  The focus would be on Ankylosing Spondylitis & other inflammatory rheumatic disease such as Rheumatoid Arthritis. I pitched the concept for this seminar to the team at Abbott, a pharmaceutical company, as we needed a sponsor and organisational resources, given it would be hard for BJC Health and me alone to pull this idea off.

Thankfully, the team there were already thinking along similar lines & were very receptive to the idea. I must congratulate and thank the managerial team at Abbott for going out on a limb to support education & for helping patient advocacy.

AS You See It Seminars for Physiotherapists came into existence.

Why did we bother?

The training physiotherapists receive at both university and post-graduate levels on rheumatic disease is negligible.  This is a shame as these diseases are common. I’m sure physios (also known as physical therapists in the US) see these patients. Think of the patient with a persistent knee effusion or recurrent back pain or a recalcitrant achilles tendon issue or bilateral tennis elbow.

And if physiotherapists believed that they didn’t see these patients, my worry was that they were missing the diagnosis.

If you don’t have an understanding or knowledge of the symptoms or the signs, there’s a good chance you won’t be looking for it.

Rheumatologists are the primary physicians for these diseases, and sadly, my craft group has been poor so far in terms of educating physiotherapists.

This unfortunately meant that patients suffering from these common diseases sometimes receive ineffective and inappropriate treatment. Patients suffer. Pain, difficulty with simple daily activities, depression and in some cases, progressive damage and deformity result. This is a situation that must change especially as very effective treatment is now available.

The 1st seminar was held in Sydney on Sunday February 20th. Our BJC Health team presented along with other committed doctors & physiotherapists. There were more than 200 attendees. Gratifying.

This was the start of a chain of events.

Another seminar was organised, in Melbourne & Adelaide simultaneously on April 10th. Another 200+ attendees in Melbourne & 100+ in Adelaide.

Momentum. A need had been identified and clear interest was being shown.

The Australian Physiotherapy Association is now on board. They’ve even now set up a specific website to help promote World Ankylosing Spondylitis Day, May 7th.

Our 3rd seminar falls on this auspicious day. It will be held in Brisbane, with a concurrent seminar & some live feed to Hobart. At the same time, there will be a webcast of the event around Australia & internationally.

This is very exciting. A simple idea has grown and taken a life of its own.

Now, 3 patient advocates from North America, who use social networking to improve awareness of Ankylosing Spondylitis have come together to help this project.

Kelly Johnston started a facebook support group over 2 years ago called “ASAP: Ankylosing Spondylitis Awareness Project”. She also writes a very thoughtful blog, Hurting But Hopeful. Rick Pokerwinski is an administrator on the ASAP facebook page and the twitter account manager for the Hope and Apples project. Jennifer Visscher, who I’ve profiled previously as I’ve been captivated by her “Apples for AS” project,  produces a unique apple art piece every day & aims to do this for a whole year.

Together, we are making a difference.

A change in physiotherapist’s knowledge base, a change in attitudes to inflammatory rheumatic diseases, should & must lead to change in outcomes for patients as they get recognised and diagnosed earlier.

BJC Health wants to continue to advocate for our patients. But to be effective, we need to continue to form partnerships with others who care. Doctors & allied health professionals need to take a stand. Pharmaceutical companies can play a role. The support of Health Associations is crucial. Patient advocates can inspire.

I hope more of you will help grow this positive chain of events.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Posted on: 05-2-2011
Posted in: Ankylosing Spondylitis, Arthritis: inflammatory, Physiotherapy, Rheumatology, Social Media & Communication

Clumsy hands and funny bones: the cubital tunnel syndrome 0

Image:Ambro/FreeDigitalPhotos.net

by Ray Jongs, Hand Physiotherapist

Nerves are wonderful things.

They have predominantly two roles: supplying sensation to an area so we can feel things, and supplying impulses to the muscles for movement.

If you have ever woken up in the middle of the night with tingling in your fingers, it is probably due to one of two major nerves in the arm: the median nerve at the wrist (carpal tunnel syndrome) or the ulnar nerve at the elbow (cubital tunnel syndrome).

Most people have heard of carpal tunnel syndrome, but due recognition should be paid to cubital tunnel syndrome. When the ulnar nerve is affected, sensation is altered to the little and ring finger, and the little muscles of the hand may become weaker (together with the wrist and finger flexors on the little finger side of the forearm). Interestingly, the thumb may be slightly affected as well; strength in pinch may be reduced, and the thumb feels less stable or dexterous.

Generally, physiotherapy will be assessing the ulnar nerve as it courses from the upper arm to the hand via the elbow. It is this fascinating anatomical course which may elicit problems at the medial (inside) portion of the triceps muscle, bands or swelling at the medial epicondyle (funny bone), or the ulnar wrist flexor immediately past the funny bone.

If the nerve is conceptualised as a string, then bending the elbow will stretch this string over the funny bone and reproduce symptoms. So although physiotherapy may address some of the fascial tissues adjacent to the ulnar nerve, hand physiotherapists may also splint the elbow to prevent the stretch around the funny bone.

So in regards to splinting, is keeping the elbow absolutely straight the best option?

If the space around the nerve at the funny bone is of primary concern, it is probably best to keep the elbow as straight as comfortable. MRI of the cubital tunnel shows a nice round space when the elbow is straight, which changes to an oval shape at the elbow is flexed. The oval shape is probably due to the roof of the tunnel being stretched as the elbow bends, and as it stretches it will flatten the tunnel and compress the nerve.

However, if you were to put a needle that measures pressure in the cubital tunnel whilst flexing and straightening the elbow, the pressure within the tunnel is least with the elbow at about 45 degrees away from full extension. So the recommendations to trial a towel wrapped around the elbow overnight to see if the symptoms improve may be doing the patient a disservice.

The best way to maintain a particular position of the elbow is probably with a custom made splint, limiting the elbow to 45 degrees from full extension.

And if you were to splint in this fashion, should the wrist be included? We know that extending the wrist increases the strain on the ulnar nerve; so there is a reason for including the wrist. However, we also know that as the shoulder is abducted away from the body, the strain on the ulnar nerve also increases, and it would be a brave physiotherapist to recommend keeping the arm by the side as we sleep.

All things considered, it is probably best to assess the ulnar nerve with a tensioning manoeuvre to determine the effect of the position of other joints on the symptoms.

Occasionally the wrist should be included in a straight position (never flexed). The shoulder is never included in the positioning of the arm for cubital tunnel syndrome.

So, if someone is experiencing increasing clumsiness of the hands, has tingling in the little and ring fingers, or has a particularly sore funny bone, it may be due to a cubital tunnel syndrome.

Physiotherapy intervention will typically follow thorough assessment. But if splinting is warranted, the type and position of the splint should be considered in terms of what position the elbow and/or the wrist should be, and how it fits within a treatment program.

Ray Jongs is a hand physiotherapist. He works at Royal North Shore Hospital and at BJC Health BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.


Posted on: 04-25-2011
Posted in: Physiotherapy, Shoulder & Upper Limb
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