Gait Abnormalities

Introduction: Observation of gait is an important aspect of diagnosis that may provide information about several musculoskeletal and neurological conditions. In particular, there are eight basic pathological gaits that can be attributed to neurological conditions: hemiplegic, spastic diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar) and sensory.

Hemiplegic Gait

The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated. Leg on same side is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb. This is most commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight circumduction may be the only abnormalities.

Diplegic Gait

Patients have involvement on both sides with spasticity in lower extremities worse than upper extremities. The patient walks with an abnormally narrow base, dragging both legs and scraping the toes. This gait is seen in bilateral periventricular lesions, such as those seen in cerebral palsy. There is also characteristic extreme tightness of hip adductors which can cause legs to cross the midline referred to as a scissors gait. In countries with adequate medical care, patients with cerebral palsy may have hip adductor release surgery to minimize scissoring.

Neuropathic Gait (Steppage Gait, Equine Gait)

Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor. If unilateral, causes include peroneal nerve palsy and L5 radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies including those associated with uncontrolled diabetes.

Myopathic Gait (Waddling Gait)

Hip girdle muscles are responsible for keeping the pelvis level when walking. If you have weakness on one side, this will lead to a drop in the pelvis on the contralateral side of the pelvis while walking (Trendelenburg sign). With bilateral weakness, you will have dropping of the pelvis on both sides during walking leading to waddling. This gait is seen in patient with myopathies, such as muscular dystrophy.

Parkinsonian Gait

In this gait, the patient will have rigidity and bradykinesia. He or she will be stooped with the head and neck forward, with flexion at the knees. The whole upper extremity is also in flexion with the fingers usually extended. The patient walks with slow little steps known at marche a petits pas (walk of little steps). Patient may also have difficulty initiating steps. The patient may show an involuntary inclination to take accelerating steps, known as festination. This gait is seen in Parkinson's disease or any other condition causing parkinsonism, such as side effects from drugs.

Choreiform Gait (Hyperkinetic Gait)

This gait is seen with certain basal ganglia disorders including Sydenham's chorea, Huntington's Disease and other forms of chorea, athetosis or dystonia. The patient will display irregular, jerky, involuntary movements in all extremities. Walking may accentuate their baseline movement disorder.

Ataxic Gait (Cerebellar)

Most commonly seen in cerebellar disease, this gait is described as clumsy, staggering movements with a wide-based gait. While standing still, the patient's body may swagger back and forth and from side to side, known as titubation. Patients will not be able to walk from heel to toe or in a straight line. The gait of acute alcohol intoxication will resemble the gait of cerebellar disease. Patients with more truncal instability are more likely to have midline cerebellar disease at the vermis.

Sensory Gait

As our feet touch the ground, we receive propioreceptive information to tell us their location. The sensory ataxic gait occurs when there is loss of this propioreceptive input. In an effort to know when the feet land and their location, the patient will slam the foot hard onto the ground in order to sense it. A key to this gait involves its exacerbation when patients cannot see their feet (i.e. in the dark). This gait is also sometimes referred to as a stomping gait since patients may lift their legs very high to hit the ground hard. This gait can be seen in disorders of the dorsal columns (B12 deficiency or tabes dorsalis) or in diseases affecting the peripheral nerves (uncontrolled diabetes). In its severe form, this gait can cause an ataxia that resembles the cerebellar ataxic gait.

Hemiplegia

Gait in the Child With Hemiplegia

Gait refers to the controlled manner of walking or moving on foot.  The functioning of the nervous system and the musculoskeletal system determines the gait pattern. In children who have hemiplegia, this delicate system is out of balance and often results in different types of gait.

Gait in the Child with Hemiplegia

A child with hemiplegia may have a tendency to walk with the toes on the affected foot striking the ground first, instead of the usual heel strike. This “toe drop” often results in our kids taking quite a few falls and tumbles. In order to clear the toe while walking, the child may develop a variety of ways to compensate, which then result in problems with his hip and or knee.   Treatments may include gait analysis, physical therapy, orthotics, serial casting, botulinum toxin and surgery. The goal of treatment is not to “cure” the condition, but to enable the child to achieve her maximum potential.

De-Quervians Syndrome

De-Quervians Syndrome:

Who are risky?

1.    Middle age woman
2.    During pregnancy

Pathology:

1.    Thickening of tendon sheath.

C/F:

1.    Pain and swelling on styloid process of radious.
2.    Movement restricted.

Sign:

1.    Tenderness of styloid process.

Test:

1.    Finkelstrains test.

D/D:

1.    Arthritis at the base of the thumb.
2.    Scaphoid non-union.

Treatment:

1.    Rest
2.    NNSAID
3.    Steroid inj
4. Physiotherapy

Surgical Treatment:

1.    Division of the tendon sheath.

How Neck Pain Can Be Treated By Exercise

How Neck Pain Can Be Treated By Exercise:

Neck Pain

We have all experienced neck pain to some degree- it may be brought on from sitting at a computer the whole day, from playing sports or possibly from an accident. Neck pain is a relatively common complaint, affecting up to 70% of individuals at some point during their life. Approximately 40-50% of the population suffers neck pain in any one year. Our Chartered Physiotherapist Niamh Connolly discusses the problem and some measures by which to reduce the chance of the problem occurring.

It tends to be a persistent and recurrent disorder where approximately 60% of individuals can expect to get some degree of on-going pain following their first episode.

The aim of physiotherapy rehabilitation of neck pain is to prevent a first episode from turning into chronic (>3 months) or recurrent pain.

The Neuromuscular system is one of the main reasons why people get a re-occurrence of their neck pain. The neuromuscular system is composed of nerves and muscles, these allow for innervations and movement of the muscles in the body. When a person undergoes pain and injury the strategies to control movement, posture and stability are compromised.

If neuromuscular function is altered this can cause:

·         Delayed activation of neck muscle

·         Changes in muscle size

·         Changes in muscle composition

·         Impaired postural endurance

·         Altered muscle activation movement

All of which can lead to neck pain:

Some examples of this type of altered function would be:

A reduced ability to maintain upright posture during a computer task, this reflects a low level of endurance in the muscles required to control the postural function of the spine, and over time if this is a repetitive position eg office / desk related job this may lead to neck/ shoulder pain.

How Is Neck Pain Treated?

The key principles in treating neck pain involve

·         Selectivity and specificity of exercise

·         Early rehabilitation

·         Pain-free rehabilitation

·         Rehabilitation for prevention of reoccurrence

How Can Exercises Help?

Exercise has been shown to improve neuromuscular impairments in people with neck pain however the type of exercise selected should be based on careful and precise physiotherapy assessment of these neuromuscular changes and therefore be specific to the impairments of the presenting patient.

This type of exercise usually commences early in the rehabilitation process and is used in combination with ‘hands on’/manual therapy if required; these exercises do not provoke pain and are designed to address the specific changes that have been identified via assessment in the muscle and neuromuscular system.

Exercises Used

The types of exercises used

·         target and activate the deep cervical muscles

·         retraining the endurance capacity of deep neck muscles

·         retrain the patterns of activation of the deep and superficial neck muscles

·         re-educate the use of muscles in posture and in functional tasks

·         address the strength and endurance  for functional requirements

Education and explanation regarding the rationale behind the treatment approach are a large component of this physiotherapy treatment as the patient’s compliance and contribution to the exercise program is critical.

Treating Lower Back Pain through the McKenzie Method:

Treating Lower Back Pain through the McKenzie Method:

We often discuss our physiotherapy treatments in our blog posts but do not always go into detail about the techniques and methods which are used by our physiotherapists. So today Mark Dockery of our Navan Road clinic in Dublin highlights how lower back pain is treated through the McKenzie method.

So What Is The McKenzie Method?

The McKenzie Method is a system of exercises used to elucidate the type of spinal issue a patient has and how best to treat it. It is commonly used worldwide in the diagnosis and treatment of low back pain, neck pain and peripheral joint complaints.

The method was created by New Zealand-based Physiotherapist Robin McKenzie (who passed away in May) in the early 1960s and is still in use today. The McKenzie Method is best applied with the aid of a Physiotherapist trained in the Method, who can diagnosis your particular problem and teach you the appropriate exercises to use at home.

The McKenzie Method implements primarily self-treatment strategies, and minimises manual therapy procedures, with the McKenzie-trained therapist supporting the patient with passive procedures only if an individual self-treatment programme is not fully effective. McKenzie himself states that self-treatment is the best way to achieve a lasting improvement of any type of back pain .

The 3 Focus Points Of The McKenzie Method

There are three main areas addressed by the McKenzie method for back and neck pain. They are posture, dysfunction and derangement . 

- Posture: End-range stress of normal structures.
- Dysfunction: End-range stress of shortened structures (i.e. scar tissue; fibrosis; nerve root adherence).
- Derangement: Anatomical disruption or displacement within the motion segment.

(The three mechanical syndromes – posture, dysfunction, and derangement – occur in all areas of the vertebral column, from the neck to the base of the back).

So What Might A Physiotherapist Advise?

Each distinct syndrome is addressed according to its unique nature, with mechanical procedures utilizing specific movement and positions. Examples of exercises prescribed by a Physiotherapist for a home-based programme might include:

- Lying prone (on your front). [McKenzie method treatment]
- Prone back extension (arching your back whilst lying on your front).
- Rotation mobilisation in extension (whilst lying prone).
- Standing posture exercises (importantly extension of the spinal column).
- Standing toe-touch.
- Pelvic side-shift movements (lateral tilt).

The McKenzie method encourages education and patient involvement, in managing their own treatment plans. This helps to reduce pain and restore normal function. This also may reduce the number of visits to the clinic. Overall most patients are able to treat themselves successfully when they are provided with the necessary information by their physiotherapist. Customised self treatment programmes will be provided by our physiotherapists should they deem this the correct method of treatment for you.

Self-Care for Tonsillitis:

Self-Care for Tonsillitis: 

Drink warm or cold fluids

Eat soft, bland foods

Gargle with warm, salty water (adolescents and adults)

Use acetaminophen or ibuprofen for pain relief and fever reduction

Use throat lozenges or eat hard candy (not recommended for young children)

Get plenty of rest

Drink plenty of fluids to prevent dehydration.

Your doctor is the best source of information on the drug treatment choices available to you.

Surgery to remove the tonsils, known as tonsillectomy, is performed infrequently, and mainly in cases where a patient has repeated, severe episodes of tonsillitis, or if bacterial tonsillitis does not respond to antibiotics. Having one's tonsils removed was once a childhood rite of passage. Today, however, tonsillectomies are rarely done because effective new drugs are now available for treating bacterial tonsillitis. In addition, doctors have developed a better understanding of the role of tonsils in the body's immune system, and no longer believe they should be routinely removed if they become infected.

A tonsillectomy may be recommended for an individual with chronic tonsillitis. A tonsillectomy may be necessary if you experience frequent episodes of tonsillitis within a year (five to seven episodes is usually the benchmark), or have five episodes a year for two straight years.

The tonsils may also be removed if they are large and are blocking the throat. Tonsils that are too large can cause breathing problems for children or adults, and a tonsillectomy is sometimes recommended to relieve this problem. Enlarged tonsils also may be removed if they seem to be causing a problem known as obstructive sleep apnea, which is a condition wherein breathing is blocked during sleep when the airway pulls shut. It can occur in children as well as in adults.

If tonsillitis is not effectively treated, it may lead to a condition called peritonsillar abscess, and require a tonsillectomy. A peritonsillar abscess is a collection of pus or infected material around the tonsils. It can occur when one or both of the tonsils become infected, and pus spreads from the tonsils to surrounding tissues. The condition can develop when antibiotics fail to cure an otherwise ordinary case of tonsillitis, or when tonsillitis improves, and then gets worse. Peritonsillar abscess may spread to the roof of the mouth, the neck, and the chest. The airway could then become obstructed, a situation requiring emergency treatment, which may include removing the tonsils. Peritonsillar abscess is infrequent, and is more common in adolescents and young adults than in children.

A tonsillectomy can be performed in the hospital or at an outpatient surgical facility. A tonsillectomy is usually done by an ear, nose, and throat specialist, or a general surgeon, often as same-day surgery. After administration of general anesthesia, the patient's mouth is held open to expose the tonsils. The tonsils are then grasped with clamps, pulled forward, cut free of surrounding tissue, and removed. The doctor will seal the blood vessels to stop the bleeding. The doctor may also remove another set of tonsillar tissues, called the adenoids, from the back of the upper part of the throat. The combined procedure is referred to as tonsillectomy and adenoidectomy.

In most cases, patients can go home several hours after surgery, although very young children (age three or under) or those with other medical problems typically require an overnight stay. The most common complication is bleeding, which may occur immediately after surgery or several days later. If bleeding occurs while you are at the hospital or outpatient center, you will be taken to the operating room for additional care. If minor bleeding occurs at home, try rinsing your mouth with ice water. Call the doctor or go to the emergency room if bleeding becomes excessive.

Side effects such as a sore throat, fever, nasal congestion, earaches, and moderate pain are likely for several days after a tonsillectomy. Consume easily swallowed foods and liquids such as custard, gelatin, pudding, ice cream, popsicles, and iced drinks for about a week after surgery. Gradually introduce more solid foods, but avoid crispy or sharp-edged foods such as bacon, toast, or chips until the throat is fully healed. Drink plenty of liquids to prevent dehydration, but do not serve citrus juices or acidic fruits that can cause irritation. Your doctor may prescribe antibiotics to prevent infection. For pain relief, the doctor may suggest acetaminophen or prescribe a pain medication. Do not use ibuprofen or aspirin, as they can increase the risk of bleeding.

A full recovery takes about two weeks. Children should rest in bed for several days, and gradually resume a normal schedule. During the recovery period, the pain may fluctuate. Contact your doctor if pain and other symptoms do not improve.

If eating is painful, you may experience weight loss. If your throat hurts, use the pain medication recommended by your doctor, and consume only easily swallowed foods. Any weight lost during the recovery period will usually be regained quickly once a normal diet is resumed.

Acupuncture may be used to treat tonsillitis pain. Acupuncture treatment may provide relief from the pain of tonsillitis, according to The World Health Organization, and may be one option to consider if conventional forms of treatment have not been successful. Many doctors can make referrals to certified acupuncturists, or identify organizations that can provide information and referrals. Although acupuncture is widely used in many parts of the world to treat a range of health problems, including tonsillitis, it is not known how widely acupuncture is used in the United States. Consult your doctor if you are considering acupuncture therapy to relieve the pain of tonsillitis.

With proper medication and self-care, most cases of tonsillitis will resolve within a week or two. Tonsillitis generally is cured within a week or two, particularly with plenty of rest and fluids. Chances of a full recovery are also increased when the full, 10-day course of antibiotics prescribed for bacterial tonsillitis is taken as directed. If bacterial tonsillitis is not treated, or if it is undertreated because all medication was not taken, there is an increased risk of rheumatic fever or kidney disease.

It probably will not be necessary to see a doctor for a follow-up visit unless complications develop, or if you or your child have had a tonsillectomy. If you or your child had a tonsillectomy, your doctor may want to follow up in a few weeks to make sure that healing has progressed. Since most cases of tonsillitis resolve on their own, however, you probably will not need to follow up with your doctor if you didn't have surgery. Call the doctor's office if your or your child's symptoms do not improve after a few days, or if the symptoms become worse.

Treatment for Tonsillitis:

Treatment for Tonsillitis:

While most cases of tonsillitis can be treated at home or by a primary care physician, emergency care may be needed in severe cases. Go to the emergency room if you or your child have extreme difficulty swallowing (i.e., can’t swallow saliva), have difficulty breathing, or feel very sick. Intravenous fluids may be necessary for children who have become dehydrated because of their inability to swallow fluids.

Contact your doctor any time you or your child have a sore throat or other symptoms of tonsillitis that cause more than minor problems such as mild fever or headache. Call your doctor if pain relievers have not improved your fever, or if a sore throat is preventing you or your child from drinking an adequate amount of fluid. You should also call your doctor if other symptoms have not improved in 24 hours. In most cases, the doctor will recommend an office visit or self-care.

Most cases of tonsillitis improve within a few days. However, you can hasten recovery by resting and modifying your diet to avoid irritating your throat. Because a sore throat makes some foods hard to swallow, drink plenty of liquids, and eat soft, bland foods including soup, ice cream, and popsicles. Either warm (but not hot) fluids—such as tea with honey or hot chocolate—or very cold fluids such as milkshakes can help soothe the throat. Soft drinks such as ginger ale are also acceptable, but avoid orange juice, lemonade, or other acidic drinks that could irritate the throat. Older children and adults can gargle every few hours with warm, salty water (use 1/4 teaspoon of salt in 4 oz of water). You can also use a cool-mist humidifier to increase the amount of moisture in the air.

You should stay in bed or pursue quiet activities as long as you are feeling unwell so that your body will have time to heal. Viral tonsillitis may last as little as 24 hours, and most people recover within a week.

Cases of bacterial tonsillitis may take longer to cure. Symptoms such as fever and sore throat usually improve within a week, although a complete recovery may take closer to two weeks. It is probably not be necessary to remain in bed after the first few days of treatment.

Over-the-counter medications can reduce pain and relieve fever. If you have viral tonsillitis, antibiotics will not help, and the condition will usually be left to run its course. In this case, use over-the-counter medications for pain relief.

Use a product such as acetaminophen or ibuprofen (i.e. Tylenol or Advil) for pain relief and fever reduction. Follow the dosage recommendations on the package, which are based on age and weight, or follow your doctor's instructions. Do not give products containing aspirin to children or teens unless your doctor recommends this type of medication. In this age group, aspirin is associated with a condition called Reye's syndrome, which is potentially fatal.

Throat lozenges may be used for adults and children over the age of four to reduce the discomfort of a sore throat. Hard candy such as butterscotch may have a similar soothing effect, but neither candy nor lozenges should be given to young children who may accidentally swallow them and choke.

De Quervain’s Disease:

De Quervain’s Disease:

Symptoms/Chief complain (C/C):

1.    Pain in the radial side of the dorsum of wrist.
2. Active movement of thumb is painful.

Signs/On Examination (O/E)

1.    Swelling may present on radial styloid.
2. Tenderness present on radial styloid.
3. Crepitus may present on palpation.
4. Abduction and extension of thumb against resistance is painful.

Treatment:

1. Complete rest of the hand with resting splint.
2. Ice.
3. UST with Naproxen gel.
4. NSAIDs.