Special test for elbow

GENERAL OBJECTIVES
To enhance the knowledge of massage therapist for application of Special test
assessment in elbow.

SPECIFIC OBJECTIVES
Upon completion of this chapter the reader will have the information necessary
to:
1. Definition of Special test
2. Explain the importance of special test
3. Explain the brief anatomy of elbow
Bone
Muscle
Nerves
4. Describe common Bells palsy sign and symptoms
5. Explain the complication in bells palsy
6. Explain the diagnosis of bells palsy
7. Demonstrate the advance clinical massage for bells palsy
Definition: What Is It?
Special tests are tests that have been designed to assess specific tissues: specific
ligaments, or tendons; meniscal pads in joints; bursa; nerve roots, etc. They can also be
seen as techniques that may help us palpate or observe tissues too deep or unavailable
for normal observation or range of motion testing.
Anatomy of elbow

Anatomy of Elbow
I.

Bones

Anatomy: Landmarks
.

Landmarks form triangle (Elbow at 90 degrees)

1.

Olecranon

2.

Lateral epicondyle

3.

Medial epicondyle

Anatomy: Bone

The elbow is often viewed as a simple hinge joint, but it actually comprises three bones:
1. Humerus
2. Radius
3. Ulna
Radius bones
Proximal

Radial Head
Radial Tuberosity
Radial Neck

Distal

Ulnar Notch
Radial styloid process

Ulna
Proximal

Olecranon
Olecranon Process
Coronoid Process
Trochlear notch
Radial notch
Ulnar tuberosity

Distal

Ulnar Styloid Process

Participating bones
1. Epicondyles
- Medial epicondyles: flexor epicondyle
- Lateral epicondyle
2. Olecranon fossa

Joints of the elbow

-

Humeroulnar
Humero-radial
Proximal radioulnar joints

Humeroulnar joint: A joint form ed by the trochlea of the humerus and the semilunar
notch of the ulna (see Fig. 8-2 ). Its primary motion ca-pabilities are fl exion and
extension, although some individuals are capable of a small amount of hyperextension.
Humeroradial joint: A modified hinge joint, but sometimes classifi ed as a gliding joint
(see Fig. 8-2 ), that is composed of the radial head, which articulates on the capitulum of
the humerus. In addition to flexion and extension, internal and external rotation occurs
during supination and pronation.
Proximal radioulnar joint: A pivot joint that is formed by the head of the radius. It
articulates with the radial notch of the ulna; the head rotates in the notch during
supination and pronation.

Ligaments
The medial collateral ligament (see Fig. 8-2 ) is the most important liga-ment for
stability in the elbow. It runs from the medial epicondyle of the humerus to the ulna in a
fan shape and is divided into three distinct bands. To feel the ligament, palpate
transversely from the medial epicon-dyle onto the proximal ulna.
-

Anterior oblique band is the primary restraint against valgus forces and is taut
throughout the entire range of motion.
Transverse band does not provide a great deal of support to the medial elbow
Posterior oblique is a capsular thickening that is taut beyond 60 of flexion.

The complex lateral collateral ligamentsupports the lateral side of the elbow (see
Fig. 8-2 ). To locate this ligament, palpate between the lateral epicondyle and the ra-dial
head. This ligament complex consists of four components:
Radial collateral ligament: Resists varus forces on the elbow and terminates on the
annular ligament. It is the most important of the four ligaments.
Ulnar collateral ligament: Resists valgus forces on the elbow and is the posterior
portion of the radial collateral ligament. It is separate from the other three ligaments.

Annular ligament: Encircles the radial head and allows for rotation of the radial head
in the radial notch.
Accessory ligament: Assists the annular ligament during a varus stress.

Muscle of the elbow

Biceps
Brachialis
Triceps
Anconeus
Pronator teres
Supinator

Humerus
1.

Widens distally forming lateral and medial epicondyles

A.

Radial Head

1.

Articulates with capitellum (at lateral epicondyle)

2.

Articulates with lateral ulna

3.

Held in position by orbicular ligament

4.

Easily palpable near lateral epicondyle

B.

Ulna

1.

Articulates with Trochlea (at Medial epicondyle)

C.

Epicondyles

1.

Adjacent to humeral condyles

2.

Provides Forearm muscle insertions

a.

Flexor-pronator muscles attach to medial epicondyle

b.

Extensor-Supinators attach to lateral epicondyle

VI.

Anatomy: Soft tissue

Muscle insertions

1.

Triceps attaches to Olecranon posteriorly

2.

Biceps and brachialis attach to radius and ulna

3.

Pronators and Supinators Mnemonic

MFP: medial (epicondyle) flexors and pronators

a.

LES: lateral (epicondyle) extensors and supinators

A.

Collateral Ligaments

1.

Medial and Lateral collateral

II.

Muscles of the face

Muscle

Position

Action

Frontalis

Forehead

Wrinkles the forehead, raises eyebrows

Orbicularis oculi

Surrounds the eyes

Closes the eyes

Orbicularis oris

Surrounds the mouth

Closes and purses lips

Buccinator

Deep cheek

Bring cheeks close to teeth

Zygumaticus

Upper cheek

Elevates the corners of the mouth

(smiling muscle)

Muscle

Position

Action

Levatorlabiisuper
ioris

Above the upper lip,

lateral to the nose

Elevates upper lip

Depressor
labiiinferioris

Below the lower lip

Depresses lower lip

Masseter

Posterior region of the

cheeks

elevates mandible, moves jaw laterally

Temporalis

Lateral cranium

Elevates mandible, retracts mandible

III.

Nerves

Signs and Symptoms

Loss of enervation to the muscles on one side of the face

Sudden onset of flaccid paralysis of the muscles of the upper and lower face
Difficult to eat, drink, and close the eye of the affected side.
Production of saliva may be increased or decreased, and taste may be distorted.
Sometimes the ear on the affected side becomes hypersensitive, because a muscle
connected to the eardrum (the stapedius) is paralyzed; this is called hyperacusis .
The affected side may have pain, but it is more likely to be in the form of
headaches or an ache behind the ear than electrical nerve pain. This is motor, not
sensory, paralysis (except for some taste buds that may be affected), so sensation
throughout the face stays intact.

Complications

A short-lived disorder with few serious complications.

About 85% of people who have it regain full or nearly full function within a few
months.
One serious problem that can occur is damage to the eye. This can develop if the
lubrication and cleaning of the eyeball provided by blinking is impaired.
Rare complication occurs when the facial nerve forges some new and inappropriate
connections asit heals. The result may be unpredictable muscle activity in the face
(synkinesis), or secretion of excessive tears during salivation.

Diagnosis

A sudden onset of motor paralysis to one side of the face is unique to this disorder.
Herpes simplex has been identified as a causative factor in most cases of Bell
palsy, but some other pathogens can cause the same kind of damage.
Cytomegalovirus and Epstein-Barr virus, both members of the herpes family.
Bilateral facial paralysis is more likely to be related to MS, Guillain-Barr syndrome,
sarcoidosis, or tumors on or around CN VII or CN VIII.

Treatment

Self-limiting
A combination of steroidal anti-inflammatories and acyclovir to slow down herpes
activity is effective for most Bell palsy patients.
Patients are counseled to tape the affected eye closed at night and to protect it
from drying and dust during the day.
Massage is often recommended to stretch and mobilize facial muscles until the
nerve is repaired.

Massage
Bell palsy is a flaccid paralysis with sensation left intact. If the underlying cause of the
neuritis has been diagnosed, then massage is a very appropriate treatment choice.
Massage keeps the facial muscles elastic and the local circulation strong. This sets the
stage for a more complete recovery when nerve supply is eventually restored.

Clinical massage for Bells palsy

1. ES on Face acupuncture points on ST 2, ST 4,ST 5, ST 7, TH 17(most important
points) GB3 and GB14 x 90 contraction for each points and 2 repetition
2. Apply facial massage
3. Thumb pressing along the meridians points on face acupuncture point 5 seconds
hold x 2 repetition
4. Thumb pressing GB 20, GV 10 and GB 21,(LI4 and Liver 3 on paralytic
sides)3seconds hold x 2 repetition
5. Facial expression looking into the mirror

Stomach 2 meridians Below St. 1, in the depression of infraorbital region

Indication:
1. Facial paralysis and pain
2. Redness and pain in the eye
3. Twitching of eyelid
Stomach 4 meridians Lateral to the corner of the mouth, directly below St. 3
Indication:
1. Deviation of the mouth
2. Salivation
3. Twitching of eyelids
Stomach 5 meridians Anterior to the angle of mandible, on the anterior border of
masseter, in the groove-like depression appearing when the cheek is bulged
Indication:
1. Deviation of the mouth
2. Swelling of cheek
3. Toochache
Stomach 7 meridiansIn the depression at the lower border of the zygomatic arch,
anterior to condyloid process of the mandible. This point is located when the closed.
Indication:
1. Facial paralysis

2. Deafness
3. Tinnitus
4. Toochache

Headaches
Definition: What Are They?
Types of headaches
Primary headaches are unrelated to serious underlying pathology
Secondary headaches are symptoms of other problems.
In addition, most headaches can be described as belonging one of four categories. These
problems dont necessarily outline well, however, and many headaches share qualities
from more than one of these classifications.
Tension-type headaches.

Most common type of headache people experience (90%92%),

Bony misalignment
Postural patterns
Eyestrain
Temporomandibular joint disorders
Myofascial pain syndrome
Ligament irritation
Other musculoskeletal imbalances.
Tension-type headaches may also be described as episodic (happening fewer than
15 times per month) or chronic(happening more than 15 times per month).

 Vascular headaches. These include classic and common migraines, cluster headaches,
and possibly sinus headaches.
They account for a total of about 6% to 8% of headaches.

Triggered by stress
Food sensitivities
Alcohol use
Chemical shifts seen with the menstrual cycle

Chemical headaches. The triggers for these headaches can be any kind of chemical
disturbance.
Traction-inflammatory headaches. These are the rarest type of headache and the most
dangerous. They indicate severe underlying pathology, such as tumor, aneurysm,
hemorrhage, or infection in the CNS.

Etiology: What Happens?

Both migraine and tension headache episodes show significant changes in serotonin
levels.
This may lead to the dilation of arteries in the periphery of the brain. This excessive
vasodilation stretches blood vessels, causing pain. In addition, local prostaglandin release
may initiate an inflammatory response, adding to the fluid in a closed cavity.
The primary difference between migraine headaches and tension headaches, therefore,
may simply be the triggers and the presence or absence of a throbbing sensation.
Migraines are generally associated with throbbing pain and chemical triggers such as food
sensitivities or hormonal shifts, while tension headaches are more often associated with
compressive head-in-a-vise pain and mechanical triggers such as tight muscles or
misaligned vertebrae.
But bothtypes of triggers evidently may lead to serotonin shifts and intracranial
vasodilation.

Tension Headaches
Definition: What Are They?
Tension headaches are headaches triggered by mechanical stresses that initiate the
CNSchanges in serotonin levels and blood vessel dilation discussed previously.
Etiology: What Happens?

The average head weighs about 18 to 20 pounds. The area of bone-to-bone contact
betweenthe occipital condyles and the facets of C1 is about the same as two pairs of
fingertips touching.
The whole mechanism is kept in balance by tension exerted by muscles and ligaments
aroundthe neck and head. The muscles primarily responsible for the posture of the head
form two inverted triangles just below the occiput. It is not surprising, then, that when
thisdelicate balance is a little off, the resulting pain reverberates throughout the whole
structure.
Similarly, when postural or movement patterns elsewhere in the body exert force on
thespine, the end result can be tension at the occipital connection. In this way, a foot that
strikesthe ground too hard on the lateral side may pull on the knee, which may then
demand compensation in the hip. The sacrum moves to adjust to the tip in the oscoxae.
This creates aslight twist in the lumbar vertebrae, which reverberates all the way up the
spine to the head.
The result: headaches because the feet are not in alignment.

Triggers These are almost too numerous to list here, precisely because staying pain free
involves such a precarious balance of muscle tension, bony alignment, and a myriad of
other factors. Here are some of the major causes of tension headaches:
Muscular, tendinous, or ligamentous injury to the head or neck structures. The
ligaments inthe neck may be most easily injured; they are vulnerable to fraying and
irritation withuncontrolled movement, and they refer pain over the back of the head.
Simple muscle tension in the suboccipital triangle or the jaw flexors. These muscles are
especially vulnerable to the effects of emotional stress. When people are worried or
angry, they tend to clench their jaws and tighten their necks.
Subluxation or fixation of cervical vertebrae. Disorders of these vertebrae can irritate
ligaments and/or cause muscle spasms, both of which lead to headaches.

 Structural problems.Misalignment of the cranial bones (which are not completely

immobile) or in the temporomandibular joint can cause headaches.
Trigger points in the muscles of the neck and head. These can refer pain all around
thehead.
Eyestrain. Chronic contraction of muscles in the eye to focus on reading material
orother visual input may be relieved when corrective eyewear reduces eye muscle
tension.
Any kind of ongoing mental or physical stress.Stress can change postural and
movementpatterns, which will lead to muscle spasm, subluxation, fixation, and so on.
Poor ergonomics, especially in repetitive work situations, are frequently the culprit
behindchronic tension headaches.

Vascular Headaches
Definition: What Are They?
These headaches are often triggered by food sensitivities, hormonal shifts, alcohol use,
stress,or other factors that are difficult to identify. The pain they cause comes from
excessively dilated blood vessels in the meninges. They are characterized by pain that
throbs with the patients pulse.
Migraines
Demographics: Who Gets Them?

About 28 million people in the United States have diagnosed migraines. This malady is responsible for an overwhelming $50 billion in lost wages and medical expenses every year.
Women get migraines more than men do. It is estimated that up to 18% of women have
a migraine at some time in their life; that number is closer to 6% for men. Many
migraines
are genetically linked; 70 to 80% of migraine patients have other family members with
the
same problem.

Etiology: What Happens?

Migraine headaches begin with extreme vasoconstriction in the affected hemisphere,
which
one would expect to be painful, but its not. Instead, for some people, a sense of euphoria
is
felt, although it is mixed with dread that the worst is yet to come. This is the prodrome of
the
classic migraine. The vasoconstriction is followed by a huge vasodilation, a flood of blood
into
the affected part of the brain. It is all still contained within the vessels, of course, but the
excessive pressure against the vessel walls and meninges causes excruciating pain.
Migraines are associated with increased risk of seizures and stroke.
Triggers No one has identified exactly what sets up the process for migraines to take
place.
Some triggers have been identified, such as the consumption of certain kinds of foods,
including red wine, cheese, chocolate, coffee, tea, aspartame, monosodium glutamate, and any
kind
of alcohol. Abnormal levels of stress can bring them on, as can hormonal shifts such as
menstruation, pregnancy, and menopause. (These hormonal shifts can also make preexisting
mi-

graines disappear.) The good news about migraines is that they usually subside by middle
age.
It is rare for mature people to have migraines.
Signs and Symptoms The word migraine comes from the French, hemi-craine , or halfhead .
This is because migraine headache has a characteristic unilateral presentation. In classic
migraines the pain is preceded by the euphoric prodrome stage. Blurred vision, the
perception
of flashing lights or auras, and even auditory hallucinations may occur. Classic migraines
constitute only about 15% to 20% of migraines. Then, as with the aura-free common
migraines,
(the other 80% to 85% of migraines) the patient has extreme throbbing pain on one side
of
the head, which may cause the ipsilateral eye and nostril to water. Hypersensitivity to
light,
nausea, and vomiting are all possible. Some patients have tingling or other sensation
changes
in their extremities. One rare version, called hemiplegia migraine, is accompanied by
temporary paralysis on one side of the body; this version has a strong genetic link. Migraine can
persist for several hours to several days and can leave the person exhausted.
Cluster Headaches
Definition: What Are They?
These are a fairly rare, not well understood variety of vascular headache. Cluster
headaches
affect men much more often than women, and they affect less than 1% of the United
States
population. Cluster headaches usually happen at night, with pain severe enough to wake
a person out of a sound sleep. Like migraines, they cause the eye and nostril of the affected
side to

water. They may also cause facial swelling and unilateral sweating. Each headache lasts
30
minutes to 3 hours, and in an episode a person may have one to four headaches every
day for
4 to 8 weeks.
Reliable triggers for cluster headaches, outside of alcohol, have not been identified. They
may occur seasonally, once or twice in a year, or just once in a lifetime.

Sinus Headaches
Sinus headaches are worth a mention among the vascular headaches because they also
have to
do with too much fluid in the skull. The fluid is in the sinuses rather than the cranium
itself.
When a person has sinus allergies or sinusitis, the membranes can become irritated and
inflamed. Sinusitis is discussed in more detail in Chapter 7.
Chemical Headaches
Definition: What Are They?
Chemical headaches are triggered by a variety of chemical imbalances in the body. They
are
often warning signs that the person has too much or too little of some substance vital to
maintaining homeostasis. Causes of chemical headaches include the following:
Very low blood sugar, indicating that the person needs to eat soon.
Hormonal shifts like those seen with the menstrual cycle and childbirth.
Extreme dehydration, either from physical exertion or from alcohol consumption.
This is the typical hangover headache.
Too much headache medication. These rebound headaches may last for 2 weeks or
more, and the only way to treat them is to stop taking pain medication.

Traction-Inflammatory Headaches
Headaches are occasionally a sign of a serious CNS injury or infection. Headaches in
combination with extreme fever often have a bacterial or viral precipitator. They are
usually
short-lived, subsiding when the fever passes the crisis point. The time to become
concerned
is when headaches are severe, repeating, and have a sudden onset (thunderclap
headache),
when they appear in a new pattern after age 50, or when they have a gradual onset but
no remission. In these cases headache may be a symptom of some serious underlying
condition.
This is true particularly if the headache is accompanied by slurred speech, numbness anywhere in the body, and difficulties with motor control. The first things to investigate in
cases
like this are encephalitis, meningitis, stroke, tumor, and aneurysm.

Treatment
Avoiding or managing headache triggers is the most proactive and least invasive way to
deal
with this problem. People who have recurrent headaches of any type are usually
encouraged
to keep a headache journal to try to pin down their own specific triggers for headaches.
As understanding of the most common types of headaches changes, treatment options
also shift. For the moment, medical headache treatment falls into two categories:
prophylactic treatment, which works to prevent the headache from beginning, and abortive
treatment,
which works to end the headache once it has begun. Because migraines often are
accompanied by nausea and vomiting, some medications are poorly tolerated when taken orally;
nasal

spray applications work well for some patients.

Cluster headaches respond well to pure oxygen inhalation if this can begin within the first
few minutes of the first headache.
Tension-type headaches are still treated primarily with nonsteroidal anti-inflammatories
when they require medical intervention at all.

Massage?
The appropriateness of massage depends on what kind of headache the client has. If it is
related to a serious underlying pathology or to a bacterial or viral infection, any massage is
obviously inappropriate.
Vascular headaches are usually so extreme and painful that clients prefer to wait until the
acute stage has passed. Hydrotherapy to draw fluid out of the congested cranium may be
successful if the client can tolerate it.
For the most common tension-type headaches, massage is resoundingly indicated. These
episodes are an excellent opportunity to demonstrate how many seemingly disconnected
postural and movement patterns can create pain in an entirely different area of the body.

Rheumatoid Arthritis
Definition: What Is It?
Rheumatoid arthritis is an autoimmune condition in which the
synovial membranes of various joints are attacked by immune system cells. Unlike many other forms of arthritis, rheumatoid arthritis can also involve inflammation of tissues outside the
musculoskeletal system.
Demographics: Who Gets It?
This disease affects 3.1 million people, or about 1% of Americans.
Women are affected about three times more frequently than men.
Statistics indicate that it is most common among 20- to 50-yearolds, but it can strike anyone, including children and adolescents.
Etiology: What Happens?
The etiology of rheumatoid arthritis is not well understood, but
most researchers consider it to be an autoimmune disease: the im-

mune system attacks parts of the body. The primary target in rheumatoid arthritis is
synovial
membranes of certain joints, but other areas (blood vessels, serous membranes, the skin,
eyes,
lungs, liver, and heart) may also be affected.
When a synovial membrane is under attack, all of the signs of inflammation develop:
heat,
pain, redness, swelling, and loss of function. Studies of joint tissues show that B cells, T
cells,
antibodies, and many other inflammatory chemicals are present during a flare. In
response,
the synovial membrane thickens and swells. Fluid accumulates inside the joint capsule,
which
causes pressure and pain. The inflamed tissues release enzymes that erode cartilage,
eventually all the way down to the bone. This is the process that causes the telltale deformation
of
the joint capsules and gnarled appearance of rheumatoid arthritis (Figure 3.27).
Signs and Symptoms
Symptoms of rheumatoid arthritis vary considerably at the onset of the disease. Many
people
have a period of weeks or months with a general feeling of illness: lack of energy, lack of
ap-

petite, low-grade fever, and vague muscle pain, which gradually becomes sharp, specific
joint
pain. Some patients have a sudden onset with joint pain alone. Rheumatic nodules, small,
painless bumps that appear around fingers, elbows, and other pressure-bearing areas, are
also
common indicators of the disease.
In the acute stage the affected joints are red, hot, painful, and stiff, although they
improve
considerably with moderate amounts of movement and stretching. The joints rheumatoid
arthritis most often attacks are the knuckles in hands and toes. It frequently develops in
ankles and wrists; knees are less common. One of the most serious places to get it is in the
neck,
where it can lead to dangerous instability. It generally affects the body bilaterally,
although it
is sometimes worse on one side than the other.
Like many autoimmune diseases, rheumatoid arthritis appears in cycles of flare followed
by periods of remission. Some patients have only a few flares in their life and are never
affected again. Moderate cases involve cycles of flare and remission up to several times a
year.
Severe rheumatoid arthritis involves chronic inflammation that never fully subsides.

Complications
If someone has rheumatoid arthritis, it means her immune system is confused about what
it
should be fighting off. Synovial membranes are just one of the types of tissue that may be
attacked. Other possibilities include:
Rheumatic nodules on the sclera (whites) of the eyes.
Sjgren syndrome (pathologically dry eyes and mouth).

 Pleuritis, which makes breathing painful and increases vulnerability to lung infection.
Carditis or pericarditis, that is, inflammation of the heart or pericardial sac.
Hepatitis, or inflammation of the liver.
Vasculitis, or inflammation of blood vessels. This complication carries another set of
risks:
Raynaud syndrome, skin ulcers, bleeding intestinal ulcers, and internal hemorrhaging.
Bursitis and anemia, especially when onset of the disease occurs in childhood.
Advanced structural damage brings a different set of complications. Deformed and bonedamaged joints may dislocate or even collapse, rendering them useless. The tendons that
cross
over distorted joints sometimes become so stretched that they snap. If the disease is at
the C1C2 joint and the joint collapses, the resultant injury to the spinal column may even result
in
paralysis.

Diagnosis
Rheumatoid arthritis can be difficult to diagnose because its early symptoms are often
subtle;
they vary greatly from one person to another; and a long list of diseases with similar
symptoms must be ruled out before a diagnosis can be conclusive. A sense of urgency exists
around
a conclusive diagnosis however, because it has been found that cartilage and bone
damage may
occur as early as the first or second year of the disease process, and if treatment can be
administered earlier, this damage can be averted.
Rheumatoid arthritis is typically diagnosed through a description of symptoms, radiography, and a blood test to check for rheumatoid factor, a substance that is present in most
but

not all cases. An erythrocyte sedimentation test may be conducted to look for signs of
general
inflammation, and the blood is also examined for signs of anemia. Even when all signs are
positive, the diagnosis is sometimes not considered conclusive until the patient has been
under
observation for a long while.
A set of diagnostic criteria has been provided by the American Rheumatology
When four of these seven signs are present, a diagnosis of rheumatoid arthritis
can be made:
Morning stiffness that lasts at least 1 hour
Arthritis in three or more joints
Involvement of the proximal interphalangeal joints (PIPs), distal interphalangeal joints
(DIPs), or wrist
Bilateral distribution
Positive serum rheumatoid factor
Rheumatoid nodules
Radiographic (x-ray) evidence

Treatment
Once the diagnosis of rheumatoid arthritis has been confirmed, the goals of treatment are
to
reduce pain, limit inflammation, halt joint damage, and improve function. Medications
that
help to achieve these goals are divided into first-line and second-line drugs.
First-line drugs include nonsteroidal anti-inflammatories, corticosteroids, and cyclo-oxygenase (COX)-2 inhibitors to limit inflammation and pain. These are often used along with
exercise, hydrotherapy, physical therapy, and occupational therapy in the hopes that
progression can be limited without further intervention.

Second-line drugs attempt to interfere with the disease process. These include biological
response modifiers and immunosuppressant drugs. They often give significant relief, but
they
also carry a long list of serious side effects and sometimes cannot be used for long-term
care.
Nonmedical intervention for rheumatoid arthritis can include adjustments to diet, exercise, and stress reduction techniques (including massage). Research is being conducted
into
the use of some alternative and complementary strategies for symptom management,
including botanicals, tai chi, and meditation.
36
Surgery can be a successful option for rheumatoid arthritis patients, if the disease has
affected
joints that can be easily treated. Joint replacement is sometimes an option, along with
surgery to
rebuild damaged or ruptured tendons and to remove portions of affected synovial
membranes.
The synovial membranes grow back, however, so this surgery is a temporary measure.

Massage?
In its acute (flare) phase, rheumatoid arthritis is an inflammatory condition caused by
agents
in the circulatory system. Any type of massage that promotes circulation is probably not
appropriate at this time.
In its subacute phase, rheumatoid arthritis leaves the joints stiff but not inflamed, and the
muscles and tendons around them are stressed and tight from chronic pain. Rheumatoid
arthritis indicates massage in the subacute stage. Massage can improve mobility and the
health
of the soft tissues surrounding the joints. In addition to the structural benefits it offers,
mas-

sage can also be an important part of the prevention strategy of keeping healthy and
stress
free. If bodywork can help to balance the autonomic nervous system, it may also help to
reduce the incidence of attack.

Osteoarthritis
What is it?
Definition: What Is It?
Also called degenerative joint disease,osteoarthritis is a condition in which synovial joints,
especially weight-bearing joints, lose healthy cartilage. This condition is distinguished
from other types of arthritis by being directly related to age and wear and tear of the joint
structures.

Osteoarthritis

Definition: What Is It?

Also called degenerative joint disease,osteoarthritis is a condition in which synovial

joints, especially weight-bearing joints, lose healthy cartilage. This condition is
distinguished from other types of arthritis by being directly related to age and wear
and tear of the joint structures.
Men and women are affected in equal numbers, but women tend to develop it
earlier and be affected more severely.
More than half of people over 75 years old have been diagnosed with osteoarthritis
in at least one joint.
Besides age, the single leading risk factor for osteoarthritis is being overweight.
Clinically obese people (those with a body mass index over30) are four times more
likely to develop osteoarthritis than the rest of the population.

Etiology: What Happens?

Joints, especially knees and hips, put up with tremendous weight-bearing stress and
repetitive movements; their design is a marvel of efficiency and durability. But the
environment inside a joint capsule is precarious. Any imbalance can have cumulative
destructive impact. This can take the shape of excessive stress on a healthy joint or
normal stress on a joint that has already been compromised. Once the path toward
arthritis has begun, it may be possible to stop it, but capacity for regeneration and repair
is limited at best.
The environment within the cartilage turns out to be the key feature in the development
of osteoarthritis. Hyaline or articular cartilage is constructed of a relatively small number
of living chondrocytes that produce collagen (mostly type II fibers), along with
proteoglycans: large negatively charged molecules that attract water. The cells, protein
fibers, and molecules of fluid are arranged in slightly different patterns, depending on
whether they are superficial, intermediate, or attached directly to the chondral surface of
the articulating bone. This gives layers of cartilage the ability to resist both shearing and
compressive forces.
Chondrocytes remain active all through life, constantly replacing and rebuilding the
cartilage surface, but they dont migrate to damaged areas. When the delicate balance in
the articular cartilage is upset, chondrocytes make less fluid and collagen, and cartilage
degrades.
This stimulates osteocytes in the epiphyses of the affected bones to become more active:
the condyle of the bone may become enlarged, osteophytes (bone spurs) may develop,
and in some cases cystlike cavities develop under the cartilage of the affected bone.
Causes

Age
Being overweight

If the ligaments that surround joints are chronically lax, the joint can become
unstable, raising the risk of arthritis; this can be a long-term problem with joints
that have been dislocated.
A history of trauma or surgery
Repetitive pounding stress, such as running or jumping with inadequate support,
can also open the door to problems.
Hormonal imbalances and nutritional deficiencies, including dehydration,
inadequate calcium metabolism, and foods that trigger inflammatory responses,
may compromise the health of joint structures.

Signs and Symptoms

All revolve around irritation of the joint structures.

Osteoarthritis is seldom hot, painful, and swollen.
More often it lingers in a chronic stage in which the joints have ongoing deep pain
and stiffness, especially when they are not warmed up or when they have been
overused. Osteoarthritis can be crippling when it occurs at the hip or knee,
because the pain and limitation are badly exacerbated by walking.
When osteoarthritis develops in the fingers, characteristic thickening of the
phalangeal epiphyses is present. Bulges at the distal interphalangeal joints
(DIPs) are called Heberden nodes. When they appear at the proximal
interphalangeal joints (PIPs), they are called Bouchard nodes.

Diagnosis
Tests may be conducted to rule out other conditions, but no blood test definitively
identifies osteoarthritis. Even X-rays radiographs can be misleading.
They may be used to confirm a diagnosis, but a surprisingly high percentage of people
who show osteoarthritis-like bony deformations on radiography have no pain at all.
Treatment
Reduce pain and inflammation and to limit or reverse the damage to the joint structures.
Nonsteroidal anti-inflammatory drugs
Topical applications.
Exercise
Nutritional supplements. Glucosamine and chondroitin sulfate are two substances that
may not only limit the progression of arthritis damage but may be able to reverse it..
Although public interest in these supplements is high they are unregulated by the FDA,
and so potency and dosages may vary from one brand to another. These supplements are
not without risk.
1. Glucosamine may affect insulin levels in diabetic patients, and it is made from the
shells of shellfish, so people with allergies should watch for reactions.
2. Chondroitin may affect blood clotting so patients who also take blood thinners
should consult their primary care providers about this risk.
Massage?
Most osteoarthritis patients seldom have acute swelling with pain, heat, and redness. This
is good news for massage therapists, who want to avoid exacerbating acute
inflammation. Chronic osteoarthritis indicates massage to reduce pain through release of
the muscles surrounding the affected joints and to maintain range of motion through
gentle stretching and passive range of motion exercises.

Subacute and chronic case

KNEE OA

1. Hot moist pack x 20 minutes

2. TENS x 20 minutes along the acupuncture or trigger points simultaneously follow
by thumb and palm pressing working proximal and distally on GB, TH, ST and SP
meridians
3. Trigger point therapy technique on quadriceps muscles(Vastus and rectus femoris
muscles) and hamstring and popliteal muscles static ischemic compression x 30
seconds hold and 3 repetition
4. MET x 7 seconds hold x3 repetitionin Hip and knee flexors and extensors followed
by gentle passive stretching tolerated by the patients

HIP OA
5. Hot moist pack x 20 minutes
6. TENS x 20 minutes along the acupuncture or trigger points simultaneously follow
by thumb and palm pressing working proximal and distally on GB, TH, ST and SP
meridians
7. MET x 7 seconds hold x3 repetition in Hip and knee flexors and extensors followed
by gentle passive stretching
8. Trigger point therapy on static ischemic compression x 30 seconds hold and 3
repetition

Gout arthritis
This desease is characterized by severe penetrating pain in the big toes during the night.
This pain subsides after one week but occurs again. The joint becomes swollen turning
red or purple, occationaly accompanied

Disc Disease
Definition: What Is It?
Disc disease is an umbrella term referring to a collection of problems in which the nucleus pulposus and/or the annulus fibrosus extends beyond its normal borders. If the disc presses on the spinal
cord or spinal nerve roots, pain will be present. If the bulge
doesnt happen to interfere with nerve tissue, no symptoms may be
present at all.
Etiology: What Happens?
A typical intervertebral disc is quite a complex package. It has an
outer wrapping of three layers of very tough, hard material called
the annulusfibrosus. This envelopes a soft, gelatinous center
called the nucleus pulposus. Ideally, the nucleus should be roughly

spherical, with the harder annulus layers forming flat surfaces above, below, and around
the
ball. This combination of textures gives the disc the advantages of strength and
resiliency,
which it needs to do its job of separating and cushioning the vertebrae (Figure 3.48). The

spine is capable of bearing a great deal of weight, partly thanks to this arrangement of
the
discs.
The ring of annulus fibrosus is an arrangement of concentric circles of collagen fibers.
These fibers are arranged in such a way that the tighter theyre pulled, the stronger they
become. On the other hand, the closer the vertebrae are, the looser (and weaker) the
annulus is.
This has great implications for the nucleus pulposus, which relies on a tight, solid exterior
wall
for support.
The annulus fibrosus is very strong, but studies show that it starts to degenerate someime during the second or third decade of life. It can sustain multitudes of microtraumas,
but
hey all contribute to setting the stage for future trouble. At the same time, the nucleus
pulposus tends to shrink and dry with age. By the time most people are in their 50s, the
nuclei of

their discs are no longer soft and gelatinous; they have hardened and thinned. This
process

begins in the neck, where the discs are thinner but eventually also affects the more
massive
lumbar discs.
As the nucleus pulposus becomes thin and dry, more stress is placed on the annulus to
bear weight and absorb shock. This puts the annulus at increased risk for tiny cracks or
fissures. The whole degeneration of the disc then adds stress to the connecting vertebrae;
osteophytes frequently develop on the lip of the vertebral bodies or around the facet joints. In
this
way disc disease is closely aligned to spondylosis, or osteoarthritis at the spine.

Types of Disc Problems

It is useful to be able to recognize the terminology for disc problems that may turn up in a
diagnosis. Disc problems are generally discussed as three major issues:

Herniated nucleus pulposus In this case the nucleus pulposus extends beyond the
posterior
margin of the vertebral body. These injuries are most common in young adults. The
nucleus
may be damaged in these ways:
Bulge. The entire disc protrudes symmetrically beyond the normal boundaries of the
vertebral body.
Protrusion. The nucleus pulposus extends out of the annulus at a specific location. If it
protrudesposterolaterally (the most common version) it may press on nerve roots. If
it protrudes straight back, it may press on the spinal cord or caudaequina.
Extrusion.A small piece of the nucleus protrudes, with a narrow connection back to the
body of the nucleus. In some cases the protrusion can separate from the nucleus altogether; this is called a sequestration.
Rupture. The nucleus pulposus has burst and leaked its entire contents into the surrounding area.

Degenerative disc disease This refers to small, cumulative tears of the annulus, along
with
decreased disc height and dehydration of the nucleus. Eventually or in relation to a
specific
trauma, the annulus may press against a nerve root of the spinal cord. Degenerative disc
disease is often considered a normal part of the aging process, although it is accelerated by
smoking, obesity, and a sedentary lifestyle.
Internal disc disruption This condition is often related to trauma in addition to cumulative
degenerative disc disease. In this case the nucleus protrudes through the annulus but
stays
within the boundaries of the whole disc.
Causes
Causes of disc injury may vary according to the general health of the connective tissues
of the
person involved. For some people a major trauma such as a car accident or a bad fall will
damage the tissues enough to cause pain. People with weak, loose intervertebral ligaments
have a
higher risk of disc damage from ordinary everyday activity. The classic scenario for this
kind
of disc damage is an incident that involves simultaneous lifting and twisting.
Progression
When an intervertebral disc is injured and presses on nerve tissue, its often because of a
certain sequence of events on top of a lifetime of normal wear and tear. Here is a typical
example of how a lumbar disc may herniate:
A person bends over to pick up something heavy, a basket of laundry, for example.
Going into trunk flexion flattens the anterior portion of the nucleus and opens up a
posterior space while stretching the posterior fibers of the annulus.

 The person jerks into an erect posture, possibly twisting at the same time, while carrying a heavy load. Suddenly coming back into extension, especially while carrying
something heavy, quickly redistributes the nucleus and shoots it into that posterior
space with great force.
The protruding section of nucleus presses against the weakest part of the posterior annulus and breaks through, which puts pressure on nerve roots. Or the force of the motion, combined with the brittleness of the annulus, causes the annulus to crack and put
pressure on nerve tissue. The chemical substance of the nucleus pulposus creates a very
extreme inflammatory response that can be a major contributor to the nerve pain that
accompanies these injuries.

Many variations may develop on this theme. Discs that cause pain usually bulge posterolaterally because that is the path of least resistance in the tight space they inhabit, but
they can
also go to the left or the right side (Figure 3.49). Occasionally a disc bulges directly
posteriorly, which puts pressure on the spinal cord or caudaequina rather than nerve roots. This
is
a very serious situation that can lead to permanent damage. But usually the protrusion is
on
nerve roots rather than the spinal cord, and the amount of herniated material is very
small. It
dries up and takes pressure off the nerve roots within a few days or weeks. This leaves
the disc
permanently thinned but doesnt necessarily lead to long-lasting problems.
L4 and L5 injuries are the most common with the kind of lifting or lifting and twisting
injury described here. Cervical disc lesions are an occasional problem for car crash
survivors;
the action of a whiplash injury can be similar to the lifting and twisting injury. Thoracic injuries are possible but rarer, since the ribs make the thoracic spine much more stable
than its

cervical and lumbar counterparts.

Signs and Symptoms

Symptoms associated with disc disease arise from pressure on nerve tissue or from the
exaggerated inflammatory response that occurs when the nucleus pulposus leaks. Nerve
pressure
can come and go as the patients position and alignment shift, and so once the initial
inflammation subsides, pain may be intermittent.
Local and radicular pain. Pain is felt locally from inflammation and ligament irritation
and along the dermatome for the affected nerve roots. A dermatome chart is a critical
piece of equipment for a massage therapist working with this population.
Specific muscle weakness. It is important to clarify the difference between general
weakness, which occurs after a time of disuse or injury to whole muscle areas, and specific
weakness, which develops fairly quickly and only in the muscles supplied by the affected nerve.
Paresthesia.Pins-and-needles sensation is felt along the affected dermatomes.
Reduced sensation.Poor sensation but not total numbness is a common symptom of ligament damage (which may frequently accompany disc damage).

 Numbness.Total numbness is one distinguishing factor between disc problems and ligament injuries. A disc protrusion can completely cut off sensation to areas within a particular dermatome, but a ligament injury cannot. Numbness in a saddle distribution,
that is, in the low back, groin, and medial thigh, is an indication of pressure on the
caudaequina, or caudaequina syndrome. This is a medical emergency that requires
immediate attention.
Complications
The most serious complication of a disc injury is the threat of pressure exerted directly
posteriorly. In the neck this means the spinal cord is compressed; in the lumbar spine it is
called
caudaequina syndrome because the disc material presses on the extensions of spinal
nerves
between T1 and S5 called the caudaequina. Direct spinal cord compression leads to some
specific signs, including hyperactive reflexes; bilateral pain, paresthesia, or numbness;
and the
loss of bladder or bowel control. Any of these problems can become permanent, or
paralysis

can develop, if pressure is not removed quickly.

Diagnosis
It is important to get an accurate diagnosis for disc injuries, because many of the signs
and
symptoms may be caused by other disorders entirely. Doctors are especially vigilant to
rule
out the possibility of tumors or infection in the spine; these two conditions can create
symptoms similar to those of disc disease but are much more serious.
Discs are generally examined through a combination of radiography, CT, and myelography, but MRI is the gold standard for identifying disc problems. However, many people
show
signs of disc injuries and are completely asymptomatic.
53
This raises the question whether a
patients significant back and radicular pain are brought about by disc disease or by some
other soft tissue injury.
One situation that mimics a disc problem but is actually much less serious is a ligament
sprain. Irritated spinal ligaments running between spinous or transverse processes can
refer
pain along the same dermatomes as the nearby discs. Ligament injuries do not cause
total
numbness or specific muscle weakness, however, and they respond well to specific types
of
massage. Further, one predictable feature with disc pain is that symptoms are reliably
exacerbated by sitting, forward bending, and vibration. This is in contrast to ligament injuries,
which tend to be irritated with side bending or twisting to the opposite side.
Treatment
The best of all possible resolutions for a damaged disc is for the bulging nucleus pulposus
or

cracked annulus fibrosus to return to its normal boundaries and remove pressure from
nearby
nerve tissue. Chiropractors and osteopaths work to correct bony alignment to create a
maximum of space for the nucleus to retreat. Medical doctors recommend short-term bed rest
or
traction, followed by movement within tolerance, for the same reason. Physical therapy
and
special classes on correct posture and body mechanics are often recommended to people
recovering from disc problems. Drugs that are prescribed for herniated discs are aimed at
the
tendency for muscles to seize up in response to this kind of trauma; these include muscle
relaxants and painkillers. If nothing else works, cortisone is sometimes injected into the
area.
This powerful anti-inflammatory helps only about half the time and is often considered the
last resort before surgery.
If bed rest followed by physical therapy doesnt help, it may be necessary to consider
other kinds of intervention. One option is chemonucleolysis. This procedure involves
injecting a preparation of papain, an enzyme from papayas that dissolves proteins (it is also
used in
meat tenderizer) into the disc. This material reduces the size of the protrusion, takes
pressure
off the nerve tissue, and so restores the patient to a pain-free state, all without major
surgery.
This procedure works best with young patients. Transcutaneous discectomy , the removal
of
disc material through a tiny incision, is sometimes also possible. Laser discectomy and
microdiscectomy are newer procedures that are not yet widely available.
Massage?

Most people with disc problems have good days and bad days. Massage therapists should
avoid
intrusive techniques on the bad days. On the good days, they should work with the
intention
of creating space for the retreat of the bulging tissue. Referred pain and muscle spasms
always
accompany this condition. Compensation patterns that develop with chronic back pain
also
demand attention.
It is especially important not to work alone with a disc injury. Muscle spasm can serve an
important protective function for newly damaged discs, and releasing it too soon may put
a
client in danger. Working with another professional who can handle the bony and/or
medical
end of the injury helps the client recover faster and more completely than with either
professional alone.