Ankle Joint Fusion

Fusion of the ankle joint may be required as a result of chronic degeneration of the joint from conditions such as osteoarthritis. A surgical procedure is performed, where the bones are fused together, reducing movement and, therefore, pain at the joint. This loss of mobility of the ankle joint can have numerous side-effects on balance, walking pattern and functional ability. Recovery from an ankle fusion is long and includes the ankle being immobilized and the patient being off the affected leg for several weeks, sometimes as long as 10-12 weeks. The patient is then put into a moon boot and partial weight-bearing will be allowed for several more weeks. Once your surgeon is satisfied that the bones have completely fused, you will be able to return to more normal activities. This prolonged recovery has significant implications on the surrounding leg muscles, joints, balance and walking pattern.

If you have had an ankle fusion, it is important to consider the implications of the fusion on the rest of your body. The lack of mobility at the joint itself will affect how you walk and your ability to carry out your daily activities, such as climbing stairs. Your posture may also be affected. These changes may cause aches and pains in other areas of your body, because you are now walking and standing differently to what you are used to. Adaptations to one’s walking pattern and functional movements will most likely need to be made to compensate for the restricted movement at the ankle joint.

The muscles of the calves and thigh will have become atrophied, or wasted, due to lack of use while the affected leg was not being used so that it could heal. It is important to rebuild the strength of these muscles following an ankle fusion, so that walking and functional ability can return to as close to normal, as soon as the fused joint will allow. Strengthening of the leg and core muscles will assist in the adaptation process of getting used to the new joint.

A biokineticist will assess and provide appropriate exercises to assist in rebuilding the leg muscles, regaining balance, and re-establishing a natural and correct posture and walking pattern. If the appropriate rehabilitation programme is followed, one will be able to return to most previous activities, with only slight adaptations needing to be made.

References

http://www.aofas.org/footcaremd/treatments/Pages/Ankle-Arthrodesis.aspx

Lower-Limb Amputation

Lower-limb amputation refers to the surgical removal of the lower limb (leg) or part of the lower limb. Of course, amputations of the upper limb, or arm, also exist, but due to the non-weight-bearing nature of the arm, this is much less complicated and so will not be discussed in this blog article.

Lower-limb amputations are caused by the following:

·         Circulatory and vascular diseases associated with type 2 diabetes and peripheral vascular disease – 70%

·         Trauma to the limb itself – 23%

·         Removal of tumours – 4%

·         Congenital deformities – 3%

Lower-limb amputations caused by vascular diseases are more common in individuals over the age of 55 years; whereas, those caused by trauma, tumours or congenital deformities are more common in individuals under the age of 50 years.

It is important to know the cause of an amputation from an exercise perspective because the purpose of the exercise therapy will differ slightly. If an amputation was caused by a vascular disease, then it is important that the exercise programme focuses on reducing the progression of the associated vascular condition. On the other hand, the purpose of the exercise programme for those with amputations caused by trauma, tumours or congenital deformities is the same as that for able-bodies individuals, the aim being, to reduce the risk of diseases associated with a sedentary lifestyle, such as high cholesterol, high blood pressure, diabetes and obesity. Individuals who have had an amputation are at greater risk of developing these diseases, as they are more likely to be sedentary, purely because of their physical limitation. However, this should not be an excuse not to exercise, as there is a wide variety of exercises that can still be performed.

Depending on the level of amputation – at the foot, below the knee, above the knee or at the hip – various factors must be considered when planning an exercise programme. Appropriate exercise modalities need to be chosen according to the individual’s physical capabilities and current level of fitness. Swimming and arm ergometry are generally both safe and appropriate forms of exercise for most lower-limb amputees. Strengthening exercises are important and can usually be done with minor adaptations. It is generally more safe to use machines, rather than free weights, because an amputee’s balance is more likely to be compromised.

Walking is important to enable individuals to become as independent as possible; however, one cannot overdo it. Individuals with a prosthetic leg are susceptible to sores and infections, as a result of the prosthesis rubbing on the skin. This can cause further disability if the sores do not heal. These individuals also expend more energy when walking than able-bodied individuals and so cannot walk as far or for as long. Phantom pain, a common complaint of amputees, is pain experienced in the amputated limb. This pain ranges from mild to severe and can also hinder one’s exercise ability.

Although amputation is considered a disability, there is still a wide range of movement and functional exercises that amputees can achieve, ranging from the normal daily activities to competitive sport. It is crucial that one does not give up following an amputation, but rather seeks professional advice, such as that of a biokineticist, to assist in implementing an appropriate exercise programme that focuses on the needs and goals of the individual.

References

ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities

Hypermobility Syndrome

Many people experience hypermobility in one or more of their joints. This means that the joint can move beyond the expected normal ranges for that joint. This is often referred to as being “double-jointed”. Usually, this condition has no symptoms and one is able to lead a normal life, unless there is an injury to the joint, causing pain and/or inflammation. If numerous joints are involved and symptoms are present, then one is believed to have hypermobility syndrome. This syndrome has a strong genetic link and thus often runs in families.

Signs and Symptoms

As mentioned earlier, a hypermobile joint often has no symptoms, unless injury to that joint occurs. However, the symptoms of the syndrome include:

·         Pain in the knees, hips, elbows and fingers

·         Clicking in the joints

·         Recurring joint sprains and dislocations due to instability of the joints

·         Fatigue

·         Dizziness and fainting

·         Scoliosis is more common in individuals with hypermobility syndrome and this can result in back pain

·         Joint hypermobility decreases as we get older, as we become less flexible with age

The following signs can be seen in individuals with hypermobility syndrome:

·         The ability to hyperextend the knees and/or elbows past 10 degrees

·         The ability to stand with the palms flat on the floor while keeping the knees straight

·         The ability to touch the thumb to the forearm

Hypermobility syndrome is diagnosed by means of physical examination according to the above-mentioned signs, as well as various additional tests. There is no blood test or x-ray to diagnose this syndrome.

Treatment and Management

Because there are often no symptoms, treatment is often not required. The condition generally improves as individuals get older because flexibility of the joints decreases with age. If a joint has been sprained or dislocated, then that joint will be treated for that specific injury. The pain associated with hypermobility syndrome can be treated with appropriate pain management drugs according to your doctor. Exercise therapy is particularly important in managing this condition, as the muscles surrounding the joints can be strengthened to improve stability of the joints, thereby reducing the risk of injury. A biokineticist can assist in prescribing and monitoring an appropriate exercise programme that strengthens the muscles while minimizing the risk of risk of injury.

Prognosis

Generally, there are few or no long-term side effects of joint hypermobility. However, in severe cases, individuals may develop arthritis at a later stage. It is, therefore, important to manage the condition with appropriate strengthening exercises from an early age to prevent any injuries and long-term side-effects.

References

http://www.medicinenet.com/hypermobility_syndrome/page2.htm

http://www.nhs.uk/Conditions/Joint-hypermobility/Pages/Introduction.aspx

Cerebral Palsy

Cerebral Palsy (CP) is a non-progressive condition that results from a lesion in the brain that occurs either before, during, or shortly after birth, resulting in the abnormal development of the brain. Failure of the brain to develop properly can occur during the first or second trimesters of pregnancy and can be caused by genetic disorders or limited blood supply. A lesion may also develop as a result of injury to the brain before, during, or after birth, such as a traumatic blow to the head or bleeding in the brain.

Depending on the severity of the lesion and the part of the brain affected, individuals with CP will present with varying degrees of disability. However, the general characteristic features of CP are limited mobility, poor coordination, and a limited ability to maintain posture and balance. These individuals may be wheelchair bound, unable to walk at all, or may be able to walk, but with an abnormal gait, or walking pattern. They will also often present with spasticity in the hands and arms, and a misshapen mouth, resulting in drooling and slurred speech. Their cognitive function is usually not affected, therefore, it is important not to treat them as cognitively impaired simply because they drool and have a slurred speech.

Because of the varying degrees of disability in CP patients, every person must be assessed and treated as an individual according to his/her goals and degree of disability. Adaptations to the assessment and management of these individuals will need to be made to accommodate each individual’s needs and goals. Any medications that the individual is taking must be considered, as these may alter his/her response to exercise. It is important to realize that the lesion in the brain cannot be reversed or changed by exercise; however, exercise therapy can help to improve the symptoms of spasticity, poor balance and muscle weakness associated with CP. It is also important to note that a person with CP may experience increased spasticity and decreased coordination shortly after exercise, but this is not uncommon and will return to normal.

Individuals with CP are often sedentary, due to their lack of mobility. This increases their risk of developing sedentary diseases, such as cardiovascular disease and stroke. It is, thus, important that they embark on an appropriate, regular exercise programme in order to reap the physiological and psychological benefits of regular exercise. Improvements in mood and self-esteem are also associated with exercise, which the CP patient will benefit from. The exercise programme should incorporate all the major muscle groups (if still functional) and should be aimed at improving cardiovascular fitness, muscles strength and flexibility, thereby increasing one’s independence to carry out his/her daily activities and, in turn, improving one’s sense of self-worth. A biokineticist can assist in the design, implementation and adaptation of such an exercise programme.

References

ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities

Anterior Cruciate Ligament (ACL) Rehabilitation

A common knee injury amongst the active population is the damage to or rupture of the anterior cruciate ligament (ACL). The role of this ligament is to stabilize the knee joint by stopping the bottom of the leg from collapsing forward under the knee joint, particularly during deceleration, landing, or turning and cutting actions. It is unusual for the ACL to be injured in isolation; often other ligaments and/or the meniscus are also injured. Those at greater risk of tearing the ACL are, therefore, those involved in jumping and pivoting sports, as well as contact sports, such as soccer and rugby. A muscle strength imbalance between the hamstrings and the quadriceps muscles (back and front of the thigh respectively) can also increase the risk of this injury occurring.

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Signs and Symptoms

As the injury occurs, a popping, tearing, or snapping sensation may be heard or felt, followed by swelling around the knee joint. Pain may be felt immediately or occur later and may range from mild to severe. The pain may be felt deep in the knee joint or, more commonly, on the front side of the knee. Generally, one is able to walk on the affected leg; however, this is often associated with a feeling of the knee wanting to collapse or a general feeling of discomfort. Because of the high likelihood of other surrounding tissues being damaged as well, it is important to consult a specialist for further investigation.

Management

Depending on the severity of the damage to the ACL and the involvement of the surrounding structures, an ACL injury is either treated conservatively or surgically.

Conservative management involves rest, ice, compression, elevation and immobilization of the knee joint to reduce swelling. Crutches can be used if walking is too painful. Pain-free range of motion exercises are performed to maintain mobility in the joint. Gentle and appropriate strengthening exercise are done to maintain muscle strength. Physiotherapy is very important in these initial stages of recovery. Upper body exercises can be continued throughout the recovery period. Strengthening, range of motion and proprioception and balance exercises can be progressed appropriately by a biokineticist until the individual is back to full function. This can take anywhere between 6 weeks to 3 months, depending on the severity of the injury and the compliance of the individual with the rehabilitation programme.

If there is a complete rupture of the ACL or multiple surrounding tissues are also affected, surgery is usually recommended so that an individual can return to contact or pivoting-type sports. Depending on the other structures damaged, the repair and recovery will be slightly different. A graft is taken from the hamstring muscle to repair the ACL, which means that the hamstring muscle also needs to be carefully rehabilitated and strengthened to avoid a later hamstring injury. After surgery, the affected leg is immobilized in a full-leg brace, which can be locked at various degrees of flexion and extension. One will more than likely be non-weight-bearing for between 2 and 6 weeks, again depending on damage to other structures, such as the meniscus. Physiotherapy is crucial to maintain range of movement in the joint and reduce swelling. Again, gentle strengthening exercises are done to maintain muscular strength around the knee. Once the brace is removed, the rehabilitation will follow in a similar fashion to the conservative treatment plan, progressing appropriately with the guidance of a biokineticist, with an additional focus on the rehabilitation of the affected hamstring muscle. If properly rehabilitated, one should be able to return to sport if they have not lost the nerve to do so.

References

Foundations of Athletic Training: Prevention, Assessment and Management