If the clinician diagnoses that the joint is the likely cause of the presenting pain and other symptoms then the differential diagnosis is the next decision to be made. Inflammatory arthritis affects the synovial lining of the joint and the tendon-bone and ligament-bone insertions. If the arthritis is not inflammatory then changes in the joint structure and function can occur such as tears to the menisci or degenerative changes to the joint surface, with a number of possible causes contributing to the overall joint condition.

In some cases knee pain may be present without obvious pathological change, perhaps due to a pain syndrome such as fibromyalgia or in very early symptoms of a condition. A joint can have several different sorts of disorder at any one period and a joint can become steadily damaged and less stable by being affected by an inflammatory condition. Pain is one of the cardinal signs of inflammatory joint change and is typically not better on rest and increased on activity and movement, especially the beginning. In wear and tear arthritic joint changes the pain is mainly relieved by rest and aggravated by movement or weight bearing.

Advanced arthritic changes in the major joints or spine can cause pain at rest and also disturb sleep. Hip joint pain and that of larger joints is less easy to localise than that in smaller joints, with pain referred from the hip appearing potentially in several areas including the buttocks, the groin, the side of the hip and down the front of the thigh. Stiffness is hard to pin down but relates to a perceived difficulty with moving a joint, particularly following a period of inactivity and which improves with continuing motion. Typical stiffness of an osteoarthritic joint may last ten to fifteen minutes but the duration can be an hour or more in inflammatory arthritis.

There are several changes which can occur in a joint to make it swell. If the joint is affected by non-inflammatory arthritis then bony growths form at the margins of the joints and the end of the fingers or the knees become knobbly joints. Or an effusion, a collection of fluid within a joint capsule, can form secondary to inflammatory disease and can be drawn off by injecting the joint. It is common for an affected joint to show a degree of loss of movement either because the soft tissues have tightened up, the joint is damaged anatomically or by restriction from pain and inflammation.

Activities of daily living are often affected by arthritic change such as dressing, self care and stair climbing, often secondary to muscle weakness and atrophy. If pain accompanies weakness the cause is likely musculoskeletal rather than neurological or due to muscle pathology. Weakness can cause functional problems such as gripping things, getting up and down from sitting or walking safely. In systemic arthritis the whole person is involved in the disease and malaise and fatigue are common. An arthritis can develop slowly or can come on quickly, joint symptoms occurring over a few hours, in response to injury, infection or crystal deposition.

It is more typical for symptoms to develop over a period of weeks or months, and this commonly occurs in rheumatoid arthritis and osteoarthritis, the two most common types. Acute occurs for less than six weeks, sub-acute from six to twelve weeks and chronic if lasting more than twelve weeks. Joint inflammation can persist in affected joints as new joints are affected or episodic occurrence of joint symptoms with pain free periods between such as gout. The number of joints affected also varies, with monoarthritis affected a single joint, oligoarthritis involving two to four and polyarthritis affecting five or more.

Non-symmetrical and symmetrical joint patterns of involvement can occur. SLE and rheumatoid arthritis tend to affect the same joints on each side of the body in a symmetrical pattern while psoriatic arthritis and reactive arthritis involve different joints on each side of the body, the asymmetrical pattern. Joints may be involved in different patterns also, for example distal finger joints in osteoarthritis and psoriatic arthritis but not in rheumatoid arthritis.

Osteoporosis is a truly global problem which affects huge numbers of people across the world. Women have a risk that they will have an osteoporotic fracture during their life of 30-40% and for men the equivalent risk is around 13%. These figures do not express the pain and disability which can occur with this bone wasting condition and research into basic biology and drug and other therapies continues strongly. Osteoporosis is a silent condition, with the patient mostly having no idea until something happens to make them realise. The importance of testing and the effectiveness of treatment both need emphasising to health professionals and the general public.

Osteoporosis is a common condition, with half of all women above fifty years old affected and nearly 90 percent of women over 75 years. It is a very common cause of fractures, with 1.5 million fractures from osteoporosis in the United States per year alone. Fracture of the neck of femur, generally referred to as hip fractures, are common and 5-20% of sufferers die in the ensuing months of the complications. Osteoporosis also has very high health costs from fractures and from the disability resulting, especially the pain and restriction from vertebral fractures.

The single greatest risk factor for getting osteoporosis is for a woman to have reached or passed the menopause, due to the reduction or abolition of the secretion of hormones which were protective of the bone density during younger adult life. Additional risk factors are smoking, drinking a lot of alcohol, hormone lack, being female, age, low calcium concentrations and a family history of the condition. Doctors are likely to investigate whether osteoporosis is present if there is a fracture without enough force to fracture normally, if there are other risk factors plus the menopause and if the person is over 65 years old.

There are few signs and symptoms of osteoporosis until something goes wrong such as an acute spinal fracture whilst bending over or lifting a weight. Spinal fracture pain is very sharp and limiting so the patient has no doubt something has occurred. Lumbar and thoracic pain is common and the thoracic curve may be increased due to anterior compression fractures of the vertebral bodies, with a dowagers hump and a distinct loss of height from their normal adult level. Any fracture occurring in normal activity should be investigated for the cause. Osteoporosis may be a clear diagnosis with compression fractures and thin bones on x-ray but a DEXA scan can document the severity and the change with treatment.

Osteoporosis prevention encompasses lifestyle change, eating a diet rich in vitamin D and calcium, avoiding smoking and excessive alcohol and engaging in weight bearing exercise. HRT (hormone replacement therapy) is used to prevent this condition in women who are past the menopause. Drugs include bisphosphonates, HRT, selective oestrogen receptor modulators and calcium and vitamin D supplements. The development of new bone rather than stopping the loss might be achievable with an anabolic drug. When we are young we lay the groundwork for our bone mass so should be encouraged to eat well and engage in weightbearing exercises to ensure a good bone density.

Vertebroplasty is an innovation in treating the acute and severe pain of recent vertebral fracture by injecting cement into the anterior part of the vertebral body to take some of the strain that the bone struts are unable to take. Relief of pain can be considerable and the procedure is done by a radiologist under x-ray guidance. Falls are a particular risk as patients fracture so easily so exercise, stronger muscles, improved balance, coordination and agility are all helpful strategies to prevent risk. Due to the ongoing difficulties with this condition, psychological and practical help may be important parts of treatment.

Bone mass and exercise are closely related and physiotherapists take exercise classes in clinics to encourage patients to exercise regularly. Younger people should be encouraged to exercise to build their initial bone mass. Exercises with impact affect the bones more strongly so walking or jogging is good rather than swimming. Improvement can occur with anyone of any age as long as they are guided by a skilled physiotherapist.

Everyone suffers difficulties and adversity of some kind, examples of which are mental illness, disability, pain, illness and stress. Not everything is under our control and we have widely varying ways and success of dealing with these stresses. How content we are with our lives and how effective we are at life management depends on our ability to cope with these events. If we can be realistic and generate a plan for managing then success is the more likely outcome. What happens to us when we suffer setbacks is complex and we need to address several parts of the situation.

All the difficulties in life which challenge us strongly have one thing in common, they involve loss. When we get a pain problem we lose the normal comfort of our bodies which is a loss as we find we cannot sit for so long, drive so far, dig the garden as we used to. Some of these changes are slow changes which inevitable follow becoming older but even these can be challenging to cope with and accept. How much harder is it to cope with the more sudden or more profound changes which might occur at a much earlier age than we expected.

Other losses we can suffer are loss of a relationship, death of a loved one, loss of job, loss of role in life, loss of income, loss of a part of the body and so a loss of our sense of self and self-esteem. Loss of some kind which leads to the single most disabling condition in the world, depression. When we are depressed we undergo a change in our brain chemistry which causes us to think negatively and to apply a continual negative bias to all our thinking and conclusions. This is important for its own sake in terms of our mental state but also because a high proportion of depressed people suffer a pain condition of some kind.

As we struggle to come to terms with our losses we can fall into depression and become hopeless and be unable to take the actions which would help us out of our situation and thereby alleviate our depression. This position may need cognitive therapy and/or antidepressant medication to start the process of a more realistic interpretation of our position and so begin to lift the negativity we have fallen into. If we do not become depressed we may react in another typical and natural way to our losses by fighting against them.

I’m just not going to let the pain beat me is a very common sentence uttered by pain patients, turning their condition into a competition which pain is not going to win. This strategy is commonly pursued as people try to maintain control in bad circumstances, pushing themselves to keep going with their duties. There is a significant downside here though and that is the very high costs of holding a continuing battle with pain by pushing on, leading to a decline of ability, increasing pain and depression.

One of the key concepts here is conflict. Conflict between what we should be able to do and what we can actually do. Conflict leads to feelings of aggression towards the pain and towards the world which is making demands upon us which we cannot satisfy. This way we develop a conflictual relationship with others and with ourselves which leads us to become stuck in one particular approach This is mostly because we have not moved towards one of the most useful reactions to a problem we can’t do much about, acceptance.

Acceptance is an important concept and not to be confused with resignation. Resignation is where we give in to the things which have happened to us and feel whatever we do will be ineffective, nothing will achieve a positive change and we just have to put up with it no matter how bad the situation is. This is a negative interpretation of our situation will inevitably lead towards a depressive state and prevent the person from taking any steps to improve their situation. So resignation is an undesirable state and learning acceptance is likely to be more functional and have better consequences for our futures.

by Jonathan Blood Smyth

Cryotherapy or cold therapy is a widespread treatment modality used by physiotherapists to treated chronic and acute conditions of differing kinds. It is safe if regard is taken of the indications and contraindications and it is simple to use and to teach patients to self manage their pain problems. Sports physiotherapists and other physiotherapists managing acute injuries use cryotherapy due to its ease of use and lack of expensive equipment needed. The contraindications and indications to ice or cold treatment should be familiar to the physiotherapist before use. Cold water, cold packs, crushed or cubed ice may be used.

As warming of the cold water or melting of the ice occurs heat is carried away from the body as the cold therapy proceeds. The main biological effects on the body are local metabolic reduction, reduction of tissue bleeding, lowering of muscle efficiency, a reduction in pain due to the sedatory effect of cold on transmission of nerves, an increase in local circulation once the blood vessel constriction phase has passed and a reduction in the amount of swelling and tissue oedema which occurs. Cold therapy also reduces spasticity and spasm in muscles as a secondary effect of reduction of pain by the cold.

Many conditions benefit from the use of cold therapies and the effects are used to reduce oedema and swelling after an injury, a reduction in muscle spasticity once the muscle has cooled after a certain time, a lowering in pain, acute inflammatory inhibition such as required after acute injury, facilitation of a local increase in circulation and a lessening of muscle spasm. To facilitate contraction of muscles for functional muscle re-education physiotherapists will use ice and to increase ranges of movement after injury by stimulating muscle contraction.

Tissue damage from an injury to an area increases the blood supply locally, is hotter and suffers from oedema, all secondary to heightened tissue metabolism as the area reacts to damage. At this early stage these responses need to be damped down so cold is preferred over heat which would increase them. Cold reduces inflammation, eases pain, prevents swelling and slows the metabolic rate of the injured tissues, encouraging injury healing. It is important to get the cold onto the injured part as close to the precipitating event as you can, with compression if possible. Compression has been shown to be effective and may be more important than the cold.

As with all therapies there are risks involved in applying cold to the skin and these should be understood before using this therapy. Physiotherapists know the contraindications to cold therapy and assess the area for normal sensation, unbroken skin and normal skin texture and colour. Oil applied to the skin can protect against the amount of cooling and reduce the skin risks. An ice pack is typically used, crushed ice being placed in a towelling bag which is then placed snugly around the body part. The towelling should be wet or cooling will be limited and any air gaps between the ice pack and the skin will again reduce the cooling effect.

Patients often use packs of frozen peas as reusable cold applications and they can be very useful but there is a possible danger. Peas from the freezer come out at minus 18 degrees centigrade and this can be damaging to the skin if put straight onto it. Patients are advised always to put a wet tea towel or other wet cloth between their skin and the frozen pack in order to reduce the likelihood of local frostbite, a form of cold induced skin damage. Cold can be applied for a length of time varying from five to twenty minutes, although it is wise to check after five or ten minutes to make sure there is no excess skin reaction, such as the development of white spots which can indicate over cooling of the skin.

Pain after operative intervention or acute injuries are good subjects for cold therapy in the first two days after onset to control inflammation and pain. Areas of altered skin sensibility should be avoided as they may react abnormally and other contraindications are arterial insufficiency, cold allergy, Reynauds syndrome and lower limb ischaemia. Physiotherapists use various techniques including cold packs, water immersion, contrast baths, spray and stretch and massage with ice. Myofascial pain syndrome trigger points are treated with spray and stretch.

About the Author:

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Solihull, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Colles’ fractures, named after Abraham Colles who first described in 1814 the common fracture of the last inch of the radius and ulna near the wrist, is a very common consequence of a fall on the outstretched hand (FOOSH). Typical treatment is immobilisation in a plaster of Paris or similar material for five to six weeks to allow bony union, followed by a rehabilitation period of a month or more, a short period of which might involve a wrist brace for comfort during activity. Due to the functional importance of the hand, the period of immobilisation is kept to a minimum to prevent dysfunction of the hand and wrist.

Once the hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand.

Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles’ fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.

After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.

Joint mobilisations are used commonly by physiotherapists to improve joint ranges of motion if the exercises do not improve this alone. Physiotherapists perform accessory movements, so called mobilisation techniques, whereby they move the patient’s joint passively to re-establish the vital gliding and sliding movements. The midcarpal, radiocarpal (wrist) and lower radio-ulnar joints can be treated this way to increase the ranges, the physiotherapist fixing one part of the joint firmly as they move the other half. This can be done with gentle movements or much more strongly, pushing against the resistance of the stiff joint structures which are preventing full movement.

Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.

In some cases a pain syndrome can develop in the hand with tight swelling, poor joint motion, high pain and hypersensitivity, at which time a doctor’s opinion is needed to exclude complications with the fracture such as non-union. Painkillers and contrast bathing are treatments for the pain, with self massage used for swelling and desensitising techniques for the abnormal sensibility. The patient should be clear that they have to go through significant pain to get their hand better again.