Risky Stretches

The following stretches (many of which are commonly performed) are considered risky (M. Alter uses the term `X'-rated) due to the fact that they have a very high risk of injury for the athlete that performs them. This does not mean that these stretches should never be performed. However, great care should be used when attempting any of these stretches. Unless you are an advanced athlete, you can probably do without them (or find alternative stretching exercises to perform). Each of these stretches is illustrated in detail in the section X-Rated Exercises of M. Alter:

the yoga plough
In this exercise, you lie down on your back and then try to sweep your legs up and over, trying to touch your knees to your ears. This position places excessive stress on the lower back, and on the discs of the spine. Not to mention the fact that it compresses the lungs and heart, and makes it very difficult to breathe. This particular exercise also stretches a region that is frequently flexed as a result of improper posture.

the traditional backbend
In this exercise, your back is maximally arched with the soles of your feet and the palms of your hands both flat on the floor, and your neck tilted back. This position squeezes (compresses) the spinal discs and pinches nerve fibers in your back.

the traditional hurdler's stretch
This exercise has you sit on the ground with one leg straight in front of you, and with the other leg fully flexed (bent) behind you, as you lean back and stretch the quadricep of the flexed leg. The two legged version of this stretch is even worse for you, and involves fully bending both legs behind you on either side. The reason this stretch is harmful is that it stretches the medial ligaments of the knee (remember, stretching ligaments and tendons is bad) and crushes the meniscus. It can also result in slipping of the knee cap from being twisted and compressed.

straight-legged toe touches
In this stretch, your legs are straight (either together or spread apart) and your back is bent over while you attempt to touch your toes or the floor. If you do not have the ability to support much of your weight with your hands when performing this exercise, your knees are likely to hyperextend. This position can also place a great deal of pressure on the vertebrae of the lower lumbar. Furthermore, if you choose to have your legs spread apart, it places more stress on the knees, which can sometimes result in permanent deformity.

Torso twists
Performing sudden, intense twists of the torso, especially with weights, while in an upright (erect) position can tear tissue (by exceeding the momentum absorbing capacity of the stretched tissues) and can strain the ligaments of the knee.

Inverted Stretches
This is any stretch where you "hang upside down". Staying inverted for too long increases your blood pressure and may even rupture blood vessels (particularly in the eyes). Inverted positions are especially discouraged for anyone with spinal problems.

EXERCISES

BENDING THE WRIST TO A TARGET:
Physiotherapist`s aim:
To improve the ability to extend the wrist.
Client`s aim:
To improve your ability to straighten your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with their forearm pronated and resting on a block on a table in front of them.
Place a cup in their hand, a sandbag on their forearm and tape a flexible straw to the dorsal surface of their forearm with the joint of the straw aligned with their wrist joint.
Instruct the patient to extend their wrist to touch the tip of the straw and then relax their wrist back into flexion.
Client`s instructions:
Position yourself sitting with your forearm resting on a block on a table in front of you and your palm facing down.
Place a cup in your hand, a sandbag on your forearm and tape a flexible straw to the top of your forearm so that the bend of the straw is over your wrist.
Practice straightening your wrist so that your hand touches the tip of the straw then relaxing your hand back down again.
Progressions and variations:
Less advanced: 1. Bend the straw down to decrease the range that the wrist needs to move through. 2. Hold a cup with a smaller diameter.
More advanced: 1. Bend the straw up to increase the range that the wrist needs to move through. 2. Hold a cup with a larger diameter. 3. Hold a cup that can deform.


BENDING THE WRIST WHILE HOLDING A CUP:
Physiotherapist`s aim:
To improve the ability to radially deviate the wrist.
Client`s aim:
To improve your ability to bend your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with their hand grasping a cup and hanging over the edge of a table.
Instruct the patient to tilt the cup up by radially deviating their wrist.
Client`s instructions:
Position yourself sitting with your hand grasping a cup and hanging over the edge of a table. Practice tilting the cup up by bending your wrist.
Progressions and variations:
Less advanced: 1. Move the cup through a smaller range of motion. 2. Use a cup with a smaller diameter.
More advanced: 1. Move the cup through a larger range of motion. 2. Use a cup with a larger diameter. 3. Use a cup that can deform. 4. Add water to the cup.


BICEPS ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the elbow flexors.
Client`s aim:
To strengthen your biceps.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of the elbow flexors.
Client`s instructions:
Place the two electrodes over the muscle belly as shown.
Precautions:
1. Perform skin tests.


BILATERAL ANKLE PLANTORFLEXOR STRETCH USING A WEDGE WHILE STANDING AGAINST A WALL:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing with their back against a wall and both feet on a wedge.
Ensure that their knees are kept straight and both feet point forwards.
Client`s instructions:
Position yourself standing with your back against a wall and both feet on a wedge.
Ensure that you keep your knees straight and both feet point forwards.
Progressions and variations:
Less advanced: 1. Decrease the angle of the wedge.
More advanced: 1. Increase the angle of the wedge.
Precautions:
1. Impaired or absent sensation of stretch.


BILATERAL ANKLE PLANTORFLEXOR STRETCH USING A WEDGE WHILE STANDING AT A TABLE:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing with both feet on a wedge and a table in front.
Ensure that their knees are kept straight and both feet point forwards.
Client`s instructions:
Position yourself standing with both feet on a wedge and a table in front.
Ensure that you keep your knees straight and both feet point forwards.
Progressions and variations:
Less advanced: 1. Decrease the angle of the wedge.
More advanced: 1. Increase the angle of the wedge.
Precautions:
1. Impaired or absent sensation of stretch.


BILATERAL CALF RAISES:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing.
Instruct the patient to plantarflex their ankles.
Client`s instructions:
Position yourself standing with your feet together.
Start with your heels on the ground.
Finish with your heels off the ground.
Progressions and variations:
Less advanced: 1. Provide hand support for balance.
More advanced: 1. Progress using strength training principles.


BILATERAL CALF RAISES ON A BLOCK:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing on a step with their heels off the edge.
Instruct the patient to plantarflex their ankle.
Client`s instructions:
Position yourself standing on a step with your heels off the edge.
Lift your body weight up onto your toes.
Progressions and variations:
Less advanced: 1. Provide hand support for balance.
More advanced: 1. Wear a backpack with weights in it. 2. Progress using strength training principles.

EXERCISES.

ASCENDING A STEP USING A DOORWAY:
Physiotherapist`s aim:
To improve the ability to ascend a step in a wheelchair.
Client`s aim:
To improve your ability to ascend a step in your wheelchair.
Physiotherapist`s instructions:
Position the patient in their wheelchair below a step.
Instruct the patient to use the doorway to pull themselves up over the step.
Client`s instructions:
Position yourself in your wheelchair below a step.
Practice using the doorway to pull yourself up over the step.
Progressions and variations:
Less advanced: 1. Decrease the height of the step.
More advanced: 1. Increase the height of the step.
Precautions:
1. Caution required to prevent forward fall from wheelchair.


ATTAINING A WHEELSTAND:
Physiotherapist`s aim:
To improve the ability to attain a wheelstand.
Client`s aim:
To improve your ability to attain a wheelstand.
Physiotherapist`s instructions:
Position the patient in their wheelchair.
Instruct the patient to flip the wheelchair into a wheelstand.
Client`s instructions:
Position yourself in your wheelchair.
Practice flipping your wheelchair into a wheelstand.
Progressions and variations:
Less advanced: 1. Perform the task on a flat surface.
More advanced: 1. Manoeuvre the wheelchair in different directions while maintaining a wheelstand.
2. Perform the task on a slope.
3. Add a weighted bag to the front or back of the wheelchair.
Precautions:
1. Ensure that wheelchair does not flip backwards.


BALANCING ON A BALL:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a large ball that is wedged between two plinths.
Instruct the patient to lift their hands up in the air without falling.
Client`s instructions:
Position yourself sitting on a large ball that is wedged between two plinths.
Practice lifting your hands up in the air without falling.
Progressions and variations:
Less advanced: 1. Sit on a plinth.
More advanced: 1. Change the size of the ball. 2. Add a concurrent task while sitting on the ball.


BALANCING ON A BALL WHILE LIFTING ONE LEG UP AND DOWN:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a large ball with their feet on the floor.
Instruct the patient to lift then lower one leg.
Client`s instructions:
Position yourself sitting on a large ball with your feet on the floor.
Practice lifting one leg up and down.
Progressions and variations:
Less advanced: 1. Provide hand support for balance. 2. Decrease the height that the leg is lifted. More advanced: 1. Increase the height that the leg is lifted. 2. Increase the movement of the raised leg (eg. add knee extension or hip abduction).


BALANCING WHILE SITTING ON A MOVING OBJECT:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a moveable object while holding onto a rope.
Instruct the patient to sit upright while getting towed across the floor.
Client`s instructions:
Position yourself sitting on a moveable object while holding onto a rope.
Practice sitting upright while getting towed across the floor.
Progressions and variations:
Less advanced: 1. Tow the patient in one direction only. 2. Tow at a slow speed.
More advanced: 1. Tow the patient in many directions. 2. Tow at a faster speed.


BEAR WALKING:
Physiotherapist`s aim:
To strengthen the shoulder and hip muscles.
Client`s aim:
To strengthen your shoulder and hip muscles.
Physiotherapist`s instructions:
Position the patient on their hands and feet with their bottom in the air.
Instruct the patient to `bear-walk` forwards along the floor.
Client`s instructions:
Position yourself on your hands and feet with your bottom in the air.
Practice `bear-walking` forwards along the floor.
Progressions and variations:
More advanced: 1. Practice `bear-walking` in different directions. 2. Increase speed of task.


BENCH PRESS:
Physiotherapist`s aim:
To strengthen the shoulder horizontal adductors and elbow extensors.
Client`s aim:
To strengthen the muscles at the front of your shoulder and chest.
Physiotherapist`s instructions:
Position the patient in supine with their shoulders abducted and elbows flexed.
Instruct the patient to lift the weights above their chest until their elbows are straight.
Client`s instructions:
Position yourself lying on your back with your shoulders out to the side and elbows bent.
Lift the weights above your chest until your elbows are straight.
Progressions and variations:
Progress using strength training principles.


BENDING AND STRAIGHTENING THE WRIST TO TARGETS:
Physiotherapist`s aim:
To improve the ability to flex and extend the wrist.
Client`s aim:
To improve your ability to bend and straighten your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with a cylindrical object on a table in front of them and a sandbag on their forearm.
Draw two target lines on the table to serve as targets for wrist movement.
Instruct the patient to flex and then extend their wrist to the target lines while grasping the object.
Ensure that the forearm does not move.
Client`s instructions:
Position yourself sitting with a cylindrical object on a table in front of you and a sandbag on your forearm. :
Practice bending your wrist backwards and forwards to the target lines while grasping the object.
Ensure that your forearm does not move.
Progressions and variations:
Less advanced: 1. Decrease the distance from the wrist to the target lines. 2. Hold an object with a smaller diameter.
More advanced: 1. Increase the distance from the wrist to the target lines. 2. Hold an object with a larger diameter. 3. Hold an object that can deform. 4. Remove the sandbag holding the forearm in place.


BENDING THE KNEE IN SITTING:
Physiotherapist`s aim:
To improve the ability to flex the knee in preparation for standing.
Client`s aim:
To improve your ability to bend your knee in preparation for standing.
Physiotherapist`s instructions:
Position the patient in sitting with their toes on a line in front of their knee.
Instruct the patient to flex their knee so that their heel touches a line behind their knee.
Client`s instructions:
Position yourself sitting with your toes on a line in front of your knee.
Practice sliding your foot back so that your heel touches a line behind your knee.
Progressions and variations:
Less advanced. 1. Place the lines closer to the heel and toes. 2. Reduce the amount of friction under the foot by using a friction-reducing device (eg. a roller-skate or slidesheet).
More advanced. 1. Place the lines further away from the heel and toes.


BENDING THE KNEE IN SITTING USING A ROLLER SKATE:
Physiotherapist`s aim:
To improve the ability to flex the knee in preparation for standing.
Client`s aim:
To improve your ability to bend your knee in preparation for standing.
Physiotherapist`s instructions:
Position the patient in sitting with one foot strapped into a roller-skate and their other foot on a block.
Instruct the patient to flex and extend their knee so that the roller-skate rolls between the lines on the floor.
Client`s instructions:
Position yourself sitting with one foot strapped into a roller-skate and your other foot on a block. Practice bending and straightening your knee so that the roller-skate rolls between the lines on the floor.
Progressions and variations:
Less advanced. 1. Place the lines closer to the heel and toes.
More advanced. 1. Place the lines further away from the heel and toes.

EXERCISES.

ACTIVE CYCLE FOR UPPER LIMBS:
Physiotherapist`s aim:
To improve fitness.
Client`s aim:
To improve your fitness.
Physiotherapist`s instructions:
Position the patient in their wheelchair with their hands in the paddles of the active cycle. Instruct the patient to cycle with their hands.
Client`s instructions:
Position yourself sitting in your wheelchair with your hands in the paddles of the active cycle. Cycle with your hands.
Progressions and variations:
Less advanced: 1. Decrease the active resistance.
More advanced: 1. Increase the active resistance. 2. Increase duration of exercise.
Precautions:
1. Check for pressure marks in areas where sensation is absent or impaired.


ANKLE DORSIFLEXOR ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of tibialis anterior.


ANKLE DORSIFLEXOR STRENGTHENING IN LONG SITTING:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in long sitting with a target held above their toes.
Instruct the patient to dorsiflex their ankles to touch the target with their toes.
Client`s instructions:
Position yourself sitting with your legs in front of you and a target held above your toes.
Practice bending your ankles to touch the target with your toes.
Progressions and variations:
Less advanced: 1. Decrease the distance to the target.
More advanced: 1. Increase the distance to the target.


ANKLE DORSIFLEXOR STRENGTHENING IN SITTING USING SANDBAG WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with a weight attached around their toes.
Instruct the patient to dorsiflex their ankle.
Client`s instructions:
Position yourself sitting with a weight attached around your toes.
Start with your toes on the floor.
Finish with your toes off the floor.
Progressions and variations:
Progress using strength training principles.


ANKLE DORSIFLEXOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their feet flat on the floor and their knees relatively extended. Instruct the patient to dorsiflex the ankles.
Client`s instructions:
Position yourself sitting with your feet together in front of you.
Start with your feet flat on the floor.
Finish with your toes lifted up.
Ensure that you keep your heels on the ground.
Progressions and variations:
Less advanced: 1. Position the feet further forwards. 2. Place a bandage around the knees to hold them together.
More advanced: 1. Position the feet further back.


ANKLE DORSIFLEXOR STRENGTHENING IN STANDING BY KICKING A BALL BACKWARDS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in standing while holding onto a ball.
Instruct the patient to kick the ball over their head.
Ensure that their ankle dorsiflexes.
Client`s instructions:
Position yourself standing while holding onto a ball.
Practice kicking the ball over your head.
Ensure that your foot bends backwards.
Progressions and variations:
Less advanced: 1. Perform the exercise in sitting.
More advanced: 1. Kick the ball further behind.


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SIDELYING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in sidelying.
Instruct the patient to dorsiflex and plantarflex their ankle.
Client`s instructions:
Position yourself lying on your side.
Start with your toes pointing down.
Finish with your toes pointing up.


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SITTING BY DRAWING CIRCLES WITH THE FOOT:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in sitting.
Instruct the patient to draw circles in the air with their toes.
Ensure that only their ankle moves.
Client`s instructions:
Position yourself in sitting.
Practice drawing circles in the air with your toes.
Ensure that only your ankle moves.
Progressions and variations:
Less advanced: 1. Move the ankle up and down only. 2. Make smaller circles.
More advanced: 1. Make larger circles. 2. Vary the ankle movement (eg. write the alpabet).


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SUPINE WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in supine.
Instruct the patient to dorsiflex and plantarflex their ankle.
Client`s instructions:
Position yourself lying on your back.
Start with your toes pointing down.
Finish with your toes pointing up.
Progressions and variations:
Progress using strength training principles.


ANKLE EVERTOR STRENGTHENING IN SITTING WITH ASSISTANCE:
Physiotherapist`s aim:
To strengthen the ankle evertors.
Client`s aim:
To strengthen the muscles on the outside of the ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the patient to evert their ankle and bring their toes to touch a target object.
Client`s instructions:
Position the child in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the child to move their toes outwards and upwards to touch an object with the outside border of their foot.
Progressions and variations:
Less advanced: 1. Position the target object closer to the toes.
More advanced: 1. Position the target object further away from the toes.


ANKLE EVERTOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle evertors.
Client`s aim:
To strengthen the muscles at the outside of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their knees together and ankles slightly apart.
Instruct the patient to evert their ankles and bring the medial malleoli to touch together.
Ensure that the knees are kept still.
Client`s instructions:
Position yourself sitting with your knees together and ankles slightly apart.
Start with your feet flat on the floor.
Finish with outside of your soles lifted off the floor and the inside part of your ankles touching together.
Ensure that your knees are kept still.
Progressions and variations:
Less advanced: 1. Place a bandage around the knees to hold them together.
More advanced: 1. Perform the exercise in standing.


ANKLE INVERTOR STRENGTHENING IN SITTING WITH ASSISTANCE:
Physiotherapist`s aim:
To strengthen the ankle invertors.
Client`s aim:
To strengthen the muscles on the inside of the ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the patient to invert their ankle and bring their toes to touch a target object.
Client`s instructions:
Position the child in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the child to move their toes inwards and upwards to touch a target object with the inside border of their foot.
Progressions and variations:
Less advanced: 1. Position the target object closer to the toes.
More advanced: 1. Position the target object further away from the toes.


ANKLE INVERTOR/EVERTOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle invertors and evertors.
Client`s aim:
To strengthen the muscles on the inside and outside of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting.
Instruct the patient to invert and evert their ankle.
Client`s instructions:
Position yourself sitting with your feet on the floor.
Start with the soles of your feet facing in.
Finish with the soles of your feet facing out.
Ensure that your knees are kept still.
Progressions and variations:
Progress using strength training principles.


ANKLE PLANTARFLEXOR STRENGTHENING IN SITTING USING SANDBAG WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in sitting with a weight attached to the top of their knee.
Instruct the patient to lift their heel off the floor by plantarflexing their ankle.
Client`s instructions:
Position yourself sitting with a weight attached to the top of your knee.
Start with your feet flat on the floor.
Finish with your heel off the floor.
Ensure that you keep your toes on the floor.
Progressions and variations:
Progress using strength training principles.


ANKLE PLANTORFLEXOR STRENGTHENING IN SITTING USING THERABAND:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions
Position the patient in sitting with their foot on a wedge and some theraband attached under the wedge and over the top of their knee.
Instruct the patient to lift their heel off the wedge by plantarflexing the ankle.
Client`s instructions:
Position yourself sitting with your foot on a wedge and some theraband attached under the wedge and over the top of your knee.
Start with your foot flat on the wedge.
Finish with your heel off the wedge.
Ensure that you keep your toes on the wedge.
Progressions and variations:
Less advanced: 1. Downgrade the colour of the theraband.
More advanced: 1. Upgrade the colour of the theraband.


ANKLE PLANTORFLEXOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in sitting with their knees together.
Instruct the patient to lift their heels off the floor by plantarflexing the ankles.
Client`s instructions:
Position yourself sitting with your knees together.
Start with your feet flat on the floor.
Finish with your heels lifted off the floor.
Ensure that you keep your toes on the floor.
Progressions and variations:
Less advanced: 1. Place a bandage around the knees to hold them together.
More advanced: 1. Place a weight over the knees.


ANKLE PLANTORFLEXOR STRENGTENING IN STANDING USING A WEDGE:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing against a wall with their foot on a wedge and their other foot resting on a stool in front of them.
Instruct the patient to lift their heel off the wedge by plantarflexing their ankle.
Ensure that most of the weight is borne through the leg on the wedge, the knee is kept straight and the back remains against the wall.
Client`s instructions:
Position yourself standing against a wall with your foot on a wedge and your other foot resting on a stool in front of you.
Start with your foot flat on the wedge.
Finish with your heel lifted off the wedge and standing on your toes.
Ensure that most of your weight is borne through the leg on the wedge, your knee is kept straight and your back remains against the wall.
Progressions and variations:
Less advanced: 1. Move the stool closer. 2. Provide hand support for balance.
More advanced: 1. Move the stool further away.


ANKLE PLANTARFLEXOR STRETCH BY WALKING UP A STEEP SLOPE:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing on a steep slope such as a slippery slide.
Instruct the patient to walk slowly up the slope.
Ensure that the back heel remains down and the back leg is kept as straight as possible.
Client`s instructions:
Position yourself standing on a steep slope such as a slippery slide.
Practice walking slowly up the slope.
Ensure that your back heel remains down and your back leg is kept as straight as possible.
Progressions and variations:
Less advanced: 1. Decrease the incline of the slope. 2. Provide hand support for balance.
More advanced: 1. Increase the incline of the slope.
Precautions:
1. Impaired or absent sensation of stretch.


ANKLE PLANTORFLEXOR STRETCH IN STANDING:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankle.
Physiotherapist`s instructions:
Position the patient in standing with one leg in front of the other and their hands resting on a wall.
Instruct the patient to lean forwards while keeping the back leg straight.
Ensure that both feet point forwards and the back heel remains on the ground.
Client`s instructions:
Position yourself standing with one leg in front of the other and your hands resting on a wall. Lean forwards while keeping your back leg straight.
Ensure that both feet point forwards and your back heel remains on the ground.
Progressions and variations:
Less advanced: 1. Decrease forwards lean.
More advanced: 1. Increase forwards lean.
Precautions:
1. Impaired or absent sensation of stretch.


ANTERIOR DELTOID ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the shoulder flexors.
Client`s aim:
To strengthen the muscles at the front of your shoulder.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of the anterior deltoid.
Client`s instructions:
Place the two electrodes over the muscle belly as shown.
Precautions:
Perform skin tests.

STROKE OR CVA

DEFINITION:
= A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.




DESCRIPTION:
# A stroke occurs when blood flow is interrupted to part of the brain.
# Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die.
# Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death.
# A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA).




INCIDENCE:
= more than one-half million people in the United States experience a new or recurrent stroke each year
= stroke is the third leading cause of death in the United States and the leading cause of disability
= stroke kills about 160,000 Americans each year, or almost one out of three stroke victims
three million Americans are currently permanently disabled from stroke
in the United States, stroke costs about $30 billion per year in direct costs and loss of productivity
= two-thirds of strokes occur in people over age 65 but they can occur at any age
strokes affect men more often than women, although women are more likely to die from a stroke
= strokes affect blacks more often than whites, and are more likely to be fatal among blacks
Stroke is a medical emergency requiring immediate treatment.
= Prompt treatment improves the chances of survival and increases the degree of recovery that may be expected.
= A person who may have suffered a stroke should be seen in a hospital emergency room without delay.
= Treatment to break up a blood clot, the major cause of stroke, must begin within three hours of the stroke to be effective.
= Improved medical treatment of all types of stroke has resulted in a dramatic decline in death rates in recent decades.
= In 1950, nine in ten died from stroke, compared to slightly less than one in three in the twenty-first century.
= However, about two-thirds of stroke survivors will have disabilities ranging from moderate to severe.
CAUSES:
# There are four main types of stroke.
# Cerebral thrombosis and cerebral embolism are caused by blood clots that block an artery supplying the brain, either in the brain itself or in the neck.
# These account for 70-80% of all strokes.
# Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the brain.
# Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the flow of blood through the affected vessel.
# Clots most often form due to "hardening" (atherosclerosis) of brain arteries.
# Cerebral thrombosis occurs most often at night or early in the morning.
# Cerebral thrombosis is often preceded by a transient ischemic attack, or TIA, sometimes called a "mini-stroke."
# In a TIA, blood flow is temporarily interrupted, causing short-lived stroke-like symptoms. #Recognizing the occurrence of a TIA, and seeking immediate treatment, is an important step in stroke prevention.
# Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free.
# If it becomes lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke.
# The most common cause of cerebral embolism is atrial fibrillation, a disorder of the heart beat. # In atrial fibrillation, the upper chambers (atria) of the heart beat weakly and rapidly, instead of slowly and steadily.
# Blood within the atria is not completely emptied.
# This stagnant blood may form clots within the atria, which can then break off and enter the circulation.
# Atrial fibrillation is a factor in about 15% of all strokes.
# The risk of a stroke from atrial fibrillation can be dramatically reduced with daily use of anticoagulant medication.
# Hemorrhage, or bleeding, occurs when a blood vessel breaks, either from trauma or excess internal pressure.
# The vessels most likely to break are those with preexisting defects such as an aneurysm.
# An aneurysm is a "pouching out" of a blood vessel caused by a weak arterial wall.
# Brain aneurysms are surprisingly common. According to autopsy studies, about 6% of all Americans have them.
# Aneurysms rarely cause symptoms until they burst.
# Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important preventive strategy.
# Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the brain's surface, just below the protective arachnoid membrane.
# Intracerebral hemorrhages represent about 10% of all strokes, while subarachnoid hemorrhages account for about 7%.
# In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates excess pressure on brain tissue, which can quickly become fatal. #Nonetheless, recovery may be more complete for a person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects usually are not as severe.
# Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells.
# This is one reason why prompt treatment can have such a dramatic effect on final recovery.



RISK FACTORS:
= Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, use of certain medications, and lifestyle choices:
= Age and sex. The risk of stroke increases with age, doubling for each decade after age 55. Men are more likely to have a stroke than women.
= Heredity. Blacks, Asians, and Hispanics have higher rates of stroke than do whites, related partly to higher blood pressure.
= People with a family history of stroke are at greater risk.
Diseases.
=Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation), high blood pressure, prior stroke, or TIA.
= Risk of stroke increases tenfold for someone with one or more TIAs.
= Other medical conditions.
= Stroke risk increases with obesity, high blood cholesterol level, or high red blood cell count.
= Hormone replacement therapy.
= In mid-2003, a large clinical trial called the Women's Health Initiative was halted when researchers discovered several potentially dangerous effects of combined hormone replacement therapy on postmenopausal women.
= In addition to increasing the risk of some cancers and dementia, combined estrogen and progesterone therapy increased risk of ischemic stroke by 31% among study participants.
= Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs.




SYMPTOMS:
# Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start, while symptoms of a thrombotic stroke come on more gradually. Symptoms may include:
# blurring or decreased vision in one or both eyes
# severe headache, often described as "the worst headache of my life"
# weakness,
# numbness,
# paralysis of the face, arm, or leg, usually confined to one side of the body
# dizziness,
# loss of balance or coordination, especially when combined with other symptoms.




DIAGNOSIS:
= The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of symptoms, presence of risk factors, and the exclusion of other possible causes.
= A brief neurological exam is performed to identify the degree and location of any deficits, such as weakness, incoordination, or visual losses.
= Once stroke is suspected, a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that guides therapy.
= Blood and urine tests are done routinely to look for possible abnormalities.
= Other investigations that may be performed to guide treatment include an electrocardiogram, = angiography,
= ultrasound,
= electroencephalogram.




EMERGENCY TREATMENT:
# Emergency treatment of stroke from a blood clot is aimed at dissolving the clot.
# This "thrombolytic therapy" currently is performed most often with tissue plasminogen activator, or t-PA. t-PA must be administered within three hours of the stroke event.
# Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined.
# t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients.
# t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months.
# Patients with clot-related (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases.
# Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or mannitol plus hyperventilation is the most common treatment. #Corticosteroids also may be used. Patients with reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders reversed, if possible.
# Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access.
#Ruptured vessels are closed off to prevent rebleeding.
# For aneurysms that are difficult to reach surgically, endovascular treatment may be used.
# In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm.
# Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery.




REHABILITATION:
= Rehabilitation refers to a comprehensive program designed to regain function as much as possible and compensate for permanent losses.
= Approximately 10% of stroke survivors are without any significant disability and able to function independently.
= Another 10% are so severely affected that they must remain institutionalized for severe disability.
= The remaining 80% can return home with appropriate therapy, training, support, and care services.
= Rehabilitation is coordinated by a team of medical professionals and may include the services of a neurologist, a physician who specializes in rehabilitation medicine (physiatrist), a physical therapist, an occupational therapist, a speech-language pathologist, a nutritionist, a mental health professional, and a social worker.
= Rehabilitation services may be provided in an acute care hospital, rehabilitation hospital, long-term care facility, outpatient clinic, or at home.
= The rehabilitation program is based on the patient's individual deficits and strengths.
= Strokes on the left side of the brain primarily affect the right half of the body, and vice versa. = In addition, in left brain dominant people, who constitute a significant majority of the population, left brain strokes usually lead to speech and language deficits, while right brain strokes may affect spatial perception.
= Patients with right brain strokes also may deny their illness, neglect the affected side of their body, and behave impulsively.
= Rehabilitation may be complicated by cognitive losses, including diminished ability to understand and follow directions.
= Poor results are more likely in patients with significant or prolonged cognitive changes, sensory losses, language deficits, or incontinence.




PREVENTING COMPLICATIONS
# Rehabilitation begins with prevention of stroke recurrence and other medical complications. #The risk of stroke recurrence may be reduced with many of the same measures used to prevent stroke, including quitting smoking and controlling blood pressure.
# One of the most common medical complications following stroke is deep venous thrombosis, in which a clot forms within a limb immobilized by paralysis.
# Clots that break free often become lodged in an artery feeding the lungs.
# This type of pulmonary embolism is a common cause of death in the weeks following a stroke. # Resuming activity within a day or two after the stroke is an important preventive measure, along with use of elastic stockings on the lower limbs.
# Drugs that prevent clotting may be given, including intravenous heparin and oral warfarin.
# Weakness and loss of coordination of the swallowing muscles may impair swallowing (dysphagia), and allow food to enter the lower airway.
# This may lead to aspiration pneumonia, another common cause of death shortly after a stroke.
# Dysphagia may be treated with retraining exercises and temporary use of pureed foods.
# Depression occurs in 30-60% of stroke patients.
# Antidepressants and psychotherapy may be used in combination.
# Other medical complications include urinary tract infections, pressure ulcers, falls, and seizures.




TYPES OF REHABILITATIVE THERAPY
= Brain tissue that dies in a stroke cannot regenerate.
= In some cases, the functions of that tissue may be performed by other brain regions after a training period.
= In other cases, compensatory actions may be developed to replace lost abilities.
= Physical therapy is used to maintain and restore range of motion and strength in affected limbs, and to maximize mobility in walking, wheelchair use, and transferring (from wheelchair to toilet or from standing to sitting, for instance).
= The physical therapist advises on mobility aids such as wheelchairs, braces, and canes.
= In the recovery period, a stroke patient may develop muscle spasticity and contractures, or abnormal contractions.
= Contractures may be treated with a combination of stretching and splinting.
= Occupational therapy improves self-care skills such as feeding, bathing, and dressing, and helps develop effective compensatory strategies and devices for activities of daily living.
= A speech-language pathologist focuses on communication and swallowing skills.
= When dysphagia is a problem, a nutritionist can advise alternative meals that provide adequate nutrition.
= Mental health professionals may be involved in the treatment of depression or loss of thinking (cognitive) skills.
= A social worker may help coordinate services and ease the transition out of the hospital back into the home.
= Both social workers and mental health professionals may help counsel the patient and family during the difficult rehabilitation period.
= Caring for a person affected with stroke requires learning a new set of skills and adapting to new demands and limitations.
= Home caregivers may develop stress, anxiety, and depression.
= Caring for the caregiver is an important part of the overall stroke treatment program.
= Support groups can provide an important source of information, advice, and comfort for stroke patients and for caregivers.
= Joining a support group can be one of the most important steps in the rehabilitation process.




PROGNOSIS:
# Stroke is fatal for about 27% of white males, 52% of black males, 23% of white females, and 40% of black females.
# Stroke survivors may be left with significant deficits.
# Emergency treatment and comprehensive rehabilitation can significantly improve both survival and recovery.
# A 2003 study found that treating people who have had a stroke with certain antidepressant medications, even if they were not depressed, could increase their chances of living longer. #People who received the treatment were less likely to die from cardiovascular events than those who did not receive antidepressant drugs.




PREVENTION:
= Damage from stroke may be significantly reduced through emergency treatment.
= Knowing the symptoms of stroke is as important as knowing those of a heart attack.
= The risk of stroke can be reduced through lifestyle changes:
# quitting smoking
# controlling blood pressure
# getting regular exercise
# keeping body weight down
# avoiding excessive alcohol consumption
# getting regular checkups and following the doctor's advice regarding diet and medicines, particularly hormone replacement therapy.
# Treatment of atrial fibrillation may significantly reduce the risk of stroke.
# Preventive anticoagulant therapy may benefit those with untreated atrial fibrillation. #Warfarin (Coumadin) has proven to be more effective than aspirin for those with higher risk.
# A new drug called ximelagatran (Exanta) with fewer side effects has been introduced in Europe.
# The drug's manufacturer was applying for FDA approval to market the drug for use in preventing stroke and other thromboembolic complications in early 2004.
# In 2003, physicians at the Framingham Heart Study derived new risk scores to help physicians determine which patients with new onset of atrial fibrillation are at higher risk for stroke alone or for stroke or death.
# Screening for aneurysms may be an effective preventive measure in those with a family history of aneurysms or autosomal polycystic kidney disease, which tends to be associated with aneurysms.



KEY TERMS:
= Aneurysm:
# A pouchlike bulging of a blood vessel. Aneurysms can rupture, leading to stroke.


= Atrial fibrillation:
# A disorder of the heart beat associated with a higher risk of stroke.
# In this disorder, the upper chambers (atria) of the heart do not completely empty when the heart beats, which can allow blood clots to form.


=Cerebral embolism:
# A blockage of blood flow through a vessel in the brain by a blood clot that formed elsewhere in the body and traveled to the brain.


= Cerebral thrombosis:
# A blockage of blood flow through a vessel in the brain by a blood clot that formed in the brain itself.


= Intracerebral hemorrhage:
# A cause of some strokes in which vessels within the brain begin bleeding.


=Subarachnoid hemorrhage:
# A cause of some strokes in which arteries on the surface of the brain begin bleeding.


= Tissue plasminogen activator (tPA):
# A substance that is sometimes given to patients within three hours of a stroke to dissolve blood clots within the brain.

DEFINITION:
# Meningitis is an infection that causes inflammation of the membranes covering the brain and spinal cord.
# Non-bacterial meningitis is often referred to as "aseptic meningitis."
# Bacterial meningitis may be referred to as "purulent meningitis."




CAUSES, INCIDENCE, RISK FACTORS:
= The most common causes of meningitis are viral infections that usually resolve without treatment.
= However, bacterial infections of the meninges are extremely serious illnesses, and may result in death or brain damage even if treated.
= Meningitis is also caused by fungi, chemical irritation, drug allergies, and tumors.




TYPES:
# Meningitis - cryptococcal
Syphilitic aseptic meningitis
# Meningitis - H. influenza
# Meningitis - meningococcal
# Meningitis - pneumococcal
# Meningitis - staphylococcal
# Meningitis - tuberculous
# Aseptic meningitis
# Meningitis gram negative
# Carcinomatous meningitis (meningitis due to cancer)


= Acute bacterial meningitis is a true medical emergency, and requires immediate hospital-based treatment.
= Bacterial strains that cause meningitis include Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (meningococcus), Listeria monocytogenes, and many other types of bacteria.
= In the U.S. about 17,500 cases of bacterial meningitis occur each year.


= Viral meningitis is milder and occurs more often than bacterial meningitis.
= It usually develops in the late summer and early fall, often affects children and adults under 30.
= Seventy percent of the infections occur in children under the age of 5.
= Most viral meningitis is associated with enteroviruses, which are viruses that commonly cause intestinal illness.
= However, many other types of viruses can also cause meningitis.
= For example, viral meningitis may occur as a complication in people with genital herpes. =Recently, West Nile virus spread by mosquito bites has become a cause of viral meningitis in most of the U.S.
= In addition to causing viral meningitis, West Nile virus may cause encephalitis in some patients and a polio-like syndrome in others.




SYMPTOMS:
# Fever and chills
# Severe headache
# Nausea and vomiting
# Stiff neck (meningismus)
Sensitivity to light (photophobia)
# Mental status changes
= Additional symptoms that may be associated with this disease:
# Decreased consciousness
# Rapid breathing
# Agitation
Opisthotonos (severe neck stiffness, ultimately resulting in a characteristic arched posture-seen in infants or small children)
# Bulging fontanelles (the soft spots in a baby's skull may bulge)
# Poor feeding or irritability in children
# Meningitis is an important cause of fever in newborn children.
# For this reason, a lumbar puncture is often done on newborns who have a fever of uncertain origin.




SIGNS AND TESTS:
= Lumbar puncture with CSF glucose measurement and CSF cell count
= Gram-stain and culture of CSF (cerebral spinal fluid)
= Chest x-ray to look for other sites of infection
= Head CT scan looking for hydrocephalus, abscess or deep swelling




TREATMENT:
# Antibiotics will be prescribed for bacterial meningitis; the type will vary depending on the infecting organism.
# Antibiotics are not effective in viral meningitis.
# Treatment of secondary symptoms including brain swelling, shock, and seizures will require other medications and intravenous fluids.
# Hospitalization may be required depending on the severity of the illness and the needed treatment.



PROGNOSIS:
= Early diagnosis and treatment of bacterial meningitis is essential to prevent permanent neurological damage.
= Viral meningitis is usually not serious, and symptoms should disappear within 2 weeks with no residual complications.



COMPLICATIONS:
Hearing loss or deafness
Brain damage
Loss of vision
Hydrocephalus




PREVENTION:
# Haemophilus vaccine (HiB vaccine) in children will help prevent one type of meningitis.
# The pneumococcal conjugate vaccine is now a routine childhood immunization and is very effective at preventing pneumococcal meningitis.
# It is highly recommended that household contacts and people with close contact with individuals with meningococcal meningitis receive preventative antibiotics to avoid becoming infected themselves.
# Some communities conduct vaccination campaigns following an outbreak of meningococcal meningitis.
# Military recruits are routinely vaccinated against this form of meningitis because of its high rate of occurrence.
# The American Academy of Pediatrics and the American College Health Association encourage college students (particularly freshmen living in dormitories) to consider being vaccinated with the meningococcal vaccine.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome
What is Carpal Tunnel Syndrome (CTS)?
Carpal tunnel syndrome is a painful disorder of the wrist and hand. CTS is classified as a cumulative trauma disorder. The carpal tunnel is a narrow tunnel formed by the bones and other tissues of your wrist. It is the area under a ligament (a tough, elastic band of tissue that connects bones and organs in place) in front of the wrist. This tunnel protects your median nerve. The median nerve, which passes through the carpal tunnel gives you feeling in your thumb, and index, middle and ring fingers. Repetitive movements of the hand and wrist can cause inflammation of structures (such as tendons and their coverings) that surround the median nerve. The inflammation may compress this nerve, producing numbness, tingling, and pain in the first three fingers and the thumb side of the hand-a condition known as carpal tunnel syndrome.
Symptoms of carpal tunnel syndrome
Numbness or tingling in your hand and fingers, especially the thumb and index and middle fingers.
Pain in your wrist, palm or forearm.
More numbness or pain at night than during the day. The pain may be so bad it wakes you up. You may shake or rub your hand to get relief.
More pain when you use your hand or wrist more.
Trouble gripping objects.
Difficulty gripping or making a fist, to dropping things.
Risk factors
Many activities outside of work may contribute to carpal tunnel syndrome: knitting, sewing, or needlepoint; cooking and housework; TV computer games and home computer work; playing sports or cards; and hobbies or projects like carpentry or using power tools for extended periods of time.
Work-related cumulative trauma of the wrist.
Diseases or conditions that predispose to the development of carpal tunnel syndrome include pregnancy, diabetes, rheumatoid arthritis and obesity.
Jobs require pinching or gripping with the wrist
People at risk include people who use computers, carpenters, grocery checkers, assembly-line workers, meat packers, violinists and mechanics.
Hobbies such as gardening, needlework, golfing and canoeing can sometimes bring on the symptoms.
Diagnosis
Physiotherapist will ask you about your, past medical history, symptoms, social history such as hobbies and occupation. They will then examine you by performing some special tests as following:
Tap the inside of your wrist. You may feel pain or a sensation like an electric shock.
Bend your wrist down for 1 minute to see if this causes symptoms.
Perform a nerve conduction test or an electromyography (EMG) test to see whether the nerves and muscles in your arm and hand
Prognosis
Carpal tunnel syndrome usually isn't serious. With treatment, the pain will usually go away and you'll have no lasting damage to your hand or wrist.
Approximately 1 percent of individuals with carpal tunnel syndrome develop permanent injury. The majority recover completely and can avoid re-injury by changing the way they do repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods when they perform the movements.
Treatment
Physical therapists can target and correct poor work habits and improper work designs, such as tools, furniture, equipment, and work space. They also can assess the risk potential of an individual and determine if that person is physically unsuited for a particular job. They work closely with employers to educate employees about CTS- what causes it and how to avoid it through proper use of the musculoskeletal system. Among their many responsibilities, physical therapists teach health awareness and job safety. A typical education program includes exercises employees can do at work and at home, adjustments to the overall work environment and individual work stations, plus early detection of symptoms to avoid painful and costly surgery.
A physical therapist will begin by observing how employees work and evaluating the ergonomics of the work environment. Ergonomics is the study and control of the effects of postures, stresses, motions, and other physical forces on the human body engaged in work. For instance, computer programmers may be sitting in a chair that forces them to slouch. Their computer screen may be too high, causing stress in the neck and shoulders, and the keyboard may be in a position that forces continued pressure on the wrist muscles. Factory workers standing on their feet all day may have to use tools that are designed for individuals with a larger grip. Their work station may be too high or too low, forcing them into an awkward body position. This action puts added strain on the neck, shoulders, and arms.
A physical therapist can show employees how to adjust their work area, handle tools, or perform tasks in a way that puts less stress on the body. They may teach employees a number of exercises to increase flexibility of their arm/hand region while they are at work. Frequent brief stretching and relaxation exercises can help reduce injuries and improve productivity in the workplace. Physical therapists also suggest short rest breaks after two hours of using the hands.
Prevention
Recent studies have shown that carpal tunnel syndrome, like all other cumulative trauma disorders, is on the rise while other workplace injuries have leveled off. Many companies are turning to physical therapists for help in designing and implementing health promotion and injury prevention programs to protect their employees from CTS.
You may need to wear a wrist splint at night, while playing sports, or when working at home. The wrist splint assists in maintaining the wrist in a neutral or straight position and allows the wrist to rest.
Avoid bending your wrists down for long periods.
Pop up your arm with pillows when you lie down.
Avoid using your hand too much.
Find a new way to use your hand by using a different tool.
Try to use the other hand more often.
Lose weight if you're overweight.
Get treatment for any disease you have that may cause carpal tunnel syndrome.
If you do the same tasks with your hands over and over, try not to bend, extend or twist your hands for long periods.
Don't work with your arms too close or too far from your body.
Don't rest your wrists on hard surfaces for long periods.
Switch hands during work tasks.
Make sure your tools aren't too big for your hands.
Take regular breaks from repeated hand movements to give your hands and wrists time to rest.
Don't sit or stand in the same position all day.
If you use a keyboard a lot, adjust the height of your chair so that your forearms are level with your keyboard and you don't have to flex your wrists to type
Your physical therapist will help you design an exercise program that allows you to enjoy daily activities at home. To begin with, your physical therapist will instruct you on exercises to stretch the forearm muscles to reduce tension on tendons that pass through the wrist. After swelling in the wrist decreases, your physical therapist will give you some isometric strengthening exercises that are correct for your particular injury.