Articles


Brain Aneurysm

Brain Aneurysm (Cerebral or Intracranial aneurysm) is the weak area of an artery in the brain which causes a localized blood filled balloon, like bulge, in the wall of blood vessel. Aneurysm is caused from wear and tear of the arteries, injury, infection and inherited tendency. It can occur to all age groups but incidence increases gradually after the age of 25. Most affected age group is 50 to 60 and women have more tendency of prevalence.
Large unruptured aneurysms lead to symptoms based on the pressure on the brain tissue, nerves and surrounding structures. Symptoms include weakness or paralysis on one side of the face, pain above and behind the eye, numbness, enlarged pupil or changes in vision. Unruptured Aneurysms require different assessment and treatment. When cerebral aneurysms rupture, bleeding is usually caused in to the brain and surrounding space known as “subarachnoid space”. Approximately 2% – 3% of people with brain aneurysm suffer from bleeding. It is an emergency situation and stiff neck, blurred vision, nausea and vomiting and loss of sensations are usual symptoms.


Diagnosis
Ruptured aneurysms are diagnosed by finding signs of subarachnoid hemorrhage via CT scan (Computerized Tomography). Cerebral Angiogram, a test, is performed by neuro-interventional expert to determine the exact size, location and shape of an aneurysm. Cerebral angiography is a medical procedure when dye is injected in to the arterial system through a catheter. MRA (Magnetic Resonance Angiography) and CTA (Computed Tomographic Angiography) are non-invasive alternative procedures to the traditional methods. Contrast dye injected in to the vein which travels to the brain arteries and images are created using CT scan. These images show how blood flows in to the brain arteries.



Treatment
There are two type treatment options available for brain aneurysm.
1. Aneurysm Clipping
2. Aneurysm Coiling



Aneurysm Coiling
Objective of Aneurysm Coiling is to isolate an aneurysm from the normal circulation without blocking off nearby arteries or contracting main vessel.
Microcatheter is inserted through initial catheter and the coil is attached with the microcatheter. Once the microcatheter reaches the aneurysm and gets inserted in to it, coil is separated from catheter with the use of electric current. This coil will cap the opening of the aneurysm and it is placed permanently in aneurysm. More than one coil may be needed depending upon the size of aneurysm. Coils used in this procedure are spring shaped and made of soft platinum metal. These coils are very thin and small, ranging from less than the width of human hair to twice to the width of a single hair. Fluoroscopy supports the whole procedure of Endovascular Coiling. It is a special type of X-ray movie. Physicians use Fluoroscopy in order to locate the aneurysm and guide catheter for all movements.
Patient can return to home spending one night in Intensive Care Unit after surgery and may be expected to resume normal life activities within 2 days. Exact details regarding procedure and discharge for a particular case could be obtained from the physician.


By

Umair Rashid Chaudhry
(Neuroradilogist)


 


CKD and Kidney Stones: Recognize before it’s too late

CKD and Kidney Stones: Recognize before it’s too late

 

Kidneys, bean shaped organs, are located just below the rib cage, one on each side of the spine. Kidneys have significance in body functionality by keeping the composition or makeup of the blood stable. They (a) prevent the buildup of wastes and extra fluid in the body (b) keep levels of electrolytes stable, such as sodium, potassium, and phosphate (c) make hormones that help

  • regulate blood pressure
  • make red blood cells
  • bones stay strong

CKD (Chronic Kidney Diseases) is sometimes called a “silent disease.” Patients rarely feel sick until their kidney disease is advanced. Symptoms may include:

  • Fatigue
  • Trouble concentrating
  • Poor appetite
  • Trouble sleeping
  • Muscle cramping at night
  • Swollen feet and ankles
  • Puffiness around eyes, especially in the morning
  • Dry, itchy skin
  • More often urination, especially at night

Black and south Asian people are three to five times more likely to have kidney failure than white people, but many are unaware of the condition.

Kidney Stones & Chronic Kidney Diseases:

Causes of kidney stones are as follows.

  • Calcium
  • Ammonia
  • Oxalate
  • Uric Acid (a waste product produced when the body breaks down food to use as energy)
  • Cysteine (an amino acid that helps build protein)

Certain medical conditions can lead to an unusually high level of these substances in urine.

Kidney stones are more likely to develop if the fluid intake is low.

Kidney stones and Chronic Kidney Diseases affect 5% and 13% of the population respectively. Infection stones (struvite) may lead to an obstructive nephropathy with staghorn calculi and are the leading cause of ESRD (End Stage Renal Disease) attributed to nephrolithiasis. Kidney stones could be considered a contributing factor in developing and progression of CKD (Chronic Kidney Diseases). One of the roles of the kidney is to excrete metabolic wastes such as calcium and oxalate at supersaturated concentrations yet prevent precipitation of crystals. Thus, stone formation could be considered an imbalance between the substances which are dissolvers of crystal and promoters by and large. This leads to kidney diseases.

There is evidence that the risk for CKD varies by stone type, but more studies are required. Population based studies often lack the granular detailed data to characterize stone type because many stone formers never have their stones analyzed or urine chemistries evaluated, and, even if so, this information often is not available in the databases available for study. Informal researches indicate that 70% of the stones are Calcium Oxalates.

Kidney Stones & Diet:

Diet plays an important role in the pathogenesis of kidney stones. Because the metabolism of many dietary factors, such as calcium, may change with age, the relation between diet and kidney stones may be different in older adults. Uncertainty remains about the association between many dietary factors, such as vitamin C, magnesium, and animal protein, and the risk of kidney stone formation. Importance of individual dietary factors in the development of symptomatic kidney stones is high. Foods that are high in calcium, potassium, and magnesium should be evaluated as part of a diet to reduce the risk of kidney stone recurrence. Although vitamin C intake is associated with an increased risk of stones, the high amount of potassium in vitamin C–rich foods suggests that limiting the intake of dietary vitamin C in men with calcium oxalate nephrolithiasis is unwarranted.

References:

Rule, A., Krambeck, A. and Lieske, C., 2011. Chronic Kidney Disease in Kidney Stone Formers. Clinical Journal of the American Society of Nephrology, 6, pp. 2069-2075.

Rule, A., Bergstralh, E., Melton, L., Xujian, L., Weaver, A. and Lieske, J., 2009. Kidney Stones and the Risk for Chronic Kidney Disease. Clinical Journal of the American Society of Nephrology, [Online] Available at: <http://cjasn.asnjournals.org/content/4/4/804.full.pdf+html>

NHS, 2015, Black and south Asian kidney health. [Online] Available at: <http://www.nhs.uk/Livewell/Kidneyhealth/Pages/BlackandAsiankidneyhealth.aspx>

Curhan, G., Willett, W., Speizer, F. and Stampfer, M., 1999, Intake of Vitamins B6 and C and the Risk of Kidney Stones in Women. Journal of the American Society of Nephrology, 10, pp. 840-845.

Taylor, E., Stampfer, M. and Churan, G., 2004, Dietary Factors and the Risk of Incident Kidney Stones in Men: New Insights after 14 Years of Follow-up. Journal of the American Society of Nephrology, 15, pp. 3225–3232.

 

By

Dr. Sameeh J. Khan

(Nephrologist)


 


Shoulder Rehabilitation

Shoulder Rehabilitation

Introduction:

Shoulder is one of the largest and most complex joints in the body. The shoulder joint is formed where the Humerus (upper arm bone) fits into the scapula (shoulder blade), like a ball and socket. Other important bones in the shoulder include:

  • The acromion, a bony projection off the scapula.
  • The clavicle (collarbone), meets the acromion in the acromioclavicular joint.
  • The coracoid process, a hook-like bony projection from the scapula.

The shoulder has several other important structures:

  • The rotator cuff is a collection of muscles and tendons that surround the shoulder, giving it support and allowing a wide range of motion.
  • The bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff.
  • A cuff of cartilage called the labrum forms a cup for the ball-like head of the humerus to fit into.
  • The humerus fits relatively loosely into the shoulder joint. This gives the shoulder a wide range of motion, but also makes it vulnerable to injury.

Shoulder Conditions:

  • Frozen shoulder: Inflammation develops in the shoulder that causes pain and stiffness. As a frozen shoulder progresses, movement in the shoulder can be severely limited.
  • Osteoarthritis: The common “wear-and-tear” arthritis that occurs with aging. The shoulder is less often affected by osteoarthritis than the knee.
  • Rheumatoid Arthritis: A form of arthritis in which the immune system attacks the joints, causing inflammation and pain. Rheumatoid Arthritis can affect any joint, including the shoulder.
  • Gout: A form of Arthritis in which crystals form in the joints, causing inflammation and pain. The shoulder is, however, an uncommon location for gout.
  • Rotator cuff tear: A tear in one of the muscles or tendons surrounding the top of the Humerus. A rotator cuff tear may be a sudden injury, or result from steady overuse.
  • Shoulder impingement: The acromion (edge of the scapula) presses on the rotator cuff as the arm is lifted. If inflammation or an injury in the rotator cuff is present, this impingement causes pain.
  • Shoulder dislocation: The Humerus or one of the other bones in the shoulder slips out of position. Raising the arm causes pain and a “popping” sensation if the shoulder is dislocated.
  • Shoulder tendonitis: Inflammation of one of the tendons in the shoulder’s rotator cuff.
  • Shoulder bursitis: Inflammation of the bursa; the small sac of fluid that rests over the rotator cuff tendons. Symptoms include pain with overhead activities or pressure on the upper, outer arm.
  • Labral tear: An accident or overuse can cause a tear in the labrum, the cuff of cartilage that overlies the head of the Humerus. Most labral tears heal without requiring surgery.

Shoulder Tests:

  • (MRI Scan): This scanner uses a high-powered magnet and a computer to create high-resolution images of the shoulder and surrounding structures.
  • (CT Scan): A CT scanner takes multiple X-rays, and a computer creates detailed images of the shoulder.
  • Shoulder X-ray: A plain X-ray film of the shoulder may show dislocation, Osteoarthritis or a fracture of the Humerus. X-ray films cannot diagnose muscle or tendon injuries.

Shoulder Treatments:

  • Shoulder surgery: Surgery is generally performed to help make the shoulder joint more stable. Shoulder surgery may be Arthroscopic (several small incisions) or open (large incision). In an Arthroscopic surgery, the surgeon makes small incisions in the shoulder and performs surgery through an endoscope (a flexible tube with a camera and tools on its end). Arthroscopic surgery requires less recovery time than open surgery.
  • Physical therapy: An exercise program can strengthen shoulder muscles and improve flexibility in the shoulder. Physical therapy is an effective, nonsurgical treatment for many shoulder conditions.

Strength:

Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.

Flexibility:

Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.

Target Muscles:

The muscle groups targeted in this conditioning program include:

  • Deltoids (front, back and over the shoulder)
  • Trapezius muscles (upper back)
  • Rhomboid muscles (upper back)
  • Teres muscles (supporting the shoulder joint)
  • Supraspinatus (supporting the shoulder joint)
  • Infraspinatus (supporting the shoulder
  • Subscapular (front of shoulder)
  • Biceps (front of upper arm)
  • Triceps (back of upper arm)

Pain relievers:

  • RICE Therapy: RICE stands for Rest, Ice, Compression (not usually necessary), and Elevation. RICE can improve pain and swelling of many shoulder injuries.
  • Corticosteroid (cortisone) injection: A doctor injects cortisone into the shoulder, reducing the inflammation and pain caused by Bursitis or Arthritis. The effects of a cortisone injection can last several weeks.

Shoulder Replacement Indications: Severe Osteo or Rheumatoid Arthritis where the predominant feature is pain.

Post-Shoulder Replacement Treatment Protocol

In Patient
Day 0
  • Master sling with body belt or Cold Compression sling fitted in theatre
  • Finger, wrist and elbow movements
  • Occupational Therapy
Day 1Level 1 Exercises
  • Body belt removed
  • Axillary hygiene taught
  • Pendular exercises
  • Scapular setting
  • Passive flexion in the scapula plane as comfortable
  • External rotation to neutral
  • Discharge usually at day 1
Out Patient
Day 5 – 3 weeksLevel 2 exercises
  • No resisted internal rotation or forced passive external rotation (reattached subscapular is muscle is vulnerable)
  • Begin passive abduction (maintain shoulder in IR)
  • Passive external rotation to neutral only
  • Active assisted flexion in supine and progress to sitting position as soon as the patient is able.
  • Progress to active when possible
  • Begin isometric strengthening of all muscle groups (except IR)
  • Remove sling as able
  • Functional reaching activities below 90 degrees
3 weeks +Level 2 exercises
  • Encourage active movement into all ranges with some gentle self-stretching at the end of range.
  • Add isometric IR
  • Progress functional activities
6 Weeks +Progress to level 3 exercises
  • Progress strengthening through range
  • Regularly stretch the joint to the end of its available range
  • Soft tissue manipulation if required

 

Improvement continues for 18 months to 2 years and the patients should continue exercising until their maximum potential has been reached.

Return to functional activities

  • Driving           After 4 weeks
  • Swimming

Breaststroke:   6 weeks

Freestyle:        12 weeks

  • Golf                 3 Months
  • Lifting            Light lifting can begin at 3 weeks.
    Avoid lifting heavy items for 6 months.
  • Return           Sedentary job: 6 weeks
    to work          Manual job: Guided by Surgeon

 

References

  1. O’Sullivan. S. and Schmitz. T.,2011. Physical Rehabilitation. 5th Edition. F.A. Davis Company.
  2. ShoulderDoc, 2015, Shoulder Replacement. [Online] Available at < https://www.shoulderdoc.co.uk/article/16> [Accessed Dec 21, 2015]
  3. Healthwise, 2014, Shoulder Replacement Surgery. [Online] Available < http://www.webmd.com/arthritis/shoulder-replacement-surgery> [Accessed Dec 21, 2015]
  4. Porter. S., .2008, Tidy’s Physiotherapy. 14th Edition. Elsevier Health Sciences.

 

By

Dr. Riafat Mehmood

(Physiotherapist)


 


Nailing the Diagnosis

Nailing the Diagnosis

Nail – A window to bone and joint health

Take a long hard look at your nail as they may be saying something about health of your joints and bones. A recent study show that a mineral deficiency in toe nails is linked to risk of Osteoarthritis and finger nails give doctors a clue about the condition that elevate the risk of Osteoarthritis.

Osteoarthritis (OA), sometimes called Degenerative Changes, is the most common chronic condition of the joints. It may affect different parts of body including

  1. Knees
  2. Fingers
  3. Feet
  4. Hip
  5. Cervical Spine
  6. Lumbar Spine
  7. Riz arthritis of the thumb (Suffered by Manual Professionals)

In 2005, a research was presented in American College of Rheumatology (Atlanta) which shows that people with lower level of mineral “Selenium” are more prone to develop OA of knees. To prove the presence of Selenium in toe nails, clippings from 1000 people were measured as toe nails grow slowly and they reflect selenium level in the body. From past several months up to a year ago, no one realized and investigated if Selenium might be related to OA. Studies suggest that deficiency of selenium is common in many parts of Asia as they are not rich in this mineral. People in these areas tend to develop Kashin Beck Disease known as Arthritis Big Joint Disease. Another study shows that abnormal formation of Disulfide bonds in cells causes problems in nails and bones. Disulfide bonds are needed for joining Protein Molecules such as Nail Protein Keratin and Bones Protein Collagen. Research of Dr. Mark Towler from University of Limerick (Ireland) depicts that weak nails among Osteoporosis delved in to nails and bone properties. Result of his work is a device called “Selectis Bone Quality Test”. This test diagnoses Osteoporosis by analyzing the Disulfide Bonds in nail clippings. Device used in the test in as accurate as Dexa Scan which is currently being used to diagnose Osteoporosis and it is less expensive. On top of it, this test doesn’t require the presence of patient as only patient’s nail is needed. Suggest

Reducing Risks

To avoid the risk of Osteoarthritis, eat plenty of food which contains selenium.

  1. Nuts
  2. Meats
  3. Poultry
  4. Fish
  5. Whole grains

Do not increase the intake of any Vitamin or Mineral (including Selenium) without the consultation of physician. It might lead to Selenium Toxicity and increased harm to bones & joints.

 

References:

  1. Stanley Birge, “Should you Supplement Selenium?” 2006, Washington University, School of Medicine, St. Louis.
  2. , J.M., 2006. Selenium & OA Development, Thurston Arthritis Research Center, University of North Carolina, Chapel Hill.
  3. , M . 2006. Weak Nails among Osteoporosis Patient, Arthritis Foundation, University of Limerick, Ireland.
  4. Osteoarthritis Foundation, 2015. [Online] Available at < http://www.arthritis.org/about-arthritis/types/osteoarthritis/> [Accessed 15 December 2015]

 

By

Dr. Shafi Muhammad Chawdhry

(Rheumatologist)