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Thoracic Outlet Syndrome (TOS) is a complex and sometimes difficult condition to identify and treat. Regardless of the symptom differentiation, the cause of thoracic outlet syndrome should be classified as a structural or functional origin in order to provide an appropriate intervention.
A paper in the journal Manual Therapy, described an interesting approach to conservative management of thoracic outlet syndrome: look at the scapula!
The authors, Watson and colleagues, noted that most neurologic-type TOS patients present with depressed scapula, both at rest as well as during shoulder abduction and flexion. The authors proposed a rehabilitation program for thoracic outlet syndrome focusing on scapular position and control, beginning in lower ranges of abduction and progressing to higher levels of elevation. The authors note that this approach is based on their clinical approach with only anecdotal evidence of success.
Promoting the role of Physiotherapy in Palliative care: Information for allied health professionals - Physiopedia, universal access to physiotherapy knowledge. Welcome to this informative online self-study tool on physiotherapy and rehabilitation in palliative care, intended for allied health professionals. Purple coloured speech bubbles will represent thoughts and opinions of Teresa Storr, Locum Consultant in Palliative Care, Cumbria. LO3 Gain knowledge of the evidence surrounding the benefits of palliative care physiotherapy. LO4 Identify the referral of suitable palliative care patients to physiotherapy and be able to apply in clinical practice. LO5 Formulate an awareness of family involvement, regarding compliance to and education about physiotherapy treatment in palliative care. Palliative care is a practice discipline, which involves progressive and life-limiting illnesses such a cancer, chronic obstructive pulmonary disease, motor neuron disease and multiple sclerosis, each of which can benefit from the involvement in physiotherapy. In addressing this commonly altered perception of palliative care physiotherapy on a preliminary level, this self-study CPD (continuing professional development) package will demonstrate the vast capability and variability of rehabilitation in such a setting. In response to staggering research on palliative care rehabilitation perceptions and lacking numbers of referral, this self-study package has been designed as an educational resource for all allied health professionals in the United Kingdom (UK). The ‘Quality Statement and Definition of Specialist Palliative Care’ provided by National Institute for Health and Care Excellence (NICE) states, “Specialist Palliative Care encompasses hospice care as well as a range of other specialist advice, support and care such as that provided by hospital palliative care teams.
Specialist palliative care is based on general palliative care but can help patients with more complex palliative care needs.
Most palliative care is received in a hospice (a specialist residential unit), run by an MDT comprising doctors, nurses and therapists. Specialist palliative care teams are available in hospitals; such teams are called Macmillan Support Teams or Symptom Control Team. An example of hospital palliative care in Scotland, is the Beatson West of Scotland Cancer Centre. The physiotherapist must consider the patient’s needs and wishes, along with their physical needs [21] .
To optimize and maintain quality of life (QoL) [23] – determined by physical functioning and psychological symptoms[24].
In a study by McIlfatrick,[4] the needs identified by patients and their caregivers in palliative care included social support and the provision of practical care, respite care, psychological support, and information and choice. The primary goal of physiotherapy in palliative care is to achieve the best possible QoL for both the patient and their families. In cancer patients, physical activity has been shown to address a decline in physical functioning and cancer-related fatigue (CRF).
There is however, a need for more feasible studies to be produced in order to further advance this emerging research in palliative care. Mandy Trickett, Macmillan Specialist Physiotherapist promotes physical activity in palliative care, view Mandy’s contribution to AHPScot Blog here, look for the entry on 16th September 2013. Referral pathways need to be viewed as a continuum and considered from the point of view of the person, not the condition. Physiotherapy objectives within each of the palliative care settings differ depending on what stage the patient is at.
It is not possible to predict the timescale of individual prognosis accurately so evidence informed, clinical reasoning is used to identify people who may benefit from supportive and palliative care.
There appears to be a lack of consensus within the available literature regarding a standardised referral process into palliative care physiotherapy. The points of transition from long-term condition management to palliative care and end of life are poorly defined and recognized. The future direction of palliative care is set to extend to accommodate the changing demographics of the population.
Synthesise what you now understand the role of physiotherapy to be in palliative care, and how this will contribute to the holistic care of patients both now and in the future. Learn about the shoulder in this month's Physiopedia Plus learn topic with 5 chapters from textbooks such as Magee's Orthopedic Physical Assessment, 2014 & Donatelli's Physical therapy of the shoulder 2012. Osteoarthritis is a slowly progressive degenerative condition affecting the knee joint cartilage and the underlying bone and resulting in gradual loss of the articular or chondral cartilage covering the knuckles of the knee. In its most severe forms the covering cartilage is lost completely allowing the bare knuckles to rub together during normal standing and walking, and producing the bone on bone contact sometimes visible on plain x-rays. What Is Fibromyalgia?Fibromyalgia is a chronic condition that affects about 5 million Americans.
Stable angina is the presenting symptom in approximately 50% of patients with coronary artery disease.1 In Europe and the United States, 30 000 to 40 000 patients per million people suffer from chronic stable angina. Most episodes of ambulatory or exercise-induced myocardial ischemia in stable coronary patients are preceded by an increase in heart rate.5,6 The likelihood of developing ischemia is related to the baseline resting heart rate as well as to the magnitude and duration of the increase. Thus reducing resting heart rate and limiting the increase in heart rate are a very rational strategy to prevent ischemia. All these findings clearly demonstrate that elevated heart rate is a key determinant of ischemia and cardiac function. Thoracic outlet syndrome occurs with compromise of the nerves and blood vessels passing from the neck into the arm through a region known as the “thoracic outlet”.
Signs of TOS include changes in sensation across multiple dermatomes or changes in the radial pulse with different positions of provocation; these respective symptoms help differentiate between neurological and vascular entrapment. Conservative treatment is recommended for all types of TOS and surgery is only indicated if conservative approaches fail.
Because the thoracic outlet passes underneath the clavicle and coracoid (a possible location for entrapment), the position and control of scapular movement may be a missing link’ in thoracic outlet rehabilitation.
Lifting the arm with insufficient upward rotation, scapular winging, and anterior tilt of the scapula may reduce clearance of the thoracic outlet. Patients begin with scapular setting drills and progress to lower levels of abduction (30, 45, and 90 degrees) and flexion below 90 degrees.

Further research is needed to validate this treatment approach, but it serves as a great suggestion for conservative management of thoracic outlet syndrome. With palliation, physiotherapy treatment aims to maintain QoL while alleviating stress from symptoms in particular, pain, and effects from treatment. The package aims to void a trough in knowledge, and degree of uncertainty or misconception, surrounding referral of appropriate palliative care patients, to physiotherapy. Their role lies in providing education, training and specialist advice on pain and symptom management to hospital staff with the ultimate aim of enhancing patient care. Each individual will have different needs depending on how well they are handling their life-limiting illness. There is a role to be played in pain management and in the relief of other distressing symptoms, Figure 3.1.
With life-limiting illnesses, cancer for example, there is also a psychological aspect, which we as physiotherapist may need to also address. Most studies to date have researched physical activity and palliative care in early phases of illnesses such as cancer. Some may be actively dying; the physiotherapy input here is based on positioning and respiratory care. Initially hospice outreach was chiefly to the community and as such most referrals arose from GPs.
There are some settings within Scotland and the UK that provide the level of care which ensures high QoL for patients’ right up until the terminal stage of the disease process.
With more elderly patients, the burden of existing co-morbid conditions will increase, therefore rehabilitation will require to be more invasive and last longer. Assessing palliative care needs: views of patients, informal carers and healthcare professionals.
Rehabilitation for elderly patients with cancer asthenia: making a transition to palliative care.
The benefits of interdisciplinary practice in a palliative care setting: a music therapy and physiotherapy pilot project.
A profile of hospice-at-home physiotherapy for community-dwelling palliative care patients. Associations between physical activity and quality of life in cancer patients receiving palliative care: A Pilot Survey. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider.
It is intended for general informational purposes only and does not address individual circumstances.
Traditionally, heart rate reduction has been effectively used to relieve angina symptoms and ischemia. Paradoxical narrowing of atherosclerotic coronary arteries induced by increases in heart rate. Myocardial ischemia during daily activities: the importance of increased myocardial oxygen demand.
Role of increases in heart rate in determining the occurrence and frequency of myocardial ischemia during daily life in patients with coronary artery disease.
Comparison of propranolol, diltiazem, and nifedipine in the treatment of ambulatory ischemia in patients with stable angina. Entrapment of this neurovascular bundle can lead to both neurological symptoms (numbness and burning of the entire hand) and vascular symptoms (coolness and discoloration of the hand). Interestingly, this pattern of dynamic scapular dysfunction is associated with muscle imbalance: tightness of the upper trapezius, levator scapula, and pectoralis minor with weakness of the serratus anterior, lower trapezius, and rhomboids.
Patients then progress to maintaining upward rotation and elevation with synchronous activation of the trapezus and serratus muscles. It is not exclusive to any one palliative care specialty area, but can be adopted for a range of palliative care areas. The whole needs of the individual must be addressed.[23]There are many forms of treatment that physiotherapists can employ in the management of patients in palliative care.
However this feeling of hope which coincides with control over disease manifestations is not apparent for all patients and even more concerning is in some instances the level of care available is a case of a postcode lottery.
Patients experience pain and stiffness in the muscles, but there are no measurable findings on X-rays or most lab tests.
It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
We’re actively working to get these issues corrected and hope to have everything smoothed out shortly. Heart rate reduction has been shown to be the primary mechanism by which β-blockers confer benefit in coronary artery disease.
The effect of altering heart rate on ventricular function in patients with heart failure treated with beta-blockers. While providing up-to-date factual information for allied health professionals, this package will endeavour to extend beyond the tangible requirements for referral to physiotherapy in palliative care.
Patients may need education on how to cope and handle the situation as best they can, to lessen the fear and anxiety they have surrounding their condition. The decision as to what option best suits each patient is quite personal and depends on the stage of the disease process and goals set.
Encouraging results have been found regarding physical activity interventions and palliative care and the ability of patients to tolerate this physical activity.
What are the main interventions used in palliative care physiotherapy and how do these aim to help the patient?Q4. While fibromyalgia does not damage the joints or organs, the constant aches and fatigue can have a significant impact on daily life. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site.
Heart rate is known to be the most important determinant of myocardial oxygen demand, and thereby a primary determinant of cardiac work and of the metabolic requirements of the heart.2,3 Increased heart rate also leads to shortening of diastole. It will provide a sound explanation of necessary personal values and the importance of suitable communication skills,[13] for interaction with patients and families in or being referred to palliative care.
Worry and anxiety are two common psychological aspects associated with life-limiting illnesses. Since myocardial perfusion occurs predominantly during diastole, decreased diastolic time can decrease myocardial perfusion in the subendocardial layers thereby increasing myocardial ischemia. The entire MDT, including the physiotherapist may be involved in the control of some of these symptoms, through education, maybe even just empathy towards the patient.
When these points are pressed, people with fibromyalgia feel pain, while people without the condition only feel pressure.

These different forms of treatment provided by physiotherapists and their suitable phase are displayed in Table 3.1 below. Because traditionally no lab tests or X-rays could confirm a diagnosis of fibromyalgia, some patients were once led to believe this pain was "all in their heads." But the medical community now accepts that the pain of fibromyalgia is real. Fibromyalgia: Who's at Risk?Women between the ages of 25 and 60 have the highest risk of developing fibromyalgia.
Doctors aren't sure why, but women are 10 times more likely to have the condition than men. Some researchers believe genetics may play a role, but no specific genes have been identified. Fibromyalgia and FatigueAfter pain, the most common and debilitating symptom of fibromyalgia is fatigue. This is not the normal tiredness that follows a busy day, but a lingering feeling of exhaustion. People with fibromyalgia may feel tired first thing in the morning, even after hours spent in bed. The fatigue may be worse on some days than others and can interfere with work, physical activity, and household chores.
Causes of FibromyalgiaThere are many theories about the causes of fibromyalgia, but research has yet to pinpoint a clear culprit.
Most experts agree that fibromyalgia probably results from a combination of factors, rather than a single cause. Fibromyalgia: Impact on Daily LifeConstantly fighting pain and fatigue can make people irritable, anxious, and depressed. You may have trouble staying on task at work, taking care of children, or keeping up with household chores. Fortunately, there are effective treatments that help many patients get back to the activities they enjoy.
Diagnosing FibromyalgiaYour doctor may diagnose fibromyalgia after hearing your symptoms and doing a physical exam.
A fibromyalgia blood test may help too.And, your doctor may do other testing to rule out other conditions. Check with local support groups and hospitals for a list of fibromyalgia experts in your area.
Fibromyalgia TriggersAn important first step is identifying what makes your symptoms worse. Studies suggest some patients remain in a shallow state of sleep and never experience restful, deep sleep. This deprives the body of a chance to repair and replenish itself, creating a vicious cycle.
Fibromyalgia and DepressionNearly a third of people with fibromyalgia also have major depression when they are diagnosed.
Others suggest that abnormalities in brain chemistry may lead to both depression and an unusual sensitivity to pain. Symptoms of depression may include difficulty concentrating, hopelessness, and loss of interest in favorite activities. Managing Fibromyalgia: MedicationThe goal of fibromyalgia treatment is to minimize pain, sleep disturbances, and mood disorders.
Doctors may recommend medications that help ease your symptoms -- ranging from familiar over-the-counter pain relievers to prescription drugs like amitriptyline.
There are also prescription drugs specifically approved for the treatment of fibromyalgia, which include Cymbalta (duloxetine), Lyrica (pregabalin), and Savella (milnacipran). Walking, stretching, and water aerobics are good forms of exercise to start with for people with fibromyalgia. Managing Fibromyalgia: DietSome experts say diet may play a role in fibromyalgia -- just not the same role in all patients. Certain foods, including aspartame, MSG, caffeine, and tomatoes, seem to worsen symptoms in some people. To find out what works for you, try eliminating foods one at a time and recording whether your symptoms improve. Managing Fibromyalgia: MassageSome research suggests massage may help relieve fibromyalgia pain, though its value is not fully proven.
Practitioners say that applying moderate pressure is key, while the technique is less important.
A significant other can learn to provide regular massages -- and a 20-minute session may be long enough to get results. Managing Fibromyalgia: AcupunctureFormal studies have produced mixed results on the use of acupuncture for fibromyalgia, but some patients say it eases their symptoms.
This traditional Chinese practice involves inserting thin needles at key points on the body.
Acupressure stimulates the same pressure points and may be a good alternative for people who want to avoid needles. Managing Fibromyalgia: Fibro FogMany people with fibromyalgia have trouble concentrating, a phenomenon known as fibro fog.
While getting treatment for pain and insomnia may help, there are other steps you can take to improve your focus.
Write notes about things you need to remember, keep your mind active by reading or doing puzzles, and break tasks up into small, manageable steps. Managing Fibromyalgia: StressStress appears to be one of the most common triggers of fibromyalgia flare-ups. While it's impossible to eliminate all stress from your life, you can try to reduce unnecessary stress. Determine which situations make you anxious -- at home and at work -- and find ways to make those situations less stressful. Does Fibromyalgia Get Better?Many people with fibromyalgia find that their symptoms and quality of life improve substantially as they identify the most effective treatments and make lifestyle changes. While fibromyalgia is a chronic condition, it does not damage the joints, muscles, or internal organs.

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