PCL 11 (Laxman's knee) tasks

First of all,

1. www.kneeclinic.com.au/index.htm
2. MRI images are available in Gray's Anatomy for Students

Now the tasks,

1. Anatomy/biomechanics of the knee (Pik Yin & Ian)

• Movement
• Stabilty
• Body weight

2. Structures present and damaged by lateral/medial trauma (Ranmali)

3. ACL tear (Bertrand & Mitch)

• Signs and symptoms
• Treatment (surgery and non-surgical)

4. Complete physical examination of the knee (Din & Matthias)

5. Problems in foot affecting knee stability (Phey Chien & Wai Kit)

6. Effects of the knee injury (Niva & Jeevetha)

• Anxiety
• Hyperventilation
• Carpopedal

ROM of joints

http://www.brianmac.co.uk/musrom.htm

Psychosocial Factors and Preventive Methods

Psychosocial Factors that contribute to pain
-preexisting depression and emotional distress
-Job Satisfaction
-Stress and ability to cope with it

Preventive Methods
-exercise regularly
-maintain proper posture
-use good body mechanics
-maintain a healthy body weight, Eat healthy foods
-Plenty of rest

analgesics :

NSAIDs :
Inhibit COX-1 and COX-2 pathways
Inhibit the synthesis of prostaglandin
Precursor : arachidonic acid
Eg. Ibuprofen, naproxen, diclofenac
Side effects :
Ulcer and gastrointestinal bleeding
Renal failure
Skin rash

opioids anagesics :
For severe chronic pain
Natural or synthetic compounds that produce morphine-like effects.
Bind to the specific opioid receptors in the CNS to produce effects that mimic the action of endogenous peptide neurotransmitters
The analgesic properties of the opioids are primarily mediated by the m receptor
Short-acting
Eg. Codeine, Tramadol, Oxycodone
Long-acting
Eg. Morphine, methadone

non-opioids adjuvant anagesics :
Tricyclic antidepressant
Eg. Amitriptyline
Antidepressants :
SSRIs (Selective serotonin reuptake inhibitors)
Eg. Paroxetine, sertraline, fluoxetine
Antiepileptics :
Eg. Gabapentin
Muscle Relaxants
Eg. diazepam

Clinical examination for Sciatica

Sensory testing

—Posterior thigh
—Lateral & posterior calf
—Foot


Power testing

—Footdrop (plantar flexed foot)
—Weakness of knee flexion


Reflex testing

—Knee jerk – INTACT
—Ankle jerk – ABSENT
—Plantar response - ABSENT


Nerve root tension tests
- Moving the legs in certain ways that stretch the sciatic nerve
- If the patient experiences pain during these tests, an irritated sciatic nerve is likely to be a source of the pain.


1. Straight Leg Raising test (SLR) & Bragard’s test
- positive if pain occurs between 20 & 70 degrees


2. Crossed straight leg raise test
- Symptoms are reproduced in the symptomatic leg by performing a straight leg raise test on the opposite leg

3. Sciatic palpation test
http://www.youtube.com/watch?v=zLIb3LGmmLI

Complications Arising from sciatica, as well as Prognosis

Complications
• 
Loss of Bowel or Bladder Function.

Urinary continence, a strong, sudden need to urinate, followed by instant bladder contraction and involuntary loss of urine. Urination occurs without knowing.Occurs during rising from bedrest, especially post-recovery after surgery.

Partial or complete loss of leg movement
• 
. Partial damage to the nerve may demonstrate
weakness of knee flexion (bending),
weakness of foot movements,
difficulty bending the foot inward (inversion),
or bending the foot down (plantar flexion). A person's reflexes may be abnormal, with weak or absent ankle-jerk reflex.

Several different tests can be performed to find the cause of sciatic nerve dysfunction.

• 
Partial or complete loss of sensation in the leg
.Abnormal sensations such as tingling or numbness which may be due from remaining in the same seated or standing position for a long time, injury to a nerve (eg: a low back injury can cause numbness or tingling down the back of the leg), pressure on the spinal nerves (eg: herniated disc) or pressure on peripheral nerves from enlarged blood vessels, tumors, scar tissue or infection.

• 
Medication Side effects : Nsaids
1.Gastric Ulceration
2.Bleeding
3.BP increase
4.Delayed Stomach Emptying
5. Depression
6. Confusion
7. Elderly : Tinnitus *ringing in the ears* , headache, dizziness, skin rash allergy*
8. Weight gain
9. Kidney failure


Prognosis
1)Studies shows 75% patients suffer
at least one recurrence of backpain over
a course of year.

2)Most acute low back pain recover within a month or so.
1/3 with uncomplicated low back pain recovers within a week.

Intervertebral disc prolapse

The intervertebral disc bursts and fragments of the outer annulus fibrosus, together with some of the inner gelantinous nucleus pulposus, press on ligaments and nerves running close to the disc and produce pain.Once this has happened, that disc will never be normal again. It's resistance to further injury is considerably reduced and anyone who has had a burst intervertebral disc is always at risk of further episodes of acute pain.
Pathophysiology
Although any disc in the entire spine can prolapse or burst, the most common ones to which this happens are the lowest two, that is between the fourth and fifth lumbar vertebrae and between the fifth lumbar and the top of the sacrum. The most likely explanation is that the stresses experienced by the spine are the greatest at these levels. Also the sacrum does not stand vertically but is tilted backwards, so producing a sharp curve in this region and giving a wedge shape to the discs. This wedge shape may concentrate the stresses in the back of the disc so making these lower lumbar discs particularly liable to damage. Briefly in a prolapse, the disc ruptures or bursts so that debris from the disc protrudes and can damage the surrounding structures. Most commonly these ruptures occur at the back of the disc but to one side or the other. These are known technically as the postero-lateral edges of the disc. Sometimes, however, the burst may occur directly backwards in the midline and this is known as a central posterior prolapse. Prolapsed disc bursting backwards and to one side due to the presence of the posterior longitudinal ligament in the spinal canal.
Stages of Spinal Disc Herniation
Disc herniation can occur in any disc in the spine, but the two most common forms are lumbar disc herniation and cervical disc herniation. The former is the most common, causing lower back pain (lumbago) and often leg pain as well, in which case it is commonly referred to as sciatica.
Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of lower back pain. The cervical discs are affected 8% of the time and the upper-to-mid-back (thoracic) discs only 1 - 2% of the time.
The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces, the sacrum, and the coccyx.
Cervical disc herniation
Cervical disc herniations occur in the neck, most often between the fith & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula,shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected.
Thoracic disc herniation
Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations.
Lumbar disc herniation
Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected.[9] Can cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.
Risk Factors
-Disc herniations can occur from general wear and tear, such as jobs that require constant sitting, but especially jobs that require lifting.
-Traumatic (quick) injury to lumbar discs commonly occurs from lifting while bent at the waist, rather than lifting while using the legs with a straightened back.
- Minor back pain and chronic back tiredness is an indicator of general wear and tear that makes one susceptible to herniation on the occurrence of a traumatic event from bending to pick up a pencil or a traumatic injury from a fall.
-Smoking is a major risk factor as the chemicals within smoke cause diminished nutrition and oxygenation of the discs leading to dehydration & degeneration which can then proceed to herniation.
-Mutation in genes coding for proteins involved in the regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.

reference
www.nlm.nih.gov/medlineplus/ency/article/000442.htm

Support for Adnan (Migrant worker)

Adnan will not be covered by SOCSO because:

- Foreigner workers (protected under the Workmen's Compensation Act 1952)

- Self-employed

Issues and barriers faced by migrant workers

1. Language

- Language difficulties in turn lead to isolation which is itself a barrier to obtaining help and support.

- Apart from translating literature and having access to appropriate translation services one of the best ways to empower migrant workers is to help them onto an ESOL (English as a Second Language) course.

2. Status

- Many migrant workers have difficulty accessing services such as a GP, bank account and state benefits

3. Work permits

- e.g. delays can also occur at the Home Office.

4. Family and dependants

- Money sent

UNISON

An international organization in UK. It does support migrant workers too.\

How UNISON helps

• Debt advice

• Listening and support

• Financial assistance

• Breaks and holidays

• General advice

Although in case we can’t help with a grant for credit card or consumer credit debts our debt advisers can talk to creditors on your behalf as part of a flexible debt management plan. You repay a regular amount that you can afford. Payplan will offer a range of solutions that best meet your needs and carefully explain the options letting you decide.

Workmen's Compensation Act 1952

For occupational disease or injury, the employer will pay for it with the presence of hospital approval,etc.

Symptoms of Sciatica

Symptoms of sciatica
-Pain that travels from the low back, through the buttocks, downward into the leg, and sometimes into the foot.
- Burning and tingling sensations( pins-and-needles feeling) in your leg.
- Partial leg numbness or weakness. In some cases, you may have pain in one part of your leg and numbness in another.
- Worsening of symptoms when squatting, coughing, trying to stand up.... coz these maneuvers can increase pressure around the nerve and magnify the symptoms of sciatica.

Seek medical attention if your pain persists — and seek immediate attention if you have any of the following emergency signs:

* Pain is getting worse.
* Pain affects your every day activities.
* Leg weakness or numbness.
* Loss of bowel or bladder control.- Cauda equina syndrome
- rare, but an emergency
- caused by a prolapsed disc.
- cause low back pain plus: problems with
bowel and bladder function (usually unable
to pass urine), numbness in the 'saddle'
area (around the anus), and weakness in one
or both legs.
- preserve the nerves to the bladder
and bowel from becoming permanently damaged

When you're describing your symptoms to your doctor, it's helpful to be as exact as possible.
So when you feel pain, is it
-especially intense above your knee?
-below your knee and into your foot?
-on the side of your foot?
-in your big toe and maybe in your ankle, too?

Alternative Treatments & Management for Sciatica

• Exercise/Stretching - strengthening the abdominal and back muscles in order to provide more support for the back.
• Ice - reduce inflammation, used in the first 48 hrs
  
• Spinal Manipulation Therapy- relieve pain and improve physical functioning
• Acupuncture & Acupressure- restore qi flow
  
• Yoga
• Cognitive based therapy- change perception of pain