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Joint Considerations for Syringomyelia with Physical Therapy

FEBRUARY 14, 2017
Kelly A Coleman, PT, DPT, OCS, GCS
Key questions asked among men, women, and children with a diagnosis of Syringomyelia are the following:  “What physical therapy exercises are recommended for Syringomyelia?”, and “Should physical therapy be a part of my recommended treatment?”  These questions are excellent and we will explore each one in greater detail this coming year. We strive to answer these questions utilizing available data, research, and updated education delivery to all physical therapists with regard to Syringomyelia and the complications that can co-exist with it. Worldwide Syringomyelia & Chiari Task Force is on a mission of education and our nurses are committed to the delivery of updated education to multiple disciplines including physical therapists about the disease Syringomyelia to open doors for excellent practice and outcomes worldwide.  Kelly Coleman is a physical therapy specialist who serves on the medical advisory board of Worldwide Syringomyelia & Chiari Task Force.  He has chosen Syringomyelia as an area of special focus and aspires to positively contribute to greater understanding of the disease in the area of physical therapy.

Published Research is Limited

There is a paucity of literature for physical therapy or physiotherapy and Syringomyelia.  Most of the literature found through PubMed, as of 2/11/17, with those search words were case studies.  Only one study to date has looked at qualitative data for the response of patients diagnosed with Syringomyelia who have also received physical therapy. (1)  Of the 69 patients in this study, only a small number of participants reported receiving some form of physical therapy.  However, the participants who had received physical therapy tended to report improvement in both pain and quality of life.  This study also reported that physiotherapy provided similar benefits to surgical interventions. The remainder of the research was case reports. None of these studies were found to provide guidance on physical therapy for Syringomyelia patients.
 
Until further research is completed, physical therapists need to know the manifestations and comorbidities common with Syringomyelia. This paper will address one of these comorbidities.

Charcot Disease

One of the most important considerations for the physical therapist is that of Charcot disease or neuropathic arthropathy. This progressive joint degeneration is reported as occurring secondary to repetitive micro-trauma with impaired sensation and/or neurovascular changes caused by pathological innervation of the blood vessels. (2,3,4) Literature reports the shoulders as being the most common joint involved followed by the elbows.  Yanik et al. reported a 25% occurrence rate of neuropathic arthropathy with 80% occurring at the shoulders with patients with Syringomyelia. (5)

Physical Therapy — Best Practices

In the absence of guidance from research with physical therapy and neuropathic arthropathy, lower forms of evidence or guidance must be considered  This author currently uses his knowledge of this disease, combined with clinical expertise and knowledge of other degenerative joint diseases as the best current guidance for physical therapy intervention. This knowledge base includes recent research development in guiding physical therapy for degenerative changes including tendinopathy.  Reversal of tendinopathy through evidence guided physical therapy is thought to be relevant to neuropathic arthropathy because of the neurovascular changes associated with the degeneration of the tendon with this condition. This author has been successfully using this research in treating tendinopathy and degenerative joint conditions in non-neuropathic arthropathy with high levels of reported improvement in strength, pain, and dysfunction.
 
The principles which this author has been using has led to the following techniques of application:
  • Preparing the joint and surrounding tendons with pendulum swings with light wrist or hand weights of 1.5 lbs. for the shoulder or elbow through pain-free range with an emphasis on the patient remaining relaxed with instruction to feel “lazy” in applied effort.
  • Monitoring the joint congruency during movement and applying neuromotor training for improving the joint relationship through movement. 
  • Using selective joint mobilization specific to the angle of joint dysfunction.
  • Controlling joint congruency during passive ROM which is designed to be pain-free for the patient. 
  • Consider using eccentric loading for those tendons which are prone to degenerative changes. This includes the long head of the biceps and the rotator cuff.
  • Training the patient to relax the shoulder muscles between repetitions involving strengthening. The duration of relaxation should be at least 2 to 3 times the duration of the total concentric and eccentric contraction time. 
  • Teaching the patient to assist the concentric phase of lifting. 
  • Instructing the patient to remain pain-free. 
  • Having the patient self-monitor the joint during the relaxation phase of the repetitions for any sign of discomfort or undesirable sensation and end the session at the first sign of undesirable sensation.   

Goals

Research-based goals specific to the above physical therapy interventions:
  • Control and lessen any joint or tendon pain if present. 
  • Restore passive range of motion without stressing joint congruency.
  • Train the patient in motor control and proprioception for maintaining joint congruency and protecting the joint throughout the available range of motion. 
  • Provide physical stimulus to the degenerative structures for influencing positive changes in cellular gene expression associated with reversal of degeneration in these tissues. 
  • Facilitate the cellular expression of Lubricin within the joint and surrounding tendon structures.

References

  1. Smith R, Jones G, Curtis A, et al. Are Established Methods of Physiotherapeutic Management for Long-term Neurological Conditions Applicable to 'Orphan' Conditions such as Syringomyelia? Physiother Res Int. Mar 2016;21(1):4-21.
  2. Johnson JT. Neuropathic fractures and joint injuries. Pathogenesis and rationale of prevention and treatment. Journal of Bone and Joint Surgery A 1967;49(1):1-30.
  3. Allman RM, Brower AC, Kotlyarov EB. Neuropathic bone and joint disease. Radiologic Clinics of North America 1988;26(6):1373-1381.
  4. Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Joint J. Sep 2016;98-B(9):1155-9
  5. Yanik B, Tuncer S, Seckin B. Neuropathic arthropathy caused by Arnold-Chiari malformation with Syringomyelia. Rheumatology International 2004;24(4):238-241. 


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