Thoracic Outlet Syndrome
[…] Clinics of North America, 2015; 23(2):309-320. Safran MR. Nerve injury about the shoulder in athletes. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004; 32(4):1063-1076. Brantigan C, Roos D. Diagnosing thoracic outlet […]
Peripheral Polyneuropathy Part 2: Treatment
[…] lidocaine 5% patch, capsaicin 8% patch (postherpetic neuralgia) pregabalin (diabetic peripheral neuropathic pain (DPNP), postherpetic neuralgia, neuropathic pain due to spinal cord injury) duloxetine (DPNP) gabapentin (postherpetic neuralgia) – including extended formulation and combination gabapentin enacarbil tapentadol extended-release (ER) – neuropathic pain associated with diabetic peripheral neuropathy Antidepressants Longevity of use has afforded tricyclic antidepressants (TCAs) an abundance of studies showing treatment efficacy in a wide variety of neuropathic pain disorders. TCAs modulate voltage-gated sodium channels, inhibiting the reuptake of norepinephrine and serotonin. A 2011 practice guideline affirms the efficacy of amitriptyline, but less robust evidence exists for the use of desipramine, imipramine, fluoxetine, or nortriptyline + fluphenazine.1,2 Where prior studies were unable to support use of nortriptyline, a recent prospective clinical trial demonstrated some effectiveness of nortriptyline in cryptogenic sensory polyneuropathy specifically.28 Tertiary amine TCAs (amitriptyline, imipramine, and clomipramine) are not recommended at doses greater than 75 mg/day in adults 65 years and older, due to major anticholinergic and sedative side-effects and potential fall risk.3 An increased risk of sudden cardiac death has been reported with TCAs at doses >100 mg daily.4 TCAs are contraindicated in patients with cardiac arrhythmia, congestive heart failure, recent myocardial infarction, glaucoma, urinary retention, bladder […]
Conversion disorder
[…] minutes after a seizure is elevated after organic, but not after nonepileptic seizures. Imaging Normal imaging of the brain and spinal cord can help eliminate organic conditions or developing pathology, such as multiple sclerosis/neoplasm. Supplemental assessment tools Purification or purgation […]
Virtual Reality and Robotic Applications in Rehabilitation
[…] and sensory disorders of the central and peripheral nervous system (CNS), including stroke, traumatic brain injury (TBI), multiple sclerosis (MS), spinal cord injury (SCI), cerebral palsy (CP), Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), chronic peripheral neuropathies (PN), cognitive dysfunction (COG), certain psychiatric disorders, chronic pain, and also muscular dystrophies (MD), musculoskeletal disease (MSKEL), patient education and post-amputation Robotic systems are uniquely suited to provide functional assistance with mobility and activities of daily living. For example, robotic exoskeletons can allow paraplegic individuals with SCI to walk independently. Brain-computer interfaces, where computers analyze brain signals from EEG or implanted electrodes and use them to control robotic devices, computers, or other communication interfaces, are being studied for patients with ALS, SCI, CP, brainstem stroke, SCI, MD, PN10, 11 Robotic systems can also serve as companions with social, psychological and physiological benefits12, 13 VR systems are also being used in the field of musculoskeletal and sports medicine in order to provide an engaging, structured environment for performing strengthening, stretching, cardiovascular exercise, and for prosthetic training. Additionally, VR systems have been used to treat cognitive disorders resulting from acute and neurodegenerative disease, specifically with improvement in executive functions and visuospatial abilities14.An emerging area is the use of VR for acute and chronic pain both in adults and children. VR is also being used for psychiatric disorders, such as post-traumatic stress disorder, which may affect patients needing rehabilitation. Relevance to Clinical Practice Clinical justification for use Repetitive, high intensity task-specific training has been shown to spur neuroplasticity and functional recovery post-stroke. Typically, this is achieved by a team of physicians and therapists. This traditional approach is time and labor intensive. With VR, AR, and robotics, these therapies could potentially become partially automated, more data-driven, reproducible, and cost effective. These emerging modalities can be used in acute as well as chronic rehabilitation as a supplement to conventional therapy. Evidence regarding robotics and VR is still too limited to provide definitive clinical practice recommendations, and it remains unclear whether incorporation is more beneficial at one stage of rehabilitation than others. Robotic, VR, and AR modalities offer options for inpatient, outpatient, and home-based settings. Workstation robots and gait trainers are stationary due to their large sizes and are used to provide therapeutic exercise, in the clinic setting. Portable VR, AR, and robotic devices may be used in all settings. For the lower extremities, robot-delivered body weight-supported treadmill training has been used for gait training. There is some evidence for use of robot-assisted gait training in patients with CVA, PD, CP, and SCI15,16. In addition VR rehabilitation training may lead to better performance in terms of gait and balance in patients with PD than does isolated traditional therapy17. In a study of powered exoskeletal robots for the lower extremities in patients with motor complete SCI, exoskeletal robots were shown to be safe and well tolerated, and participants were able to walk independently for periods of five to ten minutes with reported physical and psychological benefits18. Additional studies have shown improvement in bowel function19, improved bone density20 cardiovascular benefits, improvement of spasticity, pain, and bladder function18,21. Wearable powered orthoses can serve both functional and therapeutic goals by compensating for a patient’s neurological deficits while training muscles and coordination. Stroke patients using an electromyogram (EMG)-controlled exoskeletal upper limb-powered orthosis showed improvement in function and spasticity.22 A randomized controlled multisite trial of post-stroke patients with a chronic paretic arm examined task-oriented training with the use of an exoskeletal robot and showed improvement in upper extremity function that was superior to conventional treatment23. One study for upper extremity robotic systems for shoulder and elbow rehabilitation in stroke patients in acute rehabilitation facilities showed benefits lasting three years.24 Another study showed improvements in both subacute and chronic population.25 Robotics may be able to help increase training intensity, and also increase repetitions of exercises. In addition to their roles as exercise training devices and as functional orthoses, robots can provide assistance with ADLs. One commercially available example is the Obi™ (Jacksonville, FL) feeder, a single-purpose robotic device used to promote feeding assistance to tetraplegic individuals. Wheelchair-mounted robotic arms, such as the JACO™ (Kinova, Canada) are available, but control mechanisms are laborious to operate. More autonomous robots could, in principle perform activities of daily living, such as retrieving an item for the user, or other ADL-related-errands. These devices remain largely experimental at present, however. Lastly social robots can perform supervisory tasks, or function as a companion. These robots remain limited in function and are not yet widely adopted. The popular ROOMBA™ (iRobot, Bedford, MA) robots can be used in the iADLs of vacuuming the floor or mowing the lawn, and SIRI™ (Apple) can be used for making phone calls, internet searches, and verbally dictating emails without physical contact. There is evidence of both cognitive and upper extremity motor gains using the VR with the RAPAEL™ smart glove (Neofect).26 Additionally, patients with severe TBI in early recovery states were found to have had attentional improvements when using a VR environment with tactile cues27. For VR systems, research has been most extensive for treatment of motor impairments due to stroke.28,29,30 A 2011 Cochrane review found that VR was more effective than conventional therapy in retraining upper limb function and with improving ADL function; however, no statistically significant increase in grip strength or gait speed was found.30 Randomized controlled trials have examined the benefit of VR following a stroke. The efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST) trial failed to show improvement of upper extremity motor abilities or functional/ADL differences when VR was used as an add-on therapy to standard task-oriented recreational activities.31 VR training for upper extremity in subacute stroke (VIRTUES) trial, a multicenter RCT, showed improvement in upper extremity motor function in both the VR and standard therapy groups but no differences between the groups.32 The two groups were in subacute phase of stroke approximately a month after their stroke and received equivalent total treatment time of therapy. Gaming and VR systems can be used for telerehabilitation, with improved upper extremity motor function when dose- and intensity-matched to therapy delivered in a clinical setting.33 A 2018 Cochrane review of electromechanical and robotic arm training following stroke showed improved arm function and ADL scores compared to usual care, though the clinical impact of these differences is unclear. More recently, a multi-site randomized controlled clinical trial (RATULS) was performed in the UK to compare robotic therapy, enhanced upper extremity limb therapy and usual care.34 Using a rigorous design and large sample size, this study did not find improvement in upper extremity motor impairments nor improved ability to perform ADLs with the use of robotics. Limitations of this study include a relatively chronic population (mean duration > 6 months), and relatively severe motor impairments. Also, the use of a particular robotic system, based on the MIT-MANUS system, […]
Juvenile Idiopathic Arthritis
[…] activity contributes to weakness, obesity (which increases load on joints) Atlantoaxial instability associated with cervical spine involvement increases risk of spinal cord injury Concerns have been raised about increased rates of cancer (does not seem to be related to treatment with biologic agents as was once thought) Uveitis, specifically iridocyclitis. More common in females affected with oligoarticular arthritis and in patients less than six years of age with a positive ANA. Usually asymptomatic, but if not diagnosed early may result in permanent blindness. Growth disturbances, including growth retardation and accelerated growth, resulting in conditions such as leg length discrepancies Micrognathia if TMJ arthritis disturbs the growth plate (particularly in polyarticular JIA) Suppression of the immune system by disease modifying antirheumatic drugs (DMARDs) increases the risk of infections Osteopenia and osteoarthritis Fractures Hepatomegaly, splenomegaly, lymphadenopathy (particularly in systemic JIA subtype) Rare pulmonary manifestations may include interstitial lung disease or pulmonary hypertension19 Macrophage Activation Syndrome (MAS) resulting from uncontrolled activation and proliferation of T-lymphocytes and macrophages is a complication with systemic JIA. It is a life-threatening condition resulting in persistent fever, pancytopenia, hepatosplenomegaly, and coagulopathy. Other autoimmune conditions, four have been associated with JIA Rheumatoid arthritis, Celiac Disease, Hypothyroidism, Systemic Lupus Erythematosus6 Pain is an incredibly common symptom. JIA patients with symptomatic pain are at higher risk of developing Chronic Amplified Pain Syndrome Essentials of Assessment History Joint pain and swelling, often noted incidentally after trauma Stiffness worse in morning or after naps and lasts more than fifteen minutes Symptoms better later in the day Persistence of symptoms for at least six weeks in a six-month period History of fever without other cause, in absence of joint symptoms; may be three days, with a double spike pattern of high temperatures Child refusing to walk, or using hands to walk Pain with ambulation, “gelling” sensation (stiffness after a joint remains in one position for a prolonged period), joint swelling, and difficulty with buttons or writing Photophobia, pain, redness, headache, and visual changes Isolated musculoskeletal pain is generally not JIA Detailed family medical history1,7 Differential diagnoses include: Perthes disease, slipped capital femoral epiphysis (SCFE), malignancy (osteosarcoma for joint pain, leukemia for fever combined with joint pain, lymphoma), ankylosing spondylitis, inflammatory bowel disease, septic arthritis, Kawasaki disease, malaria Physical examination Musculoskeletal: Painful, swollen joints Tenosynovitis>Bursitis Number of joints 2-4: Oligoarticular 5 or more: Polyarticular Any joint can be affected, including small joints of the […]
Pes Cavus
[…] cause. Taking into account the time course is also important. An acute onset of unilateral pes cavus is concerning for spinal cord involvement. Whereas chronic, mild lateral foot pain symptoms aggravated by activities is more consistent with subtle or idiopathic pes cavus.6 Physical Examination A thorough lower extremity neurologic exam, musculoskeletal exam of the foot including static alignment and active range of motion, and skin exam should be performed. Goal of exam is to identify pes cavus deformity, assess severity, determine etiology and to evaluate musculoskeletal sequelae that may be causing pain or dysfunction. The clinician should evaluate: Inspection: Skin: observe spine for signs of spinal dysraphism Look for foot calluses or ulcers usually under 1st and 5th metatarsals with/without tenderness Muscle bulk: Muscle hypotrophy of Peroneus Brevis and Tibialis Anterior Foot alignment: observe in standing and in supine Elevated medial arch Hindfoot varus (inverted calcaneus) (Figure 1a) Peek-a-boo heel sign in standing (medial heels are seen from the front (Figure 1b)) Forefoot valgus (1st ray lower than the rest of the forefoot (Figure 1c)) which drives hindfoot into varus Palpation: Palpate bony landmarks of the foot, ankle and knee with particular attention to areas of pain commonly associated with pes cavus 5th metatarsal Sesamoids Tarsal tunnel Peroneal tendons Plantar fascia Anterior talofibular ligament Medial tibia IT band and lateral knee Range of Motion: Look for reduced passive range of motion of ankle dorsiflexion Reduced subtalar pronation (relatively more range of motion of supination) Strength: Manual muscle testing of dorsiflexion, inversion, eversion, and plantar flexion Special Tests: Coleman Block Test: evaluation for examining the flexibility (reducibility) of hindfoot varus. Place a block under the lateral side of the forefoot and examine whether hindfoot returns to neutral position from varus. If hindfoot remains to be in varus position, the hindfoot deformity is likely rigid and not correctable with orthosis. Anterior drawer and varus stress to assess ankle stability Neurologic exam: Full neurological examination including sensation and deep tendon reflexes: If neurological impairment is noted in clinical examination, further work-up including electrodiagnostic study is warranted.1,3,15,16 Clinical functional assessment: mobility, self-care cognition/behavior/affective state Gait evaluation is essential especially in cavus feet of neurological etiology. Clinicians look for Steppage gait or foot drop (weak dorsiflexor tibialis anterior) Toe hyperextension (compensate with extensors for weak dorsiflexor tibialis anterior) in swing phase Functional tests are useful in subtle pes cavus to assess ankle stability and functional alignment Single leg balance Single leg heel rise Single leg squat Footwear evaluation lateral wear of outsole deformation of upper lateral aspect of shoe excessive wear and pressure points on 1st and 5th metatarsal heads Laboratory Studies If hereditary neuropathy is suspected, electrodiagnostic study, nerve biopsy, and genetic testing is recommended. Imaging Radiographs of foot (at least 3 views) are obtained for evaluation of pes cavus deformities including lateral ankle/foot, frontal view of hindfoot (Meary or Salzman), dorsoplantar of forefoot.3 All imaging of foot is taken in weight bearing position. This serves to evaluate for any fractures or degenerative changes that may be associated as well as to determine the presence of cavus by certain radiographic parameters: Cavus: Forefoot Cavus – Hibb’s Angle also known as Calcaneum to First Metatarsal angle >45 degrees Meary’s Angle – Talus to Frist Metatarsal angle >5 degrees Hindfoot Cavus – Calcaneus to ground angle > 30 degrees Equinus: Tibio-talar angle > 105 degrees CT and MRI scans are not used often but they are useful for peroneal tendinopathy for future reconstruction […]
Diabetic Neuropathy
[…] fasting glucose, HbA1c, or glucose tolerance test.10 Imaging Magnetic resonance imaging of the lumbar spine and arterial studies may identify spinal or vascular etiologies of symptoms that mimic DN. Plain films may diagnose and follow the progression of neuroarthropathies, such […]
Chemodenervation and Neurolysis
[…] of botulinum toxin into areas associated with post-herpetic neuralgia, post-traumatic neuralgia, peripheral nerve lesions, diabetic neuropathy, neuropathic pain associated with spinal cord injury, and trigeminal neuralgia.16 Residual Limb hyperhidrosis: The use of intradermal botulinum toxin has been used in case reports to […]
Outcome Measurement in Rehabilitation
[…] include the qualitative bedside Manual Muscle Test, as well as population specific measures such as the International Standards for Neurological Classification of Spinal Cord Injury (SCI) – ASIA Impairment Scale).5 Spasticity/Spasms: Bedside measures of spasticity and spasms include the (Modified) Ashworth Spasticity Scale and the Penn Spasm Frequency […]
Acute Immune Related Neuropathies
[…] Demyelinating GBS is characterized by inflammatory infiltrates, consisting of T cells and macrophages, and areas of segmental demyelination found in spinal roots and large and small motor and sensory nerves. There is often secondary axonal degeneration. The antibody immune response […]