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Juvenile Idiopathic Arthritis
Disease/ Disorder Definition Juvenile idiopathic arthritis (JIA), previously known as juvenile rheumatoid arthritis (JRA) or juvenile chronic arthritis (JCA) is a form of arthritis (i.e., swelling or limitation in range of movement of a joint with warmth, pain or tenderness)
Slipped Capital Femoral Epiphysis
Disease/Disorder Definition Slipped Capital Femoral Epiphysis (SCFE) is a hip disorder resulting in posteroinferior displacement of the proximal femoral epiphysis (femoral head) in relation to the metaphysis (femoral neck), through a skeletally immature physeal growth plate. It is characterized by
Stress Fracture of the Hip
Disease/ Disorder Definition Stress fractures are common injuries that tend to occur in athletes or other people who participate in activities that place repetitive and excessive stress on bone. They are part of a continuum of injuries which is broadly
Pulmonary Issues in the Athlete/Exercise Induced Bronchoconstriction
Disease/ Disorder: Definition Exercise-induced bronchoconstriction (EIB) is defined as the transient airway narrowing that occurs following exercise without regards to the presence or absence of asthma.1,2 While the term “exercise-induced asthma” (EIA) has been used, the term is misleading as exercise is not an independent risk factor for asthma, but, instead, a trigger for bronchoconstriction in some asthmatics.1 EIB may be present in patients with or without underlying asthma and can affect athletes of all levels.3, 11 Etiology EIB occurs following high-intensity exercise when high minute ventilation dehydrates the airways and ultimately results in the release of inflammatory mediators.4 This occurs more frequently in cold/dry environmental conditions.4,5 The sustained high-level ventilation reached during exercise and the water content of inspired air are the two most important factors of EIB.5 Epidemiology including risk factors and primary prevention The prevalence of EIB is 5%-20% of the general population and is likely underestimated due to lack of gold standard for diagnosis, while the prevalence in asthmatics is 40-90%3. EIB affects athletes of any level with studies showing higher rates (30%-70%) in Olympic/elite athletes.5 Those participating in indoor (i.e. ice hockey, swimming), endurance, and winter sports are more susceptible, and high-intensity training may contribute to the development of EIB.5 Environmental exposures such as cold air, dry air, ambient ozone, airborne particulate matter, gases associated with ice rink resurfacing equipment, and elevated levels of trichloramines in indoor pools are also thought to contribute to EIB.5 Poorly controlled chronic asthma, oral breathing, personal/family history of cardiovascular disease, allergic rhinitis, sinusitis, atopy and urbanization are additional risk factors.1,5 Patho-anatomy/physiology The mechanism of EIB is likely multifactorial and not entirely understood, with several theories existing to explain the pathophysiology12. The osmotic theory is the most universally accepted. It infers that large volumes of cool, dry air inhaled during exercise lead to changes in the osmolarity of the airway surfaces.2,3 A hyperosmolar environment results, triggering a mast cell-mediated release of mediators (i.e. histamine, leukotrienes, prostaglandins) from inflammatory cells, which cause bronchial smooth muscle constriction and edema.1 Uncontrolled underlying airway inflammation may exacerbate this response.1,2 These osmotic and mechanical stresses due to repeated heavy ventilation may also contribute to airway remodeling in the long-term through effects on epithelial cells. Over time this process alters smooth muscle contractile properties, leading to increased bronchial hyper-responsiveness .1,2,12 The re-warming hypothesis has some supporting evidence, but is mostly overlooked for the above hypertonicity mechanism.1 Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Symptoms of EIB usually occur during or after exercise, but may only occur in specific environments (i.e. ice rinks or swimming pools), or at a certain intensity or duration.5 In the acute phase, athletes may experience coughing, shortness of breath (SOB), chest tightness, and wheezing, or subtle symptoms such as fatigue, headache, dizziness, or impaired performance.2 Peak onset occurs within a 10-15 of exercise and lasts 30-90 minutes.3 Recovery is spontaneous with FEV1 returning to 95% baseline in 30-90 minutes.5 Patients can be refractory to another exercise stimulus for up to four hours and some can develop symptoms 4-8 hours after exercise, known as a late-phase response.5,13 Airway hyperresponsiveness may improve or normalize (weeks to years) if athletes refrain from competitive participation.2,6 Specific secondary or associated conditions and complications Co-existing conditions, or conditions that may mimic EIB, include asthma, upper-airway cough syndrome, chronic eosinophilic bronchitis, allergies, rhinitis, gastroesophageal reflux (GERD), exercise induced laryngeal obstruction (EILO), central airway obstruction, exercise-induced anaphylaxis, restrictive lung disease, swimming-induced pulmonary edema, and environmental exposures. EILO, is a frequent imitator of EIB, but does not respond to bronchodilators, symptoms resolve upon exercise cessation, and leads to persistent dyspnea.7 Additionally, SOB may be caused conditions other than airway dysfunction including anemia, infectious diseases, cardiovascular disease, and musculoskeletal conditions.7 Potential complications of misdiagnosis include persistent or worsening symptoms, impaired performance, discontinuation of a sport, hypoxemia, and, in extreme cases, death.7 Essentials of Assessment History The history should include when symptoms occur, initial onset, duration, frequency, and severity. Inquire if the patient has difficulty breathing, coughing, excessive mucous production, or chest tightness associated with exercise, that gradually improves upon stopping. Distinguishing inspiratory stridor with or without expiratory wheezing from inspiratory stridor alone is important, especially to help discern EIB from EILO14. Atypical symptoms may include fatigue, feeling out of shape or unable to keep up with peers, and abdominal discomfort. History of prior injury to the head/neck/chest, family/personal history of cardiopulmonary conditions, prior hospitalizations and current/past treatment are relevant. Physical examination A comprehensive physical should include examinations of the head, ear, nose, and throat (HEENT), chest, cardiopulmonary, extremity, and skin systems. HEENT exam should look for any signs of allergic rhinitis, sinusitis, or otitis. Examination of the chest (and back) should look for any structural deformities (such as pectus excavatum) or spinal scoliosis. On cardiopulmonary exam, auscultate for cardiac murmurs, wheezing, rales, or rhonchi and palpate pulse to detect arrhythmias. Examine skin and extremities for signs of eczema, cyanosis, digital clubbing, or edema. Functional assessment The impact of EIB on athletic performance has not been well established.8EIB may hypothetically impair performance due to exercise airflow limitations, increased work/oxygen cost of respiratory muscles, dyspnea/perception of effort, and ventilation/perfusion mismatch.8 Follow-up with patients once a treatment plan has been implemented to ensure compliance with treatment, assess that co-morbidities are adequately addressed, and to monitor for ongoing dyspnea, fatigue, or underperformance.7 From a psychological perspective, recent studies have described the negative emotional burden associated with EIB and EIA. This has been particularly seen in the adolescent population with reports of lower quality of life (QoL) and more mood symptoms including anxiety, depression, and frustration.11,15-17 Laboratory studies Symptoms of EIB are non-specific and have a poor predictive value.5 Serial lung function measurements, using forced expiratory volume in one second (FEV1), objectively determine the presence and severity of EIB.5 Indirect challenges (exercise challenge or surrogate testing) are more sensitive than direct challenge (i.e., methacholine). During an exercise challenge test, spirometry measures FEV1 pre-exercise and at 5, 10, 15, and 30-minute intervals post-exercise.5 An athlete should reach >90% of maximum heart rate at 2 minutes and maintain this level for another 6 minutes during the exercise. Airway response is the percent fall in FEV1 from baseline, […]
Pediatric Fractures in Developing Bone
[…] issues In cases of suspicion of child abuse, the clinician is legally obligated to make a report to Child Protective Services. The abused child should receive adequate supportive measures and counseling, and consideration of foster placement if the home environment […]
Differential Diagnosis and Treatment of Visceral Pain in the Pelvis and Abdomen
[…] from the skull to the coccyx along the anterior aspect of the vertebral column and terminate in the only unp aired ganglion of the sympathetic chain, the ganglion impar (ganglion of Walther) on the ventral surface of the coccyx. After […]
Peripheral Polyneuropathy Part 2: Treatment
Disease/ Disorder See Peripheral Polyneuropathy Part 1: Evaluation and Differential Diagnosis Essentials of Assessment See Peripheral Polyneuropathy Part 1: Evaluation and Differential Diagnosis Rehabilitation Management and Treatments Available or current treatment guidelines Pharmacologic treatment of peripheral neuropathy hinges upon treating
Nonsteroidal Anti-Inflammatory Medications
Disease/ Disorder Definition Non-steroidal anti-inflammatory drugs (NSAIDs) are medications used to reduce inflammation and to relieve pain. They are one of the most commonly used medications in adults. NSAIDs are frequently used for their analgesic, anti-inflammatory, and antipyretic properties.1 For
Pes Planus/Adult Acquired Flatfoot Deformity
[…] assessed. It is also important to determine whether the flatfoot deformities (tibiotalar and subtalar joints and Chopart and Lisfranc joint- lines) are reducible for orthotic management. With stage III PTT dysfunction, the flat foot deformity can no longer be passively […]
Upper Limb Prosthetics
[…] activation of the TD). This is accomplished by passing a single cable through two separate sections of cable housings (f air lead cable system). In transradial and transhumeral amputations, biscapular abduction and/or humeral flexion control elbow flexion and/or the TD. […]