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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 […]
Osteoarthritis
[…] it is not only due to “wear and tear” but may also be due to abnormal mechanics, inflammation, post-surgery, etc. 1 OA can be primary or secondary. Etiology Primary Idiopathic (eg, aging persons, females) Familial Secondary Predisposing factors include: Trauma/micro-trauma […]
Trigeminal Neuralgia
[…] and promotes ephaptic cross-talk between adjacent nerve fibers. Tactile stimulus from fast-myelinated (A-beta) fibers can directly activate slow nociceptive (A- delta fibers), resulting in the high frequency discharges that TN is known for.1,3,6 Symptomatic or secondary trigeminal neuralgia (STN) is […]
Discogenic Lumbar Pain
[…] diagnosis of low back pain. It is thought to originate from late degenerative disk disease (DDD) and internal disc disruption. 1 DLP symptoms are distinct from those occurring as a result of spinal deformity or radiculopathies. Etiology Strong familial predisposition […]
Torticollis in Children and Adolescents
[…] is categorized as congenital or acquired. Congenital muscular torticollis (CMT) is the most common form. A newer classification proposed in 20 12 uses non-paroxysmal (nondynamic) and paroxysmal (dynamic) torticollis as the two main categories.1 Etiology Non-paroxysmal or nondynamic torticollis1 CMT Osseous […]
Pulmonary Rehabilitation Before and After Pulmonary Transplantation
[…] coal miners, hard rock miners, tunnel workers, industrial workers, and transportation industry workers. Additional factors included prior tuberculosis history, outdoor air pollution, respiratory infections, genetics, lower socioeconomic status, nutrition, and other medical comorbidities. Lung growth and development deficits and oxidative stress have also been linked to COPD. Influenza and pneumococcal vaccines are recommended for COPD patients to prevent respiratory tract infection.6 The US Centers for Disease Control (CDC) also recommends the Tdap vaccine (also called dTaP/dTPa) for prevention of pertussis, tetanus, and diphtheria for adults with COPD, as well as shingles vaccine and COVID-19 vaccine in line with national recommendations.6 IPF typically presents as progressive dyspnea in the sixth or seventh decades of life.7 It is a chronic and progressive disorder with a median survival time of 3-5 years after diagnosis if left untreated. There is substantial variability in the clinical course of IPF, from slow progression to acute exacerbation, rapid loss of lung function and early death. The two main risk factors for IPF are aging and cigarette smoke exposure8. The majority of patients with IPF have a history of cigarette smoking. Other risk factors include gastroesophageal reflux, chronic viral infections (Epstein-Barr virus or hepatitis C), and a family history of interstitial lung disease (ILD).7 Patho-anatomy/physiology During a lung transplant, the host lung is surgically denervated. When this occurs the lung’s lymphatic drainage and circulation is altered.9 The lung receives blood supply from the pulmonary and bronchial arteries, but during lung transplantation, only the pulmonary artery circulation is reattached. The rationale behind this decision is that direct revascularization has been seen as too difficult and often unreliable to perform routinely; also, de novo regrowth of the bronchial arteries has been observed. There is some association of this alteration in lung vasculature to bronchiolitis obliterans, which is a common postoperative complication.10 Following lung transplantation there is increased airway hyperresponsiveness, altered cough reflex, and reduced mucociliary clearance. Injury to the vagus, recurrent laryngeal nerve, and superior laryngeal nerve during surgical procedure can also lead to swallowing and gastroesophageal dysfunction.11 Skeletal and respiratory muscle dysfunction is another common complication in lung transplantation. The etiology is thought to be multi-factorial due to critical illness myopathy, chronic steroid use, and injury to the phrenic nerve. Additionally, there is increased incidence of sleep disordered breathing in lung transplant recipients. Pulmonary function tests typically show the most improvement during the first year after transplant. Decline in forced expiratory volume in 1 second (FEV1) could be a sign of organ rejection, infection, airway stenosis or other issues. Patients typically experience improved exercise and functional capacity following lung transplantation, though they typically experience chronic limitations including reduced peak oxygen consumption and early onset of anaerobic threshold; a pattern compatible with skeletal muscle deconditioning.9 Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) The Global Initiative for Chronic Obstructive Lung Disease (GOLD) formulated a staging system as follows: Stage I: forced expiratory volume in one second (FEV1) more than 80% of expected; minimal shortness of breath with/without cough and/or sputum. Stage II: FEV1 50% to 80% of predicted; moderate to severe shortness of breath on exertion, with/without cough, and sputum or dyspnea. Stage III: FEV1 30% to 50% of predicted; severe shortness of breath, with/without cough, sputum or dyspnea, exacerbation, reduced exercise capacity, and fatigue. Stage IV: FEV1 less than 30% of predicted; serious impairment in quality of life caused by shortness of breath with frequent exacerbation, and life threatening at times.6 According to the American Lung Association, there is no formal staging system for pulmonary fibrosis. Prognostication based on symptoms, pulmonary function tests, and imaging with high resolution CT scan is utilized to categorize disease as mild, moderate, or severe. A scoring system called the GAP Model (Gender, Age, and Physiology) was recently developed which uses gender, age and physiology to stage pulmonary fibrosis. There are multiple studies assessing the prognostic value of the GAP Model, however it is not yet widely utilized.12 Specific secondary or associated conditions and complications Primary graft dysfunction (PGD) is a syndrome of acute lung injury that occurs within 72 hours of lung transplant and is characterized by pulmonary edema and diffuse alveolar damage. The incidence of grade 3 PGD is approximately 16.8%. PGD cases can last anywhere from 48 hours to several weeks. Acute cellular rejection (ACR) is a host lymphocyte reaction to donor antigens; the incidence of ACR is estimated at 35% of adult lung transplant recipients within the first year but it is only responsible for 4% of deaths within the first month of transplant. Antibody-mediated rejection also occurs when the recipient forms donor-specific antibodies. Bronchiolitis Obliterans Syndrome (BOS) is a manifestation of chronic lung transplant dysfunction that typically occurs within the first 3 months of transplant and is responsible for the majority of deaths in the first year after transplant. BOS occurs in greater than 50% of lung transplant recipients by year five. Recurrence of primary disease most commonly occurs in patients with sarcoidosis which recurs at a rate of 35% after transplant. Lymphangioleiomyomatosis has also been found to recur.13 There are other medical complications that commonly arise after lung transplant as an adverse effect of anti-rejection and other post-lung transplant medications. For example, calcineurin inhibitors can be implicated in the development of hypertension (HTN) and renal failure after lung transplant. The prevalence of diabetes mellitus (DM) is estimated at greater than 30% in lung transplant patients, often secondary to or exacerbated by chronic steroid and calcineurin inhibitor use. Lung transplant patients frequently suffer from steroid-induced osteopenia or osteoporosis and rapid bone loss after transplant.4 Due to immunosuppression, lung transplant patients are also at high risk for opportunistic infections such as cytomegalovirus, aspergillosis and pneumocystis jiroveci.13 Essentials of Assessment History Medical history: age, severity of respiratory disease, cough, sputum production, oxygen supplementation needs, dyspnea, history of lung infections, malignancy, prior thoracic surgeries, vaccination history, hospitalizations as a result of pulmonary issues, and assessment for any comorbid conditions (e.g., heart disease, weight loss, esophageal dysmotility, connective tissue diseases) and assessment for any conditions that would preclude patient from receiving a transplant (active infections, sepsis, or stroke or coronary event within the past 30 days). Environmental history: primary or second-hand smoke exposure, high pollution environment and biomass disease fuel use in enclosed spaces. Occupational history: work type and exposure to inhaled gases and/or particulate matter inhalation. Psychosocial history: tobacco use or any inhaled illicit drugs, known or progressive cognitive impairments or uncontrolled psychiatric illnesses that could interfere with medication adherence, social support, and resources available. Functional history: premorbid functional status, current functional status, assistive device use, and dyspnea during activity. Physical examination Patient assessment should focus on the following: Lung auscultation to evaluate for effusion, areas of atelectasis and bronchial constriction. Assessment of supplemental oxygen requirements Inspection to evaluation for accessory muscle use and to assess for any deformity. Heart auscultation to assess for cardiac/valvular disease. Examination of the muscle bulk for any signs of atrophy or cachexia including measurement of BMI. Manual muscle testing to assess strength focusing on muscles used for ambulation. Both before and after transplant, examination should also focus on signs of comorbid and secondary diseases (e.g., diabetes, renal disease, neurologic examination, gastrointestinal involvement). Functional assessment Mobility: six-minute walk test, FIM, and cardiopulmonary exercise study. Multidimensional prognostic model: BODE index (BMI, airflow limitation as measured by forced expiratory volume in 1 second (FEV1), dyspnea and six-minute walk test) Self-care: index of independence in activities of daily living, instrumental activities of daily living, Barthel Index of activities of daily living, and FIM. Cognition/behavior/affective state evaluation tools: Minnesota Multiphasic Personality Inventory-2, clinical interview, Montreal Cognitive Assessment, among others. Laboratory studies Pretransplant evaluation includes laboratory analysis of hepatic and renal function to assess for potential multi-visceral transplant candidacy. Viral serologies are also measured in order to assess compatibility with donor serologies to decrease risk for reactivation and viremia. During the posttransplant period, surveillance of immunosuppressant levels for dose titration is indicated, and its frequency will be dictated based on the patient’s clinical status. Monitor for electrolyte disturbance, such as hypomagnesemia and hypophosphatemia, among others. Further laboratory monitoring and workup should be tailored to what is indicated for each individual patient. Imaging The needs for imaging will be dictated by the patient’s clinical status and time frame posttransplant. The following are some of the most used: Chest radiographs with a selection of views depending on the suspected diagnosis. Useful to assess for lung expansion, donor size mismatches, pulmonary infection, presence of pneumo/hemothoraces, effusions, and/or diaphragmatic paralysis. Routine follow-up radiographs are usually done serially during the first 3 months posttransplant. Fluoroscopic examination to rule out diaphragmatic paralysis, if suspected, posttransplant. Chest computed tomography (CT), both non-contrast and contrast enhanced, is useful to assess the presence of common pulmonary pathology, such as effusions and consolidation, among others. CT is useful for confirming and quantifying infiltrates, selecting appropriate regions of the lung for bronchoscopy, and determining the response to specific antimicrobial treatment. It is also useful to evaluate for well-established complications of transplant such as vascular and bronchial anastomotic abnormality, lung torsion, pulmonary embolism, rejection, infection and bronchiolitis obliterans. Early predictions of outcomes Decreased 1-year survival has been associated with the number of human leukocyte antigen mismatches, primary pulmonary hypertension and pulmonary fibrosis, pretransplant psychologic illness, clinical status, mechanical ventilator dependency, and age over 60 years. Transplant recipient selection criteria vary from center to center; nonetheless, because of lung allocation scoring system changes, increased transplant recipient age has been observed and associated with decreased survival. Environmental Particulate aspiration and gases (biomass fuel, diesel exhaust, etc.) have been identified as triggering agents for airflow limitation, therefore contributing to COPD and COPD-like illnesses. During the posttransplant stage, some patients will possibly require droplet precautions and/or contact precautions caused by the development of viral infections or resistant bacteria during their hospital stay. The proper hand-washing technique is the most advocated infection control measure per the Centers for Disease Control guidelines. Some immunocompromised patients with neutropenia benefit from positive air pressure and a high-efficiency particulate filter. Some transplant centers will, after discharge, require the avoidance of enclosed spaces/densely populated spaces, favor face mask use until steroids are tapered to the lowest possible dose, and require the avoidance of handling pet feces and plants.14 When handling materials with a higher chance of contamination such as soil, moss and manure, gloves should be worn. Shoes, long sleeves and pants should be worn while participating in activities such as gardening, yard work and being in parks and heavily wooded areas. As for possible percutaneous infectious exposure, body piercing and tattoos should be obtained from reputable centers with strict adherence to sterile technique. As for all activities mentioned above, extra caution should be taken during periods of enhanced immunosuppression. The same can be said for times when community spread of viral illness is increased.15 Social role and social support system Pretransplant, an evaluation is conducted to determine whether the patient has support from family/friends or access to care services for transition to the community posttransplant. A patient’s cognitive abilities will be crucial regarding medication management to yield a higher rate of success posttransplant and help prevent complications. Household contacts should be educated on good hygiene practices such as hand washing, coughing and sneezing etiquette. Additionally, all close contacts should remain up to date on standard immunizations and yearly influenza vaccine. Professional issues A close evaluation of the patient’s medical needs, tolerance to activity, and need for supplemental oxygen is vital to establish goals for the rehabilitation process, inpatient or outpatient. Accurate documentation and coding will safeguard proper reimbursement and accounting for the patient’s complexity during evaluation and management. As for patient professional considerations, lung transplant recipients have a lower pretransplant incidence of employment as compared to other solid organ transplant (SOT) recipients such as kidney, heart and liver. Studies have suggested return to work rates around 28% in lung transplant patients. Additionally, compared to other SOT recipients, lung recipients are less likely to return to work posttransplant.16 Some factors shown to positively affect return to work include pretransplant employment, self-reporting being physically able to work, greater posttransplant improvement in percent predicted forced vital capacity, and posttransplant 6-minute walk > 550 meters.17 Return to work becomes much less likely one-year post-transplant. For individuals desiring returning to work in fields such […]
Severe Pediatric Traumatic Brain Injury
[…] cerebral edema, elevated ICP, seizures, and hydrocephalus. Management of medical issues may help determine recovery. In the ED, the child’s airway, breathing, and circulation is assessed and managed. Glasgow Coma Scale (GCS) or the Pediatric GCS scores are obtained. Patients […]
Congenital Hip Dysplasia
[…] to a spectrum of pathologies that result from abnormal hip development secondary to insufficient acetabular coverage of the femoral head. 1 Presentation may vary from mild acetabular dysplasia with a stable hip to subluxation and dislocation of the joint. The diagnosis is often associated with a progressive course.1,2 Currently, developmental dysplasia of the hip is the preferred term for this disease spectrum as not all cases are recognized or present at birth; rather, many patients are diagnosed in childhood during periods of growth and development.1 Etiology The etiology of congenital dysplasia of the hip is estimated to be multifactorial in origin, including one or more hormonal, mechanical, or genetic factors.1,2,3,4 Proposed hormonal involvement Imbalance of estrogen and progesterone Higher levels of progesterone related to higher rates of dislocation. Gender -related factors: female patients at higher risk2 Mechanically, periods of high growth or stimulation can result in development of DDH.1 Demonstrated both in utero and childhood development If persistent subluxation or dislocation: femoral head flattens femoral anteversion Acetabulum becomes shallow and dysplastic. Increased laxity of the hip capsule Hip instability Disrupted smooth articulation at the interface of the femoral head and the acetabulum increased likelihood of subluxation or dislocation Genetic involvement: multiple genes associated Includes CX3CR1,PAPPA2, COL2A1, HOXD9, GDF-5, and TGFB1.2,4 Epidemiology including risk factors and primary prevention The incidence of DDH/CDH varies with age, race, and symptomology. Prevalence is 1-1.5% of infants. Incidence varies between sexes, with males and females having an incident rate of 5 versus 13 out of 1,000 respectively. In infancy, hip instability is relatively common; however, in cases of mild instability, 90% of children will improve within 8 weeks after birth.2,3 Major risk factors are as follows5 Gestational positioning Most significant risk factor: breech positioning in the third trimester. Other physical limitations include large for gestation age, oligohydramnios, and twin pregnancies Post-maturity at birth. Genetics and familial predispositions6 Female sex: females are four times as likely to develop this disease. First degree relatives are 12 times more likely to acquire DDH/CDH Post-birth positioning Adducted and extended positions when swaddled Musculoskeletal deformities secondary to a crowding phenomenon in the womb associated with DDH Metatarsus adductus in 4%8 of cases Torticollis in about 8% of cases.6,9 Patho-anatomy/physiology To understand the pathogenesis of this disease process, it is important to understand the anatomy of the hip. In a nondysplastic hip joint, the femoral head is situated inside the acetabulum. Optimal function depends intimately on a smooth, concentric reduction between the acetabulum and the femoral head with movement aiding in hip development. The joint is supported by the capsule, teres ligament, and transverse acetabular ligament with the labrum being the cartilage cushioning the bony surfaces.1 When the femoral head and acetabulum are not approximated appropriately, the acetabulum will flatten over time, leading to dysplasia and instability at the hip joint. This instability can lead to subluxation or dislocation at the hip which can further worsen the dysplastic changes. The success of a functional hip joint relies on the close approximation of the femoral head and acetabulum; therefore, treatment goals are to achieve stable reduction between the femoral head and acetabulum and thus promote normal development5 Key factors that influence pathoanatomy include: Disruption of femoral head and acetabulum relationship Fatty tissues in the depths of the hip, preventing reduction and stability Hypertrophy of the ligamentum teres, preventing reduction. Thickened transverse acetabular ligament, narrowing the opening of the acetabulum Shortened iliopsoas tendon across the anterior hip creates an hourglass shape to the hip capsule limits access of the femoral head to the acetabulum. Infoldings and thickening of labrum secondary to increased pressure on acetabular rim and labrum Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Congenital hip dysplasia, or developmental dysplasia of the hip, refers to a spectrum of pathology, with four distinct clinical patterns noted. These presentations include varying degrees of hip instability to include1,2,3,5 Acetabular dysplasia: a shallow hip socket which leads to increased pressure on the rim of the hip socket Hip subluxation: a presentation where the femoral head is not appropriately sitting in the acetabulum Hip dislocation: the femoral head is fully displaced from the acetabulum Symptom presentation and symptom load also varies by age and development. Neonates: DDH will be asymptomatic and requires screening by specific clinical maneuvers (Ortolani test and Barlow test, as subsequently described in the Physical Examination section) and/or imaging.5,7,8 Infants: After 2 to 3 months, soft tissues tighten and specific physical findings include limited hip abduction, thigh shortening (Galeazzi or Allis sign), and asymmetry of gluteal or thigh folds. Ambulatory children: Often present after a leg-length discrepancy, limp, or waddling gait is noticed. These children will have a positive Trendelenburg sign, with a shortened femur on the affected side. DDH is more commonly seen in the left hip (60%) but can often be found to be present bilaterally.9 Specific secondary or associated conditions and complications Associated conditions and complications of DDH include avascular necrosis of the femoral head, persistent dislocation, residual subluxation, progressive acetabular dysplasia, persistent limp, premature degenerative arthritis of the hip, leg length discrepancy, lumbar lordosis, knee pain, scoliosis, and degenerative changes of the spine. Patients with progressed dysplastic changes have higher rates of total hip arthroplasty and earlier onset of arthritis.5,9, 10,11 If in utero hip dislocation occurs and the hips are not reducible on neonatal examination, chromosomal or neuromuscular conditions should be considered in the differential diagnosis. These conditions include myelomeningocele, arthrogryposis, and Ehlers-Danlos syndrome.5,9 Essentials of Assessment History A thorough review of the listed risk factors (i.e., positive family history, female sex, breech positioning, conditions leading to a tighter intrauterine space) should help guide the examiner’s suspicion for DDH when screening. Physical examination Hip examination is recommended to be performed on all infants during routine clinical examinations. Hip instability in the neonate is classically screened via the Galeazzi, Barlow, and Ortolani tests, with the infant in a supine position12: Galeazzi (Allis) sign, which screens for shortening of the thigh as an indication of hip dysplasia With the infant supine, the examiner flexes the hips and knees, looking for asymmetry in the height of the knees. this test is positive if one knee (when flexed) is lower than the other. Barlow test, click of exit maneuver, which screens for dislocation of a non-displaced hip.12 The examiner adducts the flexed hip and gently pushes the thigh posteriorly to try and dislocate the femoral head. The test is positive if the hip is felt to slide out of the acetabulum. Ortolani test, click of entry maneuver, which screens for dislocation by trying to reduce a dislocated femoral head.12 Grasping the child’s thigh between the thumb and index finger, the examiner lifts the greater trochanter with the 4th and 5th fingers while simultaneously abducting the hip. The test is positive when the femoral head slips into the hip socket with a fine clunk that should be palpable but not audible. The Barlow and Ortolani tests are now frequently done in conjunction and with the assistance of ultrasound guidance. Ultrasound is utilized to ensure that bilateral dislocations are not missed during the execution of these tests as bilateral dislocations may feel symmetric dislocation and reduction.12 Note that clicks audible during Barlow and Ortolani maneuvers are usually benign and result from soft tissues snapping over bony prominences. An estimated 1/100 newborns have evidence of some hip instability with a positive Ortolani or Barlow sign; however, a true dislocation is reported to be 1-15/1000 births. After 2 to 3 months of age, the soft tissues around the hip tighten, so the Barlow and Ortolani tests become less reliable. In infants at this stage of development, the examiner must consider other physical findings as follows. Galeazzi (Allis) sign Asymmetry of the gluteal or thigh folds. Limited hip abduction, especially if asymmetric (more difficult to detect if DDH is bilateral). Limb length discrepancies13 A direct measurement of the ‘true’ limb length can be obtained from anterior superior iliac spine to the medial malleoli. A walking child may present with abnormal gait signs, including any of the following13 Limp. Waddling gait. Hyperlordosis. Positive Trendelenburg sign. Asymmetry of pelvic alignment, as viewed from the frontal plane (use pelvic brim, anterior superior iliac spine, posterior superior iliac spine, and/or greater trochanters as landmarks). Functional assessment Manual serial hip examinations are recommended until a child ambulates. Once a child begins to ambulate, age-appropriate gait evaluation is imperative to assess for alterations to normal gait patterns. Ambulating children may experience pain with walking, a waddling gait, or limp. Likewise, range of motion testing assesses for asymmetries in motion or evidence of impingement symptoms. As children age into adolescence, early arthritic symptoms, including impingement, pain or limitations with internal rotation and hip adduction can present.1,10,11,13 Imaging Ultrasound is the diagnostic modality of choice, especially in infants from birth to six months of age because it is superior to radiographs in evaluating cartilaginous structures of the femoral joint. After approximately six months, the cartilaginous structures of the hip are ossifying, resulting in ultrasound being less effective than other imaging modalities. Ultrasound visualization limits exposure to radiation, contrast, or the need for sedation.1,2 Placing the transducer on the greater trochanter allows visualization of the ilium, bony acetabulum, labrum, and femoral epiphysis, allowing visual confirmation of femoral head displacement, as well as pathologic malformation of bony and cartilaginous structures.2 A dynamic technique, which assesses stability of the femoral head in the acetabulum as well as the static anatomy, is preferred. False-positives can occur in the early newborn period, because the acetabulum is immature and the joint has some temporary laxity (0-4 weeks of age). The Graf method of classification was developed in 1980 with severity ratings from type I (normal hip) to type IV (dislocated hip). A good quick reference for this classification is found at: http://radiopaedia.org/articles/graf-method-for-ultrasound-classification-of-developmental-dysplasia-of-the-hip Some centers utilize ultrasonography in patients with a positive Ortolani sign and its used progressively to monitor subluxation or dislocated hip being treated in a Pavlik harness Radiographs (anteroposterior view) are recommended after femoral head ossification (4-6 months) occurs.2,14 Lateral femoral head migration is measured by the intersection of the Hilgenreiner line (horizontal through the triradiate cartilage) and the Perkins line (vertical from the lateral acetabulum). The AP view is interpreted via the acetabular index (AI), which measures the slope of the ossified acetabular roof. AI >30 degrees is abnormal. A broken Shenton line (a curved line drawn from the medial femoral neck to the lower […]
The Early History of Physical Medicine and Rehabilitation in the United States
[…] controversy about this young medical field that held promise but had produced little research to back its claims. Coulter ch aired the Council from 1932 until his death in 1949. A small group of other physical therapy physicians joined Coulter […]
Environmental Assessment
[…] components and potential environmental risk factors that may contribute to injury, prevent recovery, or limit accessibility to those with imp aired mobility. It is important to evaluate for potential environmental risk factors that may predispose to injury, create barriers to […]