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Endocrine Abnormalities Affecting the Musculoskeletal System
[…] (IGF)-1 directly stimulate osteoblasts and modulate osteoclast turnover.1,24 There is an association between fibromyalgia and GH deficiency, attributed to alpha- delta sleep anomalies.21,25,26 In acromegaly, early musculoskeletal complaints include enlarged cartilage and joint capsules with hypermobility and instability.11 Schwann cell […]
Pediatric Syringomyelia
[…] in skin protection and bowel/bladder care are essential. If primary caretakers are unable to provide adequate support, referral to social services is required. External resources include the following: Chiari and Syringomyelia Foundation (http://csfinfo.org/) American Syringomyelia & Chiari Alliance Project (http://asap.org/) Teenage […]
Lower Limb Prosthetics
[…] and unlimited household ambulator. K2 Has the ability or potential for ambulation with low-level environmental barriers such as curbs, st airs, and uneven surfaces. Typical of the limited community ambulator. K3 Has the ability or potential for ambulation with variable […]
Cognitive Issues in Brain Injury and Other CNS Disorders
[…] legal, and medical benefits may need to be addressed. The Family Caregiver Alliance has put together information describing resources and services for patients and caregivers, listing agencies that may provide information and benefits.59 Rehabilitation Management and Treatments Available or current […]
Osteochondritis Dissecans
[…] subchondral bone, with secondary damage to overlying articular cartilage. It is characterized by degrees of osseous resorption, collapse, and fragmentation. 1 There are juvenile and adult forms of this condition; the juvenile form occurs in children or adolescents with open […]
Venous Insufficiency: Rehabilitation Management of Venous Stasis and Postphlebitic Syndrome
[…] worsening and alleviating factors Pain in the upper or lower extremities, pelvis, flank, back Skin changes in the extremities: discoloration/hyperpigmentation/redness/cold/pallor/numbness/h air loss/ulcers22 Edema in the calves or feet Symptoms of intermittent claudication Redness or tenderness Prior treatments/compression therapy23 Pregnancies Age […]
Downed Runner
[…] Pre- and post-race weight (if known) Physical examination While on the course, address life-threatening issues focusing on level of responsiveness, airway patency, breathing, circulation and any obvious bleeds and other exposures (e.g., open fractures). Once stabilized, a secondary assessment should […]
Somatic Abdominal and Pelvic Pain
[…] or the viscera. Somatic pain is a subset of nociceptive pain, a normal response to noxious stimulus to these tissues. 1 Somatic pain can be characterized as pain that is intermittent or constant, well localized, and described as aching, throbbing, sharp, cramping or gwaning.19 Etiology The differential diagnoses of pain from the abdomen and pelvis can be broad and vague, with nociception originating from any organ system. As such, a thorough history and review of systems is paramount in elucidating causative pain generators, including gender-specific considerations. Injuries to the musculoskeletal system of the abdomen and pelvis may include abdominal or pelvic muscle strains or sprains, pelvic fractures, sacroiliac dysfunction, pubic symphysis dysfunction and diastasis pubic symphysis. High-velocity trauma can also cause Morel-Lavallée lesions (degloving injury of skin and subcutaneous tissue from underlying fascia) which commonly affect the thigh, hip, and pelvis2. Morel-Lavallee lesions are associated with underlying fractures of the acetabulum, proximal femur or the pelvis.20 Referred pain to the abdomen and pelvis may occur from failed back surgery from T9-L1 (or rarely from muscles attaching to this region like latissimus dorsi2,3), vertebral lesions of the spine, as well as degenerative joint disease of sacroiliac joints and lumbar spine zygapophyseal joints. Chronic post-surgical pain may result following gastrointestinal surgery, hysterectomy, or hernia repair.5 Some post-operative pain (especially following lower abdominal surgery) stems from cicatricial entrapment of cutaneous nerves. Infections, including lower urinary tract infections (UTI) and upper UTI (extending beyond the bladder), commonly present with irritation of the urethra and peri-urethral skin. Gender-specific considerations include prostatitis, prostatodynia, as well as vulvar and vaginal canal pain. Masses that cause somatic pain of the abdomen and pelvis commonly include abscesses, hematomas, and tumors of the iliopsoas, pelvic bones, and other tissues. Epidemiology including risk factors and primary prevention Somatic abdominal and pelvic pain cover a wide variety of individual diagnoses, each with its own prevalence, risk factors and prevention. Diagnoses may include nerve injury, myotendinous strain/sprain/trauma, childbirth trauma, fractures, ligamentous injury, infection, masses/tumors, neuralgia, post-surgical pain and/or complications as well as rheumatologic disease. Because of the etiologic uncertainty, between 30%-50% of chronic pelvic pain diagnoses remain uncertain and are classified as “chronic pelvic pain without obvious pathology.17” The prevalence of chronic pelvic pain alone is estimated to affect one out of every seven women with an estimated cost of $881 million annually in the United States.12 Risk for chronic post-surgical pain is 20-32%; epidural anesthesia as opposed to general anesthesia may reduce this risk.5 Abdominal oblique muscle strains constitute about 5% of all baseball injuries, with a re-injury rate around 12%, complete treatment with physical therapy and sufficient core muscle strengthening may reduce re-injury.6 Athletic pubalgia, “sports hernia” (disruption of the rectus abdominus muscle from the pubic tubercle) may occur in recreational, high school, college, or professional athletes.7 Chronic pelvic pain is present in 5-43% of women, with musculoskeletal disorders present in 75-85% of these women.8 Chronic Abacterial Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is also a significant male-specific problem representing 9% of all urologic visits, one study estimating a prevalence of 3.2% of males under 50.13,14 Patho-Anatomy/Physiology9 Nerves Nerves of the Anterolateral Abdominal Wall (may be susceptible to injury or irritation with abdominal surgery) Thoracoabdominal (T7-T11) – muscles of anterolateral abdominal wall and overlaying skin 7th-9th lateral cutaneous branches of the 7th- 9th intercostal nerves – skin of right and left hypochondriac regions Subcostal (T12) – muscles of anterolateral abdominal wall and overlaying skin Iliohypogastric (L1) – internal oblique, transversus abdominis, skin over the iliac crest, upper inguinal and hypogastric regions Ilioinguinal (L1) – inferior-most internal oblique, transversus abdominis, skin over lower inguinal region, mons pubis, anterior scrotum, and labia majora Pelvic Nerves (susceptible to injury during childbirth or surgery) Sacral plexus may be compressed by fetal head Obturator nerve vulnerable during lymph node retrieval in lateral pelvic wall Pudendal nerve is often involved with genital pain Muscles Muscles of anterolateral abdominal wall (susceptible to strain/sprain, as a group called oblique muscle strain or side strain): Side strains are common in sports where trunk rotation generates power for the upper extremities like baseball, tennis, golf, cricket, and Olympic throwing events.6 Rectus Abdominis Transverse abdominal Internal Oblique External Oblique Pyrimidalis (absent in 20% people) Walls and Floor of the pelvic cavity (susceptible to childbirth trauma) Obturator Internus – lateral wall Piriformis – posterolateral wall Floor Coccygeus (ischiococcygeus) Levator Ani (“Pelvic Myalgia”) Pubococcygeus (most commonly torn during childbirth trauma) Iliococcygeus Bones (and associated ligaments) Pelvic Girdle: Susceptible to fracture from high force injuries and childbirth trauma, ligamentous injuries as well as rheumatologic problems, such as ankylosing spondylitis. Ilium Ischium Pubis Sacrum Coccyx Pubic Symphysis Sacroiliac Joints Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Disease progression in abdominal and pelvic somatic pain will vary widely depending on the specific diagnosis. Correct early diagnosis and treatment can abate progression to the chronic pain state. New Onset/Acute Pain is characterized by a sudden, sharp onset of pain with localized tenderness Subacute Recovery Stage: In routine healing, the patient’s somatic pain will continue to improve with decreased use of analgesics and improved function. Chronic/Stable Untreated or undertreated pain may progress to the chronic pain state. Chronic pelvic pain may be a result of viscero-visceral, viscero-somatic or somato-visceral convergence,7,8 whereby pathology in one viscera or myotome may create pathology in another organ or muscle group which share the same innervation levels in the central nervous system. Pre-Terminal Metastases to pelvic girdle or abdominal wall may be a pain-generating source or may lead to pathologic fractures or tissue injuries. Essentials of Assessment History Identify location, onset, and palliative/provocative factors. Assess quality, radiation of pain, severity and timing. Past surgical history, including remote and recent surgeries, as well as pregnancies and delivery history may provide direction to identify traumatic cause in abdominal and/or pelvic pain. Visceral source for the pain must be ruled out, including red flags for malignancy or infection. Psychosocial aspects include psychiatric illness (ex. depression or anxiety), catastrophizing, disability and history of rape or abuse. Physical examination Due to the association between trauma and chronic abdominopelvic pain, a Trauma-Informed Care (TIC) approach is strongly recommended to avoid potential re-traumatization and ensure safety of the patient and staff.21,23 General assessment of appearance and degree of discomfort, including a detailed dermatologic exam to assess for surgical/traumatic scars Vital signs to help to rule out systemic or visceral pathologies Abdominal examination including palpation, percussion and auscultation to evaluate both superficial musculature as well as to rule out visceral pathologies including masses, hernias, ascites, hepatomegaly or splenomegaly. Carnett’s Sign (worsened abdominal pain with tension of abdominal muscles) can help distinguish visceral from abdominal wall pain. Comprehensive musculoskeletal assessment, as per Baker, “musculoskeletal dysfunctions contribute to signs and symptoms of CPP and in many cases may be the primary factor.18” Pelvic and genital examination including bimanual examination for cervical, adnexal and uterine tenderness as well as pelvic floor muscle tenderness. Provocative pelvic maneuvers can include the P4 Test (hip flexed to 90 degrees while supine), Pace (abduct leg against resistance) and Freiberg (forced internal rotation of leg) maneuvers for piriformis syndrome, and pelvic floor muscle test. Rectal examination including prostate examination Special Tests: CVA percussion (Pasternacki’s sign) for renal pathology, rebound, guarding, Murphy’s sign for gall bladder pathology, Rovsing’s sign for appendicitis Evaluation with provocative maneuvers for myofascial pain (trigger points, referral patterns). Hip examination including ROM, muscle testing and FABERE/FADIR tests. Psychiatric, psychosocial, and psychosexual assessment to evaluate for depression, anxiety, somatization, physical or sexual abuse, drug abuse or dependence, family problems, marital problems, or sexual problems. Functional assessment: Mobility, self-care, cognition/behavior/affective state Severe abdominal and/or pelvic somatic pain, such as that caused by pelvic fractures or post-operative pain, may limit a patient’s independence with mobility and/or self-care. Both inpatient and outpatient evaluations of patients with severe pain should address this possibility. Chronic abdominal and/or pelvic pain has a strong association with psychological comorbidities, including anxiety, depression, and disability. Laboratory studies Laboratory studies are used to rule out visceral and systemic causes of abdominal and pelvic pain, including (but not limited to): urinalysis, complete metabolic panel, amylase, lipase, stool occult blood, PAP smear, CRP, ESR, CK, CBC. If visceral source for pain is suspected, referral to an internist, gastroenterologist or gynecologist is appropriate. Imaging Imaging may be ordered to rule out visceral pathology or for definitive diagnosis of musculoskeletal pathology. Musculoskeletal ultrasound is gaining increased utilization for abdominal wall sprains, strains and nerve injuries.3,6,7 Plain films will show most fractures as well as pubic symphysis diastases, though advanced imaging (MRI or CT) may be required in some cases if strong clinical suspicion persists despite negative X-rays. Supplemental assessment tools Pelvic EMG to evaluate for pelvic floor dysfunction Pudendal nerve conduction study Perineometry (instrumental measurement of pelvic muscle tone and/or strength) Diagnostic nerve blocks Behavioral and psychological screening Pain Catastrophizing Scale10 Musculoskeletal ultrasound Early prediction of outcomes Patients with prior psychiatric diagnoses, prior history of drug and/or alcohol abuse, unemployed status, higher pain catastrophizing scores, higher emotional distress, less family/social support and poor motivation may be more likely to progress to chronic pain state.10,11 Environmental For athletes with injuries inhibiting return to play, it is important to ensure the athletic directors, managers, patient and physicians are on the same page so as to allow proper healing and decrease the risk for re-injury. For patients with chronic pain, a social worker or case manager may be utilized to assist with home assessments and to evaluate for safety in cases where physical or sexual abuse is apparent or suspected. Social role and social support system Support groups or counseling may be available for patients with chronic pain or cancer pain, as well as patients with a history of physical abuse or rape. For patients for whom their pain inhibits or interferes with sexual activity, specialized support is needed and may be crucial. Ethical and legal considerations Patients with a history of polysubstance abuse may face physician bias when presenting with pain. Use of opiates in patients with a history of substance abuse is controversial and often under-prescribed for patients with real pain and this past medical history. Unnecessary progression to opiate use may contribute to a patient’s progression to the chronic pain state, upsetting the balance between maleficence and beneficence. Rehabilitation Management and Treatments Available or current treatment guidelines The hallmark of treatment for somatic abdominal and pelvic pain relies on proper diagnosis of the underlying pathology. The treatment and rehabilitation program for abdominal and pelvic pain depend on the exact cause or the specific pain treatment used for medical management. Just like any treatment plan, conservative therapies or management (e.g., patient education, pharmacotherapy, psychotherapy, exercise, or physical therapy) should be trialed first before aggressive treatment. This can provide improved quality of life for the patient. Postoperative pain and fractures may require more aggressive acute pain treatment to prevent progression to the chronic pain state. Pain from metastases to the pelvic girdle or abdominal wall may also require high amounts of pain medications and more aggressive treatments. When conservative treatment therapies fail, aggressive methods can be used. Such examples are ablative procedures, sacral neuromodulation, neurolysis, hysterectomy, vulvar/vestibular surgery, resection, and prostatectomy.16 At different disease stages New-Onset/Acute Activity modification It is important for patients to modify their type of activity when initial symptoms or new onset of abdominal/ pelvic pain occur. Patient education about activity modification plays a big role in treatment. In urogynecology disorders change in bladder diary and diet regimens should be encouraged for the patient.16 Patients should avoid consumption of acidic drinks, coffee, or alcohol to decrease the further complications of abdominal or pelvic floor related pain. Analgesia Tylenol, NSAIDs first line Opiates may be indicated for severe pain, post-operative pain, fractures Muscle relaxants may be considered Gradual increase in activity Core or pelvic floor muscle strengthening Behavioral modification can play a critical role in the patient education. Such modified behaviors as timed urination and controlled fluid intake can provide symptomatic improvement in patients with weakness in pelvic floor muscles.16 Physical therapy Subacute, Chronic/Stable Includes all of the above Botulinum toxin type A for abdominal or pelvic wall muscle spasms.8 A study was conducted to see the effects of botulinum injections with patients that suffer myofascial pelvic pain resistant trigger points and found improvement was observed in 58% of patients with myofascial pelvic pain at eight weeks after the application of botulinum toxin to the iliococcygeus, puborectalis, obturator internus, and rectus muscles with physiotherapy program.16 Interventional procedures and Surgical techniques Nerve blockades such as Ilioinguinal, iliohypogastric, genitofemoral nerve blocks, as well as sympathetic ganglion blocks (celiac/hypogastric plexus, Ganglion of Impar) may be considered in the treatment of CPP.16 Spinal injections have success when a referred or radiculopathic pain is suspected. Caudal ESI (epidural steroid injection) plays a particularly relevant role in CPP. Temporary yet consistent response to nerve blocks may guide the interventionalist to consider more permanent procedures, such as chemical neurolysis, pulsed frequency neuromodulation, or radiofrequency ablation. Considered as a permanent measure, neuromodulation with spinal cord stimulators or peripheral nerve stimulators can be considered if all other prior measures have been trialed, or if patient is found to be an exceptional candidate with a permanent disease/illness. Other surgical techniques may include pre-sacral neurectomy, laparoscopy and hysterectomy.12 Pre-Terminal or End-of-Life Care Cancer-related abdominal wall pain may require opiates or interventional procedures including nerve blocks. Palliative radiation may be considered with bony metastases. Spectrum of treatment approaches Treatment availability may vary greatly depending on regional resources. Physical therapists trained in pelvic floor rehab are often sparse, as may be physiatrists with knowledge in this area. Accordingly, these patients may be cared for by gynecologists and internists. It is important to advocate for the patient to utilize all resources available, and to proceed in a step-wise, risk-averse pattern. Benzon et al (2017) described an algorithm for a step-wise, interventional approach to CPP:12 physical therapy>trigger point injection>lumbosacral epidural steroid injection>peripheral nerve block>sympathetic block>spinal cord stimulator>surgery>intrathecal pump Patient & family education Both the patient and family members should be kept informed of diagnosis and disease […]
Cervical Radiculopathy
[…] in the presence or absence of pain. This condition is most often associated with degenerative spine conditions causing neuroforaminal stenosis. 1 Etiology Dysfunction of the spinal nerve or nerve root can be secondary to external causes, such as compression due […]
HIV in Children and Adolescents
[…] developing chronic lung disease. A 2018 systematic review of lung function in CWHIV showed HIV-infected participants had increased irreversible lower airway expiratory obstruction and reduced functional aerobic impairment on exercise, compared to HIV-uninfected participants. Furthermore, pulmonary function tests in children […]