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Traumatic Brain Injury 1

What can be done to prevent reinjury in a teenager who sustained TBI?
• Decrease fatality of MVA: airbags and seatbelts reduce fatalities by 50%
• Use of helmet in motorcycle
• Discourage drugs and alcohol
• Prevention of falls (more important in elderly) by decreasing polypharmacy, minimizing sedating medications, and addressing postural hypotension and addressing gait/balance abnormalities.

What are important prognostic factors after severe TBI?
• Avoid telling family percentages
• Initial GCS score
• Length of coma (time until following commands)
• Duration of PTA*: measured by Galveston Orientation and Amnesia Test. The GOAT is a standard technique for assessing PTA, involving orientation questions and memory. It is scored out of 100 pts and 75 is normal. A score of >75 on 2 days in a row marks the end of PTA. 5-10 minutes PTA is mild, 1-24hrs is moderate, 1-7 days is severe, 1-4weeks is very severe, greater than 4 weeks is extremely severe. For moderate severity or less, a quick and full recovery should be expected. For a severe injury, residual deficits are expected.
• Results of early MRI/CT
• Age
• Pupillary reaction to light
• Time since injury (recovery less likely after 6 months)

Why might a teenager with a CT-negative TBI still remain unresponsive 1 week after injury?
• Diffuse axonal injury: can be primary or secondary
• Systemic hypoxia
• Poor cerebral circulation
• Excitotoxicity

What are the national guidelines for early management of severe TBI?
• IVC to monitor intracranial pressure if needed
• Avoid prophylactic hypoventilation
• Use of steroids not recommended (increases mortality)
• Mannitol and saline solution are not TBI treatment standards, but can be used
• Recommend maintenance of Cerebral Perfusion Pressure at > 60 mmHg

Spinal Cord Injury 6

What are the lifelong economic costs of complete tetraplegia after SCI?
• Costs include: hospital charges, rehab, home and vehicle modifications, assistance with ADLs, loss of wages

What is a life care plan for T6 paraplegia?
• Comprehensive interdisciplinary document of future medical and rehab needs
• Should be undertaken after patient has stabilized medically and functionally
• Components: medical problems, psychological, vocational, recreational, social, rehab, prognosis, equipment needs, preventive medicine, aging complications

What are factors predicting return to work in T6 paraplegia?
• 14% RTW at year one, 40% at 20 years
• Educational level, functional status, driving, pre-employment in white collar job, computer experience, fewer medical complications

What is key legislation to advance rights in SCI?
• Rehabilitation Act: guaranteed civil rights of people with disabilities within federal programs
• Americans with Disabilities Act (ADA): broad nondiscrimination law

Spinal Cord Injury 5

What are common medical complications one year post-injury in a 20 year old C4 ASIA A?
• Pressure ulcers most common complication: risks include cigarettes, sleep meds
• Pneumonia (more common in tetraplegics) leading cause of death from SCI
• UTI: ppx antibiotics not supported
• Urolithiasis: risks are recurrent UTI, indwelling catheters, vesicoureteral reflux, prior stones, hypercalciuria --> can treat with shock wave lithotripsy
• Bladder cancer: risk including indwelling catheters, smoking, kidney stones
• OSA
• Loss of bone mineral density --> no strong evidence for use of bisphosphonates
• Fractures

What are the health maintenance recommendations for this 20 year old C4 ASIA A?
• Question about B/B, BP control, skin, pain, spasticity, sexual function, equipment needs, changes in strength or function
• Counsel on smoking cessation
• Annual renal US for upper urinary tract, video urodynamics for lower urinary tract
• For a woman, there may be increased spasticity, dyautonomia during menstruation --> hormone contraceptives may help; pregnancy at high risk for UTI, AD; no higher risk of cancers or osteoporosis

What are options for a male with C4 ASIA A regarding sexual function and fertility?
• 92% of men can get an erection, but only about half can have successful intercourse, and less than 5% can have unassisted ejaculation
• Vacuum suction and constrictor ring, penile implants (metal rod or inflatable implant)
• PDE-5 inhib (Viagra) used, side effects mimic AD (HA, facial flushing)
• Penile vibratory stimulation is first line treatment for anejaculation --> other treatments are electroejaculation, rectal probes
• Sperm count may be normal, but quality and motility can be poor --> intrauterine insemination, IVF

How is diffuse pain assessed in a 20 year old tetraplegic?
• Pain in 64-80% of SCI
• 15% report visceral pain
• 19-24% have neuropathic pain
• 42% have msk pain: most common in shoulders, followed by wrists, hands, and elbows --> treat with stretching and strengthening, local injections, NSAIDs, occasional opiates

Spinal Cord Injury 3

What are the functional goals for the first 6 months after rehab in a 20 year old C4 ASIA A?
• C1-4: C4 may wean off vent, need rehab for caregiver training, equipment, and prevention of complications, intro to advanced technology
• C5: Prevention of elbow flexion and supination contractures, power wheelchair
• C6: Tenodesis, which may allow patient to do ICP
• C7-C8: C7 is key level for independence at transfers, weight shifts, light meal prep, may do bowel program
• T1-12: Household ambulation may be possible for lower levels of thoracic injury
• L1-2: Ambulation for short distances, but WC for functional ambulation
• L3-4: Usually lower motor neuron, so sacral reflexes are lost. Bowel management through contraction and manual disimpaction. Bladder through ICP. Ambulation with AFO.
• Community ambulation requires b/l hip flexors to be > 3/5, 1 knee extensor at least 3/5

How can you prevent and treat common medical complications in the first 6 months postinjury for a 20 year old man with C6 ASIA A injury?
• Autonomic dysreflexia: rise in BP of 20-40 mmHg above baseline, reflex bradycardia, HA. Can lead to stroke, hemorrhage, seizure, MI, death. Other signs are flushing, sweating, and nasal congestion above level of injury. Causes include: overdistended bladder, kidney or bladder stones, ingrown toenails, menstrual cramps, infection, bowel impaction, pressure ulcers, msk conditions, abdominal pathology. Treated by sitting patient upright and identifying underlying cause.
• Neurogenic bowel: Bowel program daily to q3days. Use of digital stimulation, adequate fluid, high fiber, oral meds, rectal evacuants. If changes in bowel meds, give at least three cycles to see effects. Colostomy if bowel program too difficult.
• Orthostatic hypotension: Compensation with gradual position changes, ace wraps, compression stockings, abdominal binders, midodrine (alpha agonist), fludrocortisones (mineralocorticoid). Usually resolves with spinal reflexes return.
• Immobilization hypercalcemia: N/V, decr appetite, lethargy, polyuria, usually presents 1-2 months postinjury. Treat with IV fluids or bisphosphonates.
• HO: Incidence between 16-53% in SCI. Presents in hips, followed by knees, elbows, shoulders. Swelling, decr ROM. Confirmed with bone scan, treat with etidronate at 20mg/kg orally for 3-6 months. Surgery if functional limitations, but wait until HO is mature.
• Spasticity: Treat with ROM, look for noxious stimuli (UTI), baclofen, benzo, dantrolene, alpha-2 agonists. Botox or phenol for localized spasticity.
• Depression 20-45%

What discharge planning is required for a 20 year old C4 ASIA A?
• Equipment: lift for transfers, padded commode or shower chair, power wheelchair with head, chin, or breath control (and independent pressure relief), manual WC for back-up, mouth stick, computer, van
• Housing evaluation and modifications

What advances are available for SCI?
• FES: improve hand grasp, lower extremity use, bladder control, respiration, and cardiovascular health
• Tendon transfers
• Wheelchairs: pushrum-activated power assist, iBOT 4000 Mobility System for climbing stairs
• Partial body weight support treadmill training
• Brain-based command signals

Spinal Cord Injury 2

How would you acutely manage a 20 year old male with a C4 ASIA A SCI from snowboarding?
• Decompression within 24 hours may improve neurologic recovery, but data inadequate
• High dose steroids called into question: may cause infection or bleeding
• Avoid hypotension, can try abdominal binders, lower limb compression, oral vasopressors (midodrine)
• Autonomic dysfunction is common: bradycardia, neurogenic shock, autonomic dysreflexia (after spinal shock over)
• Spinal shock: loss of reflex neurologic activity in spinal cord (loss of reflexes)
• Neurogenic shock: hypotension of neurogenic origin --> need volume resuscitation and vasopressors
• Bradycardia may occur due to unopposed vagal tone --> usually self-limited but can use atropine
• “quad fever” without identified source can occur in early weeks
• Anticoagulation for DVT or IVC filter within 72 hours
• High risk of stress ulcers --> should start PPI for 4 weeks

What physiatric interventions in acute care can prevent complications in this patient?
• Early ROM, especially in shoulders
• Splinting and orthosis to preserve joint ROM in hands and feet
• Bowel program after starting enteral feeding
• Can remove Foley when patient no longer requires IV fluid --> avoid cath volumes greater than 500 cc
• Pulmonary complications at all levels
• Clearance of secretions: difficult with weak abdominal muscles, manual assisted cough better at clearing secretions than suctioning (hands placed over lower rib cage), mechanical insufflators-exsufflator is effective
• Atelectasis present in 60% of SCI patients on admission, support of use of high tidal volumes
• High rate of dysphagia, especially in patients with C-spine surgery, trachs, prolonged intubation, halo, TBI
• Pressure ulcers: early most common in sacrum, heels, and occiput --> minimize time on backboard, use pressure-relief beds, routine turning q2hrs

How is neurologic recovery prognosticated in SCI?
• Exam at 72 hours better than at 24 hours for prediction
• Most UE recover occurs in first 6 months, mostly in first 3 months
• Most patients recover 1 root level of function with cervical lesions
• UE motor recovery twice as great in incomplete tetraplegia --> more favorable if pinprick spared
• 80% of patients with incomplete paraplegia regain antigravity hip flexors and knee extensors
• 6% of ASIA A convert to ASIA B and none developed volitional motor below injury
• Spinal shock: worse prognosis
• Crossed adductor response to patellar tendon taps is highly predictive of functional motor recovery
• Normal cord on MRI is positive predictor for recovery

What is the acute evaluation of a 30 year old woman with profound and rapid onset of nontraumatic incomplete tetraplegia?
• DDx: Myelopathy, motoneuron disease, MS
• MRI for MS very sensitive but nonspecific
• Spinal angio for diagnosis of spinal cord AV malformations
• CT for bone mets
• CSF: diagnosis of inflammatory disorders
• Labs: test for Lyme, syphilis, HIV, DM, APA

Spinal Cord Injury 1

What are the epidemiologic factors relevant to a 70 year old man who fell and sustained an incomplete C4 injury?
• Average age of onset of SCI has been increasing
• Most common cause of SCI is MVA (50%), but rate for falls has been progressively increasing, rate for sports is decreasing
• Increasing percentage of cervical injuries

What are common causes of nontraumatic SCI in a 30 year old woman with subacute onset of paraplegia with a T6 sensory level?
• Nontraumatic SCI more likely to be incomplete and less likely to have spasticity, DVT, autonomic dysreflexia
• DDx: MS, degenerative CNS diseases, neoplasm, vascular disease, inflammatory disease, spinal stenosis, spinal cord tumors, epidural abscess, epidural hematoma
• Transverse myelitis: can be primary or secondary to vasculitis or rheum d/o, more common in females
• Radiation myelopathy can occur months after treatment

What are the epidemiologic factors related to a girl born with L2 spinal bifida?
• Spina bifida has decreased due to folic acid
• Most common is myelomeningocele: neural elements exposed, complete neurologic deficits --> closure within 24 hours
• Meningocele: dural sac exposed, neural elements may be intact
• Occult spina bifida: closed spinal deficits including lipoma, tethered cord --> should be investigated
• Hydrocephalus seen in 90% of patients with myelomeningocele --> most require VP shunt --> underlying Chiari II malformation
• Hydrosyringomyelia (syrinx) are common in myelomeningocele --> presents with cervical pain, new weakness, spasticity, and scoliosis (can also be a sign of tethered cord)
• Scoliosis affects people with myelomeningocele at thoracic levels --> monitor curvature less than 25 degrees, greater may require TLSO or surgery

Musculoskeletal 6

What are the risks and benefits of steroid injection for lateral epicondylitis?
• Only minor complications reported: 10% postinjection pain, 2% skin atrophy, skin depigmentation, localized erythema, facial flushing
• Post-injection exacerbation lasts < 4 days
• Multiple injections may be a risk for tendon rupture
• Lit review concluded that injections associated with improved pain and grip strength in short term (<6 weeks)
• Botox has shown mixed results

What are the risks and benefits of steroid injection for de Quervain’s tenosynovitis?
• Pooled analysis recently showed symptomatic cure was established in 83% of wrists that received injection alone with low risk of complications
• Side effects: skin color changes, SQ fat atrophy, flare, nontender nodules, and superficial thrombophlebitis

What are the risks and benefits of steroid injection for carpal tunnel syndrome?
• Inject just ulnar to Palmaris longus tendon at wrist into ulnar bursa
• Meta-analysis showed steroid injection had benefit over placebo or oral steroids at 1 month
• RCT showed local steroids better than surgical decompression at 3 months and equal at 1 year
• Median nerve latencies may improve with injection, even at 12 months
• Intracarpal insulin injections may be effective in patients with NIDDM

What are the risks and benefits of steroid injection for Achilles tendonitis?
• No definitive consensus regarding benefits and risks
• 1% incidence of side effects
• No rigorous studies evaluating risk of Achilles rupture
• Weak benefit from NSAIDs
• Studies have shown no real benefit of injection

What are the risks and benefits of steroid injection for persistent plantar fasciitis?
• 80-90% of patients respond to nonsurgical treatment of plantar fasciitis
• Injections found to be more effective than extracorporeal shockwave therapy
• Posterior tibial nerve block may prevent injection pain
• Risk of rupture difficult to determine --> one study showed correlation
• Plantar fat pad necrosis may be another complication of injection

Musculoskeletal 5

What is the DDx and procedural management for a worker with LBP and leg pain in which conservative treatment has failed?
• Rule out systemic disease: cancer, rheum
• DDx: lumbar disc herniation, SI joint pain, facet pain, diskogenic pain, piriformis syndrome, spondylolisthesis, lumbosacral plexopathy, and lumbar spinal stenosis
• Facet pain: makes up 15-40% LBP patients. Intraarticular facet blocks can be therapeutic and diagnostic. For pure diagnosis, can do an anesthic block of the medial branches of the dorsal rami. If beneficial, can consider radiofrequency ablation.
• SI joint pain: 18-30% chronic LBP. Intraarticular SI joint steroid injections are controversial.
• ESI not proven well by studies
What are the biomechanical changes and treatment recommendations for a 40 year old dockworker diagnosed with lumbar disk herniation?
• Natural history favorable for spontaneous improvement
• At 10 year follow up, surgical group did similar to conservative group
• Caudal and intralaminar injections provide easy access to epidural space, although studies show 1/3 of blind injections do not access epidural space
• Transforaminal ESI delivers meds to anterior epidural space where nerve root traverse, always done with fluoro, may help patients reduce pain and avoid surgery

What is the efficacy of interventional procedures in diagnosis and treatment of posterior element pain in a patient with predominant LBP?
• Posterior elements: facet joints, SI joints
• Criteria that increase likelihood of facet pain: age > 65, pain relieved with recumbency, no pain exacerbation with coughing, sneezing, forward flexion, hyperextension.
• Facet pain may refer to lower back and hip
• Medial branch blocks can be diagnostic and therapeutic
• Intraarticular facet injections have been validated as an effective treatment, but limited long term efficacy
• Radiofrequency ablation of the medial branch effective in 85% of patients who responded to anesthetic block --> nerve regenerates in 90 days, no associated weakness
• SI joint: true joint with 2-3 ml of synovial fluid --> pain from trauma, sheer forces, ankylosing spondylitis, pregnancy, idiopathic
• Pain maps of SI joint intersect with facet and radic pain
• Intraartic injection of steroid and anesthetic is common treatment --> can get relief up to a year

What further diagnosis and treatment should be done on a 40 year old with disk degeneration, LBP, and referred leg pain if conservative management has failed?
• In pts with chronic LBP, prevalence of diskogenic pain is 40%
• High intensity zone on MRI within intervertebral disk may reflect annular tear, although also present in asymptomatic patients
• Diskography: performed at 3 levels in L-spine to provide at least 1 control. Procedure is painful and risks include nerve injury, diskitis, and epidural abscess --> may identify painful disk but limited value in predicting success in surgical fusion
• Intradiskal electrothermal annuloplasty: heating element catheter applied to annulus --> used on patients with axial pain and sitting intolerance >6 months with 50% preservation of disk height --> about 50% of patients have good relief, but mixed studies
• Percutaneous nucleoplasty: uses radiofrequency energy to break down molecular structures in the nucleus pulposus --> may cause disk to shrink --> not much literature to support
• Disk arthroplasty: completely replacement of disk --> new, little data

Musculoskeletal 4

How can facet injections and Botox be used to treat a worker with upper thoracic and neck pain related to whiplash injury, with failure of conservative treatment?
• Trigger point injections commonly used for whiplash, with pain relief for 1-3 weeks
• Hypotheses behind trigger point injections: MEPPs at trigger points, uncontrolled ACh release resulting in chronic muscle fiber contraction (--> Botox useful?)
• Cervical facet pain estimated to be present in 25% of neck pain patients and 50% whiplash injuries (most often C2-3 and C5-6)
• Facet pain suggested by neck pain with cervical extension and rotation, but history and physical alone are unreliable --> can do medial branch block as diagnostic tool
• Advantages of medial branch blocks: safer than intra-articular blocks, technically easier to perform
• Radiofreq neuroablation: safe and effective --> 70% response rate for cervical facet pain when performed after diagnostic block
• Medial branch of dorsal ramus regenerates in 90 days but relief may last 7-9 months
• Pulsed radiofreq ablation investigated --> lower levels of heating and lower risk of deafferentation pain --> few trials

After failure of Botox and facet injections in the above patient, who is now having neck, shoulder, and arm pain, what are other possible interventions?
• Cervical transforaminal ESI has shown promising results for clear-cut cervical radiculopathy
• Complications of cervical ESI: infection, nerve root injury, vertebral artery dissection, paralysis, stroke, high spinal block
• Interlaminar ESI may provide less availability of steroid anteriorly, but has less risk of inadvertent arterial particulate steroid deposition --> complication rate of 16.8% although most are minor
• Cervical transforaminal injection should be performed under live fluoro to avoid intravascular injection

Musculoskeletal 3

What is the efficacy of modalities and splinting in plantar heel pain?
• Limited evidence that stretching exercises and heel pads associated with better outcome than orthoses for people who stand > 8 hrs/day
• Limited evidence that topical steroids with iontophoresis would be helpful
• Limited evidence that dorsiflexion night splints reduce heel pain
• For plantar fasciitis, study showed non-WB stretching of plantar fascia better than WB stretching of Achilles --> prefabricated soft insoles and 3 weeks of NSAIDs also helpful

What is the utility of soft cervical collar and modalities for neck pain following rear-end auto collision?
• Recent study showed no utility of soft collar for pain, ROM, ADLs
• People with soft collar took longer to return to work than those treated with early mobilization
• Lack of evidence for: thermotherapy, massage, EMG biofeedback, mech cervical traction, US, e-stim

What is the utility of counterforce bracing, modalities, and exercise in a secretary with lateral epicondylitis?
• Counterforce brace: nonelastic strap curved for better fit and support of forearm, decreases muscle force on lat epicondyle --> mixed evidence for splinting
• Isotonic eccentric exercise program found to be more effective than stretching program
• Lack of evidence for modalities
• 83% of cases improved overall --> poor improvement assoc with manual jobs, high baseline pain, neuropathic sx, keyboarding, highly repetitive monotonous work

What is the utility of bracing, modalities, and exercise in assembly worker with CTS?
• Mod effectiveness for short term oral steroids
• Limited evidence for US, yoga, carpal bone mobilization
• Benefit seen from 6 weeks of nocturnal splinting, greater benefit when splints worn full time

What is the utility of lumbosacral supports and directional-based exercises for LBP?
• Moderate evidence that LS support is ineffective for primary LBP
• No evidence that support useful for secondary LBP prevention
• RCT showed McKenzie method and intensive dynamic strength training equally effective
• Study showed that patients who received direction-specific exercises (in those who had a directional preference identified) had greater improvement than non-direction-specific

What is the evidence for modalities and exercise for Achilles tendonosis?
• Weak evidence of benefit from oral NSAIDs
• Weak or no evidence for heel pads, topical laser therapy, heparin, steroid injection, modalities
• Eccentrically loading the Achilles tendon via calf muscle training is a well-supported treatment

Musculoskeletal 2

In a patient who was rear-ended and experienced immediate neck pain with decreased ROM but no focal neurologic problems, what is the usefulness of muscle relaxants in getting the patient back to work as a transportation worker?

• Side effects: all cause significant drowsiness, do not drive or operate heavy machinery, use with caution in patients with liver/kidney disease
• Baclofen (GABA-agonist) and tizanidine (a2-agonist) approved for spasticity and sometimes used for msk pain
• Metaxalone (Skelaxin): low side effects, no sedation, some double blind placebo studies showing positive effects of reducing back pain
• Cyclobenzaprine: structurally similar to TCAs, sedation, anticholinergic effects, more effective when used in combo with NSAIDs
• Carisoprodol (Soma): sedation, no reproducible benefits, reports of abuse and impaired driving


How can NSAIDs be used to treat the above patient?

• NSAIDs work by inhibiting COX-2 activity
• Side effects: GI bleeding, renal dysfunction, platelet inhibition, cardiovascular effects
• Celecoxib: COX-2 specific
• Meloxicam and etodolac: COX-2 selective


What is a medication treatment algorithm for acute pain in a worker who fell off a ladder, injuring his foot and ankle?

• Tylenol: has equivalent analgesia to NSAIDs for ortho injuries, liver toxicity
• Ibuprofen 800-1200mg per day has excellent safety profile --> higher dose associated with more side effects
• Opioids can be used for acute mod-severe pain, more effective with Tylenol
• Codeine metab by cyt P450, which is lacking in 10% of whites --> poor efficacy
• Tramadol: central analgesic with low affinity for opioid receptors, inhib NE and serotonin reuptake, less likely to lead to dependence


What is the rationale for use of topical analgesics to treat lateral epicondylitis in a 50 year old secretary?

• Topical meds: high concentration in dermis, muscle, and penetration into synovial fluid, can have local cutaneous reaction
• No studies to address topical opioids for acute msk pain
• Capsaicin: induces analgesia via desensitization from substance P and activates vanilloid receptors --> benefits in postherpetic neuralgia, trigem neuralgia, cluster HA, OA, not useful for acute pain
• Lidoderm: more evidence in chronic pain

Musculoskeletal 1

What is the diagnostic approach to a warehouse worker who develops heel pain within several weeks of starting a job that involves prolonged walking and standing on concrete floors?

• Midfoot: navicular, cuboid, and 3 cuneiform bones
• Hindfoot: talus and calcaneus
• Major soft tissue regions: calcaneal fat pad, plantar fascia, Achilles insertion
• Tendons under medial flexor retinaculum: PT, FDL, FHL
• Tendons under lateral retinaculum: peroneal tendons
• Plantar fasciitis: most common 40-70 yrs, in runners, obese. 90% of patients achieve resolution w/o surgery. Pain loc in anteromedial or central heel, gradual onset, exacerbated by toe walking, worse in AM. History may include change in footwear. Risks include pes cavus/planus, decr subtalar motion, and a tight Achilles tendon. PE shows limited ankle DF with max tenderness at anteromedial aspect of inf heel, palpate for gap (sign of rupture)
• Imaging: limited role, used to assess for calcaneal stress fx or other bony lesion. Heel spur is often noted, but of no value. Bone scan if stress fx suspected. MRI can be used for suspected AVN. Ultrasound rarely used.
• DDx: fracture, infection, malignancy, rheum d/o.
• Calcanial stress fx: 2nd most common stress fx in foot, after metatarsals. Vague pain worsens with WB. Calcaneal squeeze may reproduce pain. Plain rads may be normal initially.
• Heel fat pad atrophy: similar sx to plantar fasciitis but more diffuse, commonly in elderly. Pain does not radiate anteriorly or worsen with toe DF and is not worse in AM.
• Achilles tendonitis: from overuse, jumping, running.
• Retrocalcaneal bursitis: Achilles tendon insertional pain, caused by abrasion and resulting in inflammation of the burse between the Achilles insertion and the calcaneus, from shoes. Associated with Haglund’s disease, bony protuberance of calc tuberosity.
• Peroneal tendon ruptures occur prox to insertion or just distal to lat malleolus, associated with swelling and tenderness after multiple ankle sprains
• Tarsal tunnel: numbness, tingling or burning pain, worsened with prolonged WBing and ambulation. Foot DF and eversion stretches nerve and can reproduce symptoms
• Other causes of neurogenic heel pain: medial calcaneal neuroma, S1 radic, neuropathy of nerve to abductor digiti quinti.



What is the diagnostic assessment of a transportation worker who p/w neck pain after a rear end collision while stopped at the side of the road?

• Most people involved in collisions have symptoms resolve in 4-6 weeks, but up to 1/3 have chronic symptoms
• Symptoms assoc with whiplash: neck pain and stiffness, arm pain, paresthesias, TMJ, HA, dizziness, visual disturbance, difficulty with memory/concentration
• Controlled diagnostic blocks show facet pain generators in 60% of patients
• Center of headrest should be at ear level and not reclined
• Symptoms may be mild after the accident but increase in the following 2-3 days
• Neurologic deficits are rare
• Imaging: flexion and extension films to r/o instability, plain rad may show decr lodosis. MRI usually unnecessary


What is the pathogenesis of job-related wrist and elbow pain?

• Risks: old age, obesity, DM, smoking, pregnancy, rheum arthritis, psych stress
• History should assess high repetitive nature of work and prolonged abnormal postures, pain at insertion of muscle or tendon
• Tx: PT/OT with work modifications
• DeQuervain’s: pain in 1st dorsal compartment (APL, EPB). Finkelstein’s test positive.
• CTS: pain, numbness, and tingling in first three digits


What is a diagnostic plan for a loading dock worker with LBP?

• History: determine if injury related to work, possible litigation
• Exclude fx, infection, cauda equina syndrome (ask about B/B symptoms). Ask about cancer history, IV drug use, fever, night sweats
• PE: Assess symmetry of muscle bulk and tone, kyphosis or lordosis, scoliosis, L-spine ROM to flexion, ext, bending and rotation. Strength testing, sensation, reflexes. Peripheral pulses.
• Schober’s test: line drawn between PSIS at S2 and draw line to 5 cm below and 10 cm above. And increase of more than 5 cm is normal.
• Check hamstring and gluteus maximus flexibility: Ely test, Thomas test
• Femoral stretch test: L4 nerve root pathology
• SLR: positive if pain below knee at 30-70 degrees of hip flexion
• SIJ pain: No tests sensitive or specific. FABER test, Gaenslen test, Gillet test.
• 5 Waddell signs: nonanatomic regional tenderness, overreaction, nonanatomic regionalization, distraction, and simulation (axial loading)  3/5 must be positive
• If no red flags, imaging may not be necessary
• Early X-rays if: age > 50, significant trauma, neurologic deficits, unplanned wt loss, assess ank spondylosis, drug/alcohol abuse, cancer history, steroid use, fever, no improvement with conservative care, pain > 7 weeks
• CT useful for assessing bones: foraminal bony narrowing and lateral recess stenosis, assess for fx if pt cannot get MRI
• MRI: useful for bone and soft-tissues, disk degen, endplate changes, neoplastic conditions. Gad contrast helps detect fracture, neoplasms, demyelination.
• 35% prevalence of DDD in young people < 40, 100% in age > 60yrs. 36% prev of herniated disk in >60 yrs.
• Bone scans for neoplasm or infection
• EMG to ID objective weakness, r/o neuropathy or neuromusc disease, localize lesion, assist in prognosis

test

this is a test

Burn rehab

--burns are number one case of accidental death in children < 2 yrs, majority of which are due to abuse
--number 2 in children under 4

--systemic response to burns: loss of fluid, hyperventilation, inhalation injury, increase followed by increase in cardiac output, multi-organ system failure
--electrical burns cause more severe injury to deeper tissue (muscle and bone)

--newer burn categorization:
• Superficial partial thickness: epidermis and upper part of dermis injured
• Deep partial thickness: epidermis and large upper portion of dermis
• Full thickness: all layers destroyed

--Rule of 9’s (% body surface area burned):
• Head: 9%
• Each UE: 9%
• Each LE: 18%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Perineum: 1%

--Worse prognosis associated with age (very young or very old), great BSA burned, depth of burn, and associated injuries

--Contractures: occur in first 1.5 years
*need 25 mm of pressure to counteract contraction of scars
--Position patient in extension and abduction
--Splinting can be used with ROM
--Compression garments are used to decrease hypertrophic scarring, worn 23 hours per day
--Silastic gel can reduce hypertrophic scarring in the absence of pressure
--Local steroids may reduce hypotrophic scarring

--Body is in highly catabolic state and may need 2000-2200 cal/day and 15gm nitrogen per sq meter of BSA

--Peripheral neuropathy present in 15-20% of burn patients with BSA of 20% or greater
--Osteophytes may occur near elbow and olecranon or coracoid process
--HO common --> most common at elbow
--Subluxation can be seen in MCP and MTP joints, prevent with splinting

Cancer rehab

--most common rehab problems in cancer: general weakness, ADL deficits, pain, difficulty with ambulation
*also have problems with speech, swallowing, respiratory, neuro impairment, skin problems, nutritional deficits, lymphedema, skeletal disease, psych
--keep high index of suspicion for swallowing problems, which are assoc with cognitive impairment, CNS involvement, radiation, and gen deconditioning
--keep high index of suspicion for metastatic involvement of spine and extremities

--Most prevalent cancer in children: 1) leukemia, 2) brain tumors
--most common posterior fossa tumor in childhood: 1) cerebellar astrocytoma (best prognosis), 2) medulloblastoma (most common in kids < 7 yrs)
--25% of patients with cancer have brain mets:
• Most common symptom: HA
• Most common focal sign: weakness
• Common first presenting sign: seixures
• Best diagnostic test: contrast CT or MRI

--Radiation effects on spinal cord:
• Induced transient myelopathy: most common, develops after 1-30 months, peak onset 4-6 months, with transient demyelination of sensory neurons in posterior column and lateral spinothalamic tract --> symmetric paresthesias. Resolves in 1-9 months
• Delayed radiation myelopathy: irreversible, begins 9-18 months after radiation, most within 30 mo. Lower extremity paresthesias followed by bowel dysfunction and weakness
--Radiation can cause peripheral nerve damage due to effects on nerve itself or by involvement of surrounding tissue
--Radiation plexopathy is uncommon, usually presenting with numbness, paresthesias, and involvement of the upper trunk, myokymia on EMG
*differentiation from Pancoast’s syndrome, caused by tumor extension into superior pulmonary sulcus, producing pain in C8-T2 nerves and Horner’s syndrome
--cognitive effects of radiation likely dose related, presents slowly, and is higher risk in children

--Chemotherapy can cause a distal, symmetrical neuropathy
*often associated with vincristine (distal axonal degeneration)
*vincristine and cisplatin can also cause autonomic neuropathies

--carcinomatous myopathy: seen in metastatic disease, c/w muscle necrosis, symptoms are prox muscle weakness
--carcinomatous neuropathy: affects peripheral nerves and muscle, often occurring with lung cancer, type II muscle atrophy

--lymphedema: damage or blockage of lymphatic system, in which accumulation of protein occurs in interstitium, drawing fluid into the interstitial space
*3 grades: pitting (reversible), nonpitting, elephantiasis
--sequential pumps help resorb water into the capillaries, but proteins remain in interstitium so must be used daily, should not be used when there are multiple edematous areas
--following mastectomy, immed post-op therapy: hand pumping, hand and elbow ROM, positioning techniques, postural exercises, and shoulder ROM exercises to 40 degrees flexion and abduction

--most common mets to bone: breast, lung, prostate
--most consistent symptom of bony mets: pain, most severe at night or with weightbearing
--skeletal mets are rarely solitary
--70% spinal mets in T-spine, 95% extradural and involve vertebral body anterior to spinal cord
--bone scans pick up met disease early, but are nonspecific
--more than 90% of UE mets involve the humerus
--most LE mets involve the hip and femur
--indications for surgical treatment of met bone disease: intractable pain, impending fx, fx
--lytic lesions (occurring w/ breast, lung, kidney, thyroid, GI, lymphoma, melanoma) are thought to be more prone to fracture than blastic lesions
--blastic lesions more likely in prostate ca

--most common primary malignant tumor of the bone in children: osteosarcoma
*occurs in adolescence, commonly involving knee and prox humerus
--multiple myeloma: punched out lytic lesions, presents with pain, usually leads to renal failure

Cancer Pain:
--from tumor invasion, chemo, peripheral neuropathy, plexopathy, postsurgical pain, procedures, other
--3 step analgesic ladder: nonopiate analgesics, tricyclics --> add step 2 opioid analgesic --> increase dose or add step 3 opioid

--serotonin antagonists (Zofran) effective as anti-emetics in cancer pts
*lack of extrapyramidal side effects
*mild HA common

Pulmonary rehab

--Benefits of pulmonary rehab: increases arterial venous oxygen (AVO2) difference for improved oxygen extraction from arteries, improved exercise tolerance, reduced dyspnea, improved ambulation, decreased hospitalizations

--Moser classification of functional pulmonary disability:
1. Normal at rest, dyspnea with stenuous exertion
2. Normal ADLs, dyspnea on stairs
3. Dyspnea with some ADLs, able to walk 1 block
4. Dependent with some ADLs, dyspnea with minimal exertion
5. Housebound, dyspnea at rest

--Patients who would benefit most from pulmonary rehab:
• Respiratory limitation of exercise at 75% max O2 consumption
• Irreversible airway obstruction with FEV1 < 2000ml or FEV1/FCV < 60%
• Restrictive lung disease with CO diffusion capacity < 80% predicted

--Maximal oxygen consumption (VO2 max) = (HR x SV) x AVO2 diff (Fick’s equation)
*dependent on body weight, age, sex, natural endowment, pathological conditions, endurance exercise training

--Obstructive Pulmonary Disease:
• increased airway resistance due to bronchospasm
• air trapping
• increased compliance
• impaired blood oxygenation (hypoxia) 2/2 perfusion/ventilation mismatch
• Flattening of diaphragm
• Causes: chronic bronchitis, emphysema, cystic fibrosis, asthma
--Emphysema: distention of air spaces distal to terminal bronchioles with destruction of alveoli --> airway collapse on exhalation, decreased gas exchange --> severe mulmonary artery HTN and RV failure
--Cystic fibrosis: generalized disease of exocrine glands, respiratory failure due to inadequate removal of secretions from bronchioles
*aerobic exercise helps increase sputum expectoration, improves mucous transport, and reduces airway resistance
--Impairment develops when FEV1 falls below 3 L/sec
--Increased RV, TLC

--Restrictive lung disease: impaired lung ventilation as a result of mechanical dysfunction of the lungs or chest wall --> stiffness of the chest wall or lung tissue
--Causes of restrictive lung disease: neuromuscular disease, thoracic deformities (kyphoscoliosis), scoliosis > 90 deg, ank spond, cervical SCI, interstitial lung disease, pleural disease, surgical removal of lung
--Respiratory complications of Duchenne’s MD: atelectasis, pna, chronic alveolar hypoventilation, ventilatory failure
--Decreased VC, TLC, RV, but normal FEV1

--Aging --> decreased VC, FEV1 (rate of 30 cc/yr), PO2, increased RV and FRC
--In smokers, FEV1 decrease will be 2-3 times as fast

--Pulmonary changes in C5 quad: 60% inspiratory capacity, weak cough, difficulty clearing secretions, decreased VC, increased RV

--Duchenne’s MD: initiate vent support when pt has dyspnea at rest, VC 40% predicted, maximal inspiratory pressure < 30% predicted, hypercapnea

--ALS: monitor PFTs, functional VC is best prognostic indicator

--Asthma: for reversible bronchospasm, can try methylxanthines, beta-2 agonists, anticholincholinergics
*young patients with moderate asthma may benefit from theophylline
--O2 recommended for pts who desat below 90% during exercise
--Benefits of home O2: reduced polycythemia, improved pulm HTN, reduced perceived effort during exercise, prolonged life expectancy, improved cognition, reduced hospital needs
--Benefits of diaphragmatic breathing: incr TV, decr FRC, incr max oxygen uptake
--Benefits of pursed-lip breathing: prevents air trapping, greater gas exchange in alveoli, incr TV, reduced dyspnea and work of breathing in COPD
--Benefits of preoperative and postoperative chest therapy: decreased pna, decreases atelectasis
--Aerobic exercises for CF: trunk exercises (sit-ups), swimming, jogging

--Glossopharyngeal breathing: can be used in restrictive lung disease in the case of ventilator equipment failure for up to 4 hours, improves volume of voice and rhythm of speech, prevents micro-atelectasis, allows deeper breaths for better cough, improves pulmonary compliance

--Intermittent abdominal pressure ventilator (pneumobelt): abdominal corset which created forced expiration by moving diaphragm cephalad, works only in sitting position, liberates hands and mouth for other activities
*contraindicated in obesity, scoliosis, and patients with decreased pulmonary compliance or increased airway resistance
--Rocking bed: rocks patient along vertical axis, using gravity to assist ventilation --> useful in diaphragm paralysis
*benefits include preventing venous stasis, improved clearance of secretions, prevents decubs, benefits bowel motility
*disadvantages: not portable, not useful in patients with decreased pulmonary compliance or increased airway resistance

--Fenestrated trach tubes: used in pts who can speak and require only intermittent vent assist  when inner unfenestrated cannula is out and tube is plugged, pt may speak
--Nonfenestrated trach: for pts who require continueous vent or are unable to protect their airway during swallowing
*one-way talking valve may be installed
--Speaking trach tubes: used in alert pts who require inflated cuff for ventilation, and have intact vocal cords
*need to speak in short sentences, quality of speech altered
*manual dexterity and strength required to occlude external port
--One-way speaking valves (Passy-Muir): air directed through trachea and up through vocal cords
*requires less work
*cannot be used in COPD patients because lung has lost elasticity so air can’t be forced out

cardiac rehab

--Total oxygen consumption (VO2) = oxygen consumption of entire body
--Myocardial oxygen consumption (MVO2) = oxygen consumption by heart, can be measured by cardiac cath
--Rate Pressure Product (RPP) = SBP x HR = work required of heart
--Cardiac Output (CO) = HR x stroke volume
--MET: 1 met = 3.5 ml O2 consumed per kg wt per minute

--Benefits of cardiac rehab: improved exercise tolerance, symptoms, and cholesterol, reduction of smoking, stress reduction, reduced mortality

--Absolute contraindications to exercise training:
• Unstable angina
• Resting SBP > 200, DBP > 110
• Significant drop (20) in SBP
• Mod to severe aortic stenosis
• Acute illness
• Uncontrolled atrial or ventricular arrhythmia
• Uncontrolled tachycardia
• Symptomatic CHF
• 3rd degree heart block w/o pacemaker
• Active pericarditis/myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST displacement > 3mm
• Uncontrolled DM
• Orthopedic restrictions

--Activities to avoid during acute period of rehab (CCU): isometrics (increases HR), valsalva (causes arrhythmia), raising legs above heart (increases preload)

--Graded exercise stress tests (GXT) = assesses ability to tolerate increase stress  functional rather than diagnostic tool, can give risk stratification and limits for therapy
--For GXT, heart rate limit is 130-140 BPM
--Most ADLs in home require < 4 mets
--Benefits of cycle ergometer over treadmill: less space, less cost, minimized movement of arm and thorax for better recording, but treadmill is more physiological
--Arm ergometer used in LE amputees
--Bruce Protocol: exercise testing on treadmill with stages of 2-3 mets each

Cardiac Functional Classification:
--Class I: can do >= 7 mets
--Class II: can do >= 5 mets, < 7 mets
--Class III: can do >= 2 mets, < 5 mets
--Class IV: can do < 2 mets only

--Exercises for cardiovascular conditioning: isotonic, rhythmic, aerobic
--Small isometric component for cardiac patients
--Resistance exercises are safe and effective for improving strength and CV endurance in low risk patients  increases aerobic capacity of both Type I and Type II fibers
--Contraindications to resistance exercises: CHF, uncontrolled arrhythmia, severe vascular disease, uncontrolled HTN, SBP>160, DBP>100, aerobic capacity < 5 mets
--Optimum O2 consumption during exercise: 55-65% max VO2, 70% max HR  exercise 20-30 mins
--Borg scale: rating from 6-20 of perceived exertion

--Heart transplant: higher resting heart rate, lower peak exercise heart rate
*Monitor ECG changes during exercise testing b/c no angina

--Greatest % increase in energy for ambulation for amputees is for bilateral AK with prostheses (280%): 3 mets to 11.4 mets
--50% increase for no prosthesis with crutches
--50% increase for hemiplegic ambulation

--For >7 mets maximum work load, patient can do any job
--For >5 mets, patient can return to sedentary job and household chores

Dysphagia following stroke

1. What are the three phases of swallowing?
2. What is required for the pharyngeal phase of swallowing?
3. What is chin tuck?
4. What % of patients have silent aspiration not detected by bedside swallow? How can this be diagnosed?
5. When does recovery of swallowing function usually occur in brainstem strokes?
6. What is nasal speech?

Answers:
1. Oral, pharyngeal, esophageal.
2. Tongue elevation, soft palate elevation, laryngeal elevation, coordination of pharyngeal constriction and cricopharyngeal relaxation.
3. Compensatory technique that prevents entry of liquid into the larynx.
4. 40-60% have silent aspiration that can be diagnosed by video fluoro study.
5. First three weeks post-stroke.
6. Hypernasality caused by partial or complete failure of soft palate to close off the nasal cavity from the oral cavity.

Stroke rehabilitation

1. What are poor predictors of motor recovery in stroke?
2. What is the treatment of shoulder subluxation?
3. What is traction neuropathy?

Answers:
1. Severe arm weakness at onset, no return of hand function by 4 weeks, severe proximal spasticity, prolonged flaccidity period, later return of proprioceptive facilitation.
2. Sling not indicated but can be used for support during ambulation, FES, armboard, overhead slings.
3. Due to hemiparetic patient sustaining a brachial plexus injury due to traction.