A case report of an adolescent with cluster headaches following neck trauma: Coincidence or trigger?

Posttraumatic headaches usually have tension-type or migraine-like characteristics. A correlation between head trauma and cluster headaches (CH) has been previously reported. CH in children are rare and require thorough differential diagnosis. We present an original case of a 15-year-old boy with cluster headaches associated with allodynia probably evoked by a neck trauma. Severe headache attacks started one month after neck trauma. At the beginning clinical presentation of our patient's headaches was very misleading. Headaches were bilateral and associated with infection. Initial diagnosis of sinusitis was made. During further observation headaches have become unilateral with typical for CH associated symptoms and additionally with allodynia. Other causes of secondary CH like cervicogenic headaches, brain tumor and vascular malformation have been excluded. The boy has undergone prophylactic treatment based on flunarizine and gabapentin with good result. Possible pathogenesis of our patient's headaches has been proposed and diagnostic traps discussed.

Functional recovery after severe traumatic brain injury: an individual growth curve approach.

OBJECTIVE: To examine person, injury, and treatment characteristics associated with recovery trajectories of people with severe traumatic brain injury (TBI) during inpatient rehabilitation. DESIGN: Observational prospective longitudinal study. SETTING: TBI rehabilitation units. PARTICIPANTS: Adults (N=206) with severe nonpenetrating TBI admitted directly to inpatient rehabilitation from acute care. Participants were excluded for prior disability and intentional etiology of injury. INTERVENTIONS: Naturally occurring treatments delivered within comprehensive multidisciplinary teams were recorded daily in 15-minute units provided to patients and family members, separately. MAIN OUTCOME MEASURES: Motor and cognitive FIM were measured on admission, discharge, and every 2 weeks in between and were analyzed with individual growth curve methodology. RESULTS: Inpatient recovery was best modeled with linear, cubic, and quadratic components: relatively steep recovery was followed by deceleration of improvement, which attenuated prior to discharge. Slower recovery was associated with older age, longer coma, and interruptions to rehabilitation. Patients admitted at lower functional levels received more treatment, and more treatment was associated with slower recovery, presumably because treatment was allocated according to need. Therefore, effects of treatment on outcome could not be disentangled from effects of case mix factors. CONCLUSIONS: FIM gain during inpatient recovery from severe TBI is not a linear process. In observational studies, the specific effects of treatment on rehabilitation outcomes are difficult to separate from case mix factors that are associated with both outcome and allocation of treatment.

[Capabilities of physiotherapy for orbital trauma].

The article describes the results of conservative treatment of 78 patients with injuries of ocular adnexa (isolated fractures of orbital walls as well as cicatrical deformities of orbits and eyelids). Ophthalmological assessment was made both in the early and the late periods following blunt trauma. All patients underwent a standard assessment of functional ability of the eye and, additionally, an orbital computed tomography scan to characterize the fractures. In all cases physiotherapy (endonasal electrophoresis with proteolytic enzymes) was carried out to resolve the orbital hemorrhage. Binocular vision evaluation was done to control the effectiveness of the treatment. For that, the extent of diplopia in the central field and the total area of peripheral double vision were measured and the vertical edges of the diplopia zone were defined.

Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger.

OBJECTIVE: To compare Stack, dorsal, and custom splinting techniques in people with acute type 1a or b mallet finger. DESIGN: Multi-center randomized controlled trial. SETTING: Outpatient hand therapy clinics (2 public hospitals and 1 private clinic). PARTICIPANTS: Patients (N=64) with acute type 1a or b mallet finger. INTERVENTIONS: Prefabricated Stack splint (control), dorsal padded aluminum splint, or custom-made thermoplastic thimble splint. All were worn for 8 weeks continuously, with a 4 week graduated withdrawal and exercise program. MAIN OUTCOME MEASURES: The primary outcome was extensor lag at 12 and 20 weeks. Secondary outcomes were incidence of treatment failure, complications, range of motion of the distal interphalangeal joint, pain (visual analog scale) patient compliance, and patient satisfaction. RESULTS: There was no difference in the primary outcome between groups at 12 or 20 weeks; however, the Stack and dorsal splints had significant rates of treatment failure (23.8% in both groups, compared to none in the thermoplastic group; P=.04). There was a medium negative correlation between patient compliance and degree of extensor lag. No significant differences between groups were observed for patient satisfaction or pain. CONCLUSIONS: As splints for mallet finger must be worn continuously for 6 to 8 weeks, and compliance correlates with favorable outcomes, treating practitioners must ensure the splint provided is robust enough for daily living requirements and does not cause complications, which are intolerable to the patient. In this study, no extensor lag difference was found between the 3 splint types, but custom-made thermoplastic splints were significantly less likely to result in treatment failure.

Effect of low level laser therapy (830 nm) with different therapy regimes on the process of tissue repair in partial lesion calcaneous tendon.

BACKGROUND AND OBJECTIVE: Calcaneous tendon is one of the most damaged tendons, and its healing may last from weeks to months to be completed. In the search after speeding tendon repair, low intensity laser therapy has shown favorable effect. To assess the effect of low intensity laser therapy on the process of tissue repair in calcaneous tendon after undergoing a partial lesion. STUDY DESIGN/MATERIALS AND METHODS: Experimentally controlled randomized single blind study. Sixty male rats were used randomly and were assigned to five groups containing 12 animals each one; 42 out of 60 underwent lesion caused by dropping a 186 g weight over their Achilles tendon from a 20 cm height. In Group 1 (standard control), animals did not suffer the lesion nor underwent laser therapy; in Group 2 (control), animals suffered the lesion but did not undergo laser therapy; in Groups 3, 4, and 5, animals suffered lesion and underwent laser therapy for 3, 5, and 7 days, respectively. Animals which suffered lesion were sacrificed on the 8th day after the lesion and assessed by polarization microscopy to analyze the degree of collagen fibers organization. RESULTS: Both experimental and standard control Groups presented significant values when compared with the control Groups, and there was no significant difference when Groups 1 and 4 were compared; the same occurred between Groups 3 and 5. CONCLUSION: Low intensity laser therapy was effective in the improvement of collagen fibers organization of the calcaneous tendon after undergoing a partial lesion.

Long-term disability after blunt chest trauma: Don't miss chronic neuropathic pain!

Introduction The main objective of this prospective study was to assess the incidence of chronic pain and long-term respiratory disability in a single-center cohort of severe blunt chest trauma patients. Methods Over a 10-month period, all consecutive blunt chest trauma patients admitted in Intensive Care Unit (ICU) were screened to participate in a 3-month and 12-month follow-up. The following variables were prospectively assessed: persistence of chronic chest pain requiring regular used of analgesics, neuropathic pain, respiratory disability, physical and mental health status. Univariate and multivariable analysis were conducted to assess variables associated with chronic chest pain, neuropathic chest pain and respiratory disability. Results During the study period, 65 patients were included in the study. Chronic chest pain and respiratory disability were reported in 62% and 57% of patients respectively at 3 months postinjury. Neuropathic pain was reported in 22% of patients, associated with higher impairment of quality of life. A thoracic trauma severity score ≥12 and a pain score ≥4 at SICU discharge were the only variables significantly associated with the occurrence of neuropathic pain at 3 months (OR = 7 [2-32], p = 0.01 and OR = 16 [4-70], p < 0.0001). Conclusion According to the current study, chronic pain and long-term respiratory disability are very common after severe blunt chest trauma patients. Special attention should be paid to neuropathic pain, frequently under-diagnosed and responsible for significant impairment of quality of life.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

INTRODUCTION: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Characterization of disability following traumatic through knee and transfemoral amputations.

INTRODUCTION: The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries. METHODS: A retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data. RESULTS: A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129). DISCUSSION/CONCLUSION: Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.

Long-term outcomes of major trauma without head injury in the West of Scotland: pilot case-control study.

The aim of this study was to identify the outcomes of survivors of blunt major trauma (without head injury) 2 years or more following injury. The study uses a case-control design, is set in the West of Scotland and includes trauma patients treated in Greater Glasgow NHS Board hospitals. Participants consisted of patients who had sustained major trauma (injury severity score >15) with little or no head injury at least 2 years before assessment, identified from the Scottish Trauma Audit Group database, and age and sex-matched controls nominated by the index case's general practitioner. Nineteen cases and seven controls completed the study from 223 potential cases and 39 potential controls. Participants and non-participants had comparable injury severity score, probability of survival (Ps) and length of stay. American Medical Association impairment scores show survivors were more impaired than controls (25.9 vs 7.4%, P=0.043). No differences were observed in Functional Independence Measure (FIM) or Community Integration Questionnaire (CIQ) scores, although a type II error is possible. Short-form 36 (SF36) Physical Component Summary (PCS) scores of survivors showed no difference compared with controls although survivors' PCS scores were below UK and US means (P=0.008). SF36 Mental Component Summary (MCS) scores of survivors were below those of controls (45.07 vs 56.65, P=0.004) and normal values of the UK population (P=0.036). No differences in work status were noted, but small sample sizes were used. Non-head-injured survivors of major trauma in the West of Scotland have poorer health status (SF36), physically and mentally, than the UK population. They have greater impairment, but have an employment status comparable to that of the controls. The lack of differences in FIM and CIQ scores between survivors and controls may be due to small sample sizes.

Use of health care services 6 months following major trauma.

To establish the use of health care services 6 months following major trauma, 243 blunt major trauma patients were recruited during their acute hospital stay and followed up by telephone interview at 6 months post-injury. Data collected at 6 months included health care service usage and their level of disability according to the Glasgow Outcome Scale--Extended (GOSE). Ninety-four percent of patients were living in the community at 6 months, and most (69%) reported continued use of health care services. Of those with ongoing disability, non-compensable patients were significantly more likely (OR 3.7; 95% CI, 1.6-8.6) to have ceased health care service use than compensable patients, independent of injury severity.

Multiple nerve and tendon transfers: a new strategy for restoring hand function in a patient with C7-T1 brachial plexus avulsions.

C7-T1 brachial plexus palsies result in a loss of finger motion and hand function. The authors have observed that finger flexion motion can be recovered after a brachialis motor branch transfer. However, finger flexion strength after this procedure merely corresponds to Medical Research Council Grades M2-M3, lowering the grip strength and practical value of the reconstructed hand. Therefore, they used 2 donor nerves and accomplished double nerve transfers for stronger finger flexion. In a patient with a C7-T1 brachial plexus injury, they transferred the pronator teres branch to the anterior interosseous nerve and the brachialis motor branch to the flexor digitorum superficialis branch for reinnervation of full finger flexors. Additionally, the supinator motor branch was transferred for finger extension, and the brachioradialis muscle was used for thumb opposition recovery. Through this new strategy, the patient could successfully accomplish grasping and pinching motions. Moreover, compared with previous cases, the patient in the present case achieved stronger finger flexion and grip strength, suggesting practical improvements to the reconstructed hand.

Environmental enrichment increases progenitor cell survival in the dentate gyrus following lateral fluid percussion injury.

Neurons in the hilus of the dentate gyrus are lost following a lateral fluid percussion injury. Environmental enrichment is known to increase neurogenesis in the dentate in intact rats, suggesting that it might also do so following fluid percussion injury, and potentially provide replacements for lost neurons. We report that 1 h of daily environmental enrichment for 3 weeks increased the number of progenitor cells in the dentate following fluid percussion injury, but only on the ipsilesional side. In the dentate granule cell layer, but not the hilus, most progenitors had a neuronal phenotype. The rate of on going cell proliferation was similar across groups. Collectively, these results suggest that the beneficial effects of environmental enrichment on behavioral recovery following FP injury are not attributable to neuronal replacement in the hilus but may be related to increased neurogenesis in the granule cell layer.

Enforced exercise after blunt trauma significantly affects biomechanical and histological changes in rabbit retro-patellar cartilage.

Our laboratory has developed an animal model to study factors leading to chronic disease in a blunt impacted joint. Studies to date indicate post trauma softening of the impacted joint cartilage, but a limited degree of histological degradation in the tissue. The model utilizes treadmill exercise of the animal post trauma. The hypothesis of the current study was that post trauma exercise helps limit histological and mechanical degradation of the impacted retro-patellar cartilage. The study involved a group of animals with enforced exercise on a treadmill and another group with cage-activity post trauma. The animals were sacrificed after 24 months. Mechanical and histological analyses were performed on the retro-patellar cartilage from each group. The impacted versus contra-lateral, non-impacted retro-patellar cartilage was mechanically softened in the exercise group, but not in the cage-activity group. Histological analyses of the tissue from the cage-activity group indicated that this cartilage had less surface integrity, more ossification/calcification, and more erosion than that in the impacted tissue from the exercise group. These tissue changes may lead to an apparent stiffening effect in the impacted cartilage from the cage-activity group at 24 months post-trauma. Potential relationships between the intensity and frequency of post trauma exercise and the mechanical character and histological degradation of the impacted cartilage need additional study. The study indicates that post-trauma exercise can significantly alter the outcome of a blunt knee joint trauma in this experimental animal model.

Bilateral femoral nerve neuropathy following blunt trauma. Case report.

A unique case of bilateral compressive injury of the femoral nerves is reported in a 19-year-old man. Traumatic femoral nerve neuropathy following operative injury, penetrating injury, anticoagulant therapy with hemorrhage, and stretch injury has been described previously, and the literature concerning this unusual clinical problem is reviewed. Bilateral traumatic femoral nerve neuropathy resulting from compressive injury has not been previously reported.

Neurological rehabilitation of severely disabled cardiac arrest survivors. Part I. Course of post-acute inpatient treatment.

BACKGROUND: Some survivors of out-of-hospital cardiac arrest (CA) sustain anoxic brain injury. The aim of this study was to offer these patients a new treatment approach, to describe the course and outcome of rehabilitation, and to judge whether rehabilitation provided benefit. METHODS: Twenty severely disabled patients (mean age 47.6 years, 17 M:3 F) were admitted for inpatient rehabilitation after sustaining anoxic brain damage secondary to CA. The multidisciplinary treatment approach aimed at orientation, communication, mobility, and self care. Function was assessed using Barthel index (BI) score. On discharge, placement and global outcome was noted. Medical charts of consecutive patients were reviewed retrospectively. RESULTS: Inpatient rehabilitation lasted on for average 12 weeks. Improvement in function was slow with a median increase of 1.88 BI score per week. Patients achieved clinically significant functional improvement as measured by pre-post comparison of BI (P<0.001). On discharge, overall disability was mild in 2 (10%), moderate in 7 (35%), and severe in 11 (55%) patients. CONCLUSION: Rehabilitation of selected CA survivors is appropriate, reducing the subsequent burden of care. Although in 55%, only minor dependence on care persisted, on a group level, the potential for rehabilitation was modest, and recovery curve was flat. Before admission, families should be given realistic information about the possible outcome, because independence was rarely achieved.

Resuscitation of the injured child.

Unintentional injury is the leading cause of death for children less than 14 years of age. Optimal injury control includes prevention, acute care, and rehabilitation. When prevention efforts fail, a dedicated well-trained team must be prepared to resuscitate and treat the injured child. This article presents an approach to resuscitation that emphasizes the primary and secondary survey. Early and aggressive airway control with cervical spine protection is stressed, followed by a rapid assessment of ventilatory mechanics and circulatory status. Clinical indicators of inadequate tissue perfusion are described, with priorities concerning intravenous access highlighted. Initial resuscitation steps, complemented by laboratory and radiological assessment, occur before the secondary survey. The secondary survey completes the early resuscitation phase and consists of a systematic and complete physical examination. Resuscitation priorities specific to the multiply-injured child are also discussed. Finally, the importance of rehabilitation and prevention efforts are included.

Successful vascular reconstruction. Determinants of disability.

Improvements in limb salvage during the last decade are a reflection of advances in angiography, antibiotics and technique. We report a 100 per cent success rate with vascular repair and a 100 per cent disability outcome in extremity injuries. Ten male patients, with a mean age of 27.3 (range 18 to 41) years, sustained trauma to the extremity with vascular injury. The etiology of injury was gunshot wounds (5), blunt trauma (4), and stab wounds (1). Time from injury to vascular repair was a mean of 186 (range 60 to 360) min. Vessels injured included popliteal artery and vein (4), tibial artery and vein (2), subclavian artery and vein (2), and axillary artery (1). Six of the injuries were associated with fracture of the adjacent bone and treated with external skeletal fixation. All patients had an associated nerve injury. Five patients underwent fasciotomy; nine were treated with 500 ml Dextran-40 for 48 hr (each day for 2 days). All patients received cephalosporin antibiotics pre-, intra-, and post-operatively. All patients had successful vascular repair, as identified by Doppler ultrasound (10 patients) and intra-/post-operative arteriography (5 patients). The median follow-up period was 22 (range 18 to 30) months. There were no primary amputations (within 30 days); there were four late amputations (2, no function and foot ulcer; 2, causalgia). The five popliteal/tibial injuries had no dorsiflexion and foot drop, two had no function and leg ulcers; two patients had femoral and sciatic nerve injury at the thigh; and three patients had injuries to the brachial plexus.(ABSTRACT TRUNCATED AT 250 WORDS)

A model of orthopaedic dysfunction for clinical decision making in physical therapy practice.

This model serves as a framework for the critical analysis of current practice concepts. The analysis obtained from using this model should be integrated with other physiological systems of the body during examination and treatment processes. Currently used as a basis for graduate study in orthopaedic physical therapy, the model helps students identify fundamental research questions, compare various examination and treatment philosophies, and comprehend generic treatment goals and strategies.