Convulsive Syncope as a Complication of Outpatient Procedures: A Case Series and Review of the Literature.

ABSTRACT: Sports medicine providers often perform various outpatient procedures to manage musculoskeletal and neuropathic conditions. Vasovagal syncope is a rare but a possible complication. Convulsive syncope is one subtype that involves brief extensor stiffening and nonsustained myoclonus and can be easily mistaken for seizures. We present a case series of convulsive syncope as a complication of common sports medicine outpatient procedures. We aim to describe how to identify this condition, and offer risk stratification and management strategies to mitigate the risks of this complication. Sports medicine providers who routinely practice outpatient procedures should be aware of this complication. Simple changes in approaching the procedure may mitigate these risks. High- and intermediate-risk features of the syncopal episode should prompt physicians to seek further evaluation by a specialist to rule out more serious conditions. In all instances, appropriate on-site support and equipment for emergent resuscitation and management should be prepared.

Procedural Approach to Ultrasound-Guided Geniculate Nerve Blockade for Knee Pain in Patients with OA.

ABSTRACT: Ultrasound-guided genicular nerve block can provide excellent pain control for patients with knee OA. This procedure has the advantage of providing sensory blockade with concomitant sparing of motor compromise, which is observed when the femoral and its lateral femoral cutaneous branches are blocked. Once the geniculate nerve of interest is identified, the operator can use ultrasound guidance to surround nerve fascicles with an injectate mixture of anesthetic and corticosteroid, yielding decreased pain sensation at the joint capsule. Given the role of the geniculate nerve in providing sensory innervation to the joint capsule and knee ligaments, blockade of this nerve can serve as a useful tool for managing patients with acute knee pain secondary to OA.

Virtually Possible: Medical Student Rehabilitation Rotations During a Pandemic.

ABSTRACT: The novel coronavirus 2019 pandemic has led to new dilemmas in medical education because of an initial shortage of personal protective equipment, uncertainty regarding disease transmission and treatments, travel restrictions, and social distancing guidelines. These new problems further compound the already existing problem of limited medical student exposure to the field of physical medicine and rehabilitation, particularly for students in medical schools lacking a department of physical medicine and rehabilitation, approximately 50% of medical schools. A virtual medical student physical medicine and rehabilitation rotation was created to mitigate coronavirus 2019-related limitations and impact on medical education. Using audiovisual technology, students had the opportunity to participate in clinical inpatient and outpatient care, live-streamed procedures, and virtual didactics, develop and showcase their clinical knowledge and reasoning skills, and become familiar with the culture of the physical medicine and rehabilitation residency program. Adaptive educational approaches, including integration of the flipped classroom model, success, pitfalls, and areas for improvement will be described and discussed. Providing nontraditional methods for physical medicine and rehabilitation education and exposure to medical students is crucial to maintain and promote growth of the field in this unprecedented and increasingly virtual era.

Extended Neuralgic Amyotrophy Syndrome in a Confirmed COVID-19 Patient After Intensive Care Unit and Inpatient Rehabilitation Stay.

ABSTRACT: The cause of neuralgic amyotrophy is often unknown but is commonly associated with a recent upper respiratory viral tract infection. Since the beginning of the COVID-19 pandemic, there has been a tireless effort to understand the sequelae of the virus. A 46-yr-old woman who presented after a COVID-19 hospitalization complicated by hypoxic respiratory failure requiring intubation and mechanical ventilation for 23 days was subsequently found to have lower limb sensorium changes as well as upper limb weakness. Left shoulder abduction and extension were both 3/5 in motor strength, and left hip flexion strength was 4/5 with diminished sensation to crude touch in the left lateral thigh. Nerve conduction studies and electromyography findings included a mild left median neuropathy at the wrist and motor unit recruitment pattern consistent with a chronic left upper trunk plexopathy with reinnervation. The case presented describes an extended neuralgic amyotrophy syndrome from an atraumatic mechanism in a previously diagnosed COVID-19 patient. An extended neuralgic amyotrophy syndrome has at least three immune mediated etiologies postulated (1) direct neuropathogenicity, (2) molecular mimicry, and (3) direct cytotoxic effects on peripheral nerves. As COVID-19 survivors continue to be seen in outpatient settings, practitioners should remain aware of diffuse neurological complications as sequelae of the virus persist.

The Role of Physical Activity in Older Adults and Practical Intervention.

Description Physical inactivity (PI), defined as not meeting guidelines for physical activity beyond baseline daily living activities, is common among older adults (age 65 and older) and contributes to increased morbidity, increased mortality and increased health care spending. Understanding the clinical impact of PI on common medical conditions among older adults will help primary care physicians (PCPs) to educate these patients successfully. Physical activity and exercise are effective in the primary and secondary prevention of chronic diseases that can lead to physical impairments, disability and/or premature death. Physical activity and exercise have been shown to improve cognitive dysfunction and painful musculoskeletal disorders as well as diminish frailty and reduce falls, which are highly prevalent among older adults with a significant impact on their ability to function and perform daily activities. Improving PCPs' ability to identify PI, educate patients about the health impact of physical activity and advocate and prescribe appropriate exercise will prevent adverse health outcomes related to PI.

Evaluation of Resident Palpation Skills in Foot and Ankle Anatomic Structures Using Bedside Ultrasound.

Objective: The objective is to determine the accuracy of foot and ankle joint and soft tissue structure palpation in Physical Medicine and Rehabilitation (PM&R) residents using ultrasonography (US) verification. Methods: PM&R residents were tested in an outpatient musculoskeletal (MSK) clinic on palpated foot and ankle anatomic structures in a human model. Once the presumed structures were localized, residents marked a 1 cm size circle on the overlying skin with a ink marker. The accuracy of the circle over the joint line and soft tissue structures was verified using US. Results: The overall palpation accuracy for 22 joint line and soft tissue structures was 38.0%. Accuracy by foot and ankle region, including the posterior, medial, lateral, plantar, and dorsal were 72.9%, 47.5%, 42.5%, 35% and 7.8% respectively. There was a positive trend with level of education without a statistically significant difference in palpation accuracy (30.4% in PGY-2, 38.3% in PGY-3, 44.2% in PGY-4, p = 0.11). Conclusions: Residents in this study demonstrated suboptimal accuracy of foot and ankle anatomic structure identification by palpation. US may be a useful adjunctive tool to advance current methods of teaching musculoskeletal examination skills to PM&R residents.

Footwear-Generated Dynamic Biomechanical Manipulation and Perturbation Training for Chronic Nonspecific Low Back Pain.

BACKGROUND: Home-based therapy optimizing biomechanics and neuromuscular control is increasingly recognized as a treatment option for chronic nonspecific low back pain (CNSLBP). However, its impact on pain, function, and gait is limited among patients in a metropolitan area. OBJECTIVE: To evaluate the change of pain, function, and gait parameters with home-based therapy with the use of footwear-generated biomechanical manipulation and perturbation training in a population with CNSLBP in a metropolitan area. DESIGN: Prospective observational study. SETTING: Outpatient rehabilitation clinic at an academic teaching hospital. PARTICIPANTS: One hundred sixteen patients with CNSLBP for more than 6 months. INTERVENTION: Six months of home-based therapy with a biomechanical device using 4 modular elements attached to a foot-worn platform. MAIN OUTCOME MEASURES: Instrumental gait analysis (gait velocity, step length, single limb support phase % of gait cycle), Numeric Rating Scale for pain, and Oswestry Disability Questionnaire Index for pain and function. RESULTS: Only 43 patients (37.1%) completed the study. Among 43 patients, mean gait velocity increased from 86.6 ± 20.7 to 99.7 ± 22.1 cm/s (P < .0001) in 6 months. Mean left step length increased from 51.1 ± 8.4 to 54.8 ± 9.8 cm (P < .0001). Mean right step length increased from 51.0 ± 7.9 to 55.4 ± 9.0 cm (P < .0001). Mean single limb support increased from 36.4 ± 2.8 to 37.2 ± 2.5%, (P = .208) in the right side and from 36.6 ± 3.0 to 37.8 ± 4.4%, (P = .019) in the left side. Median Oswestry Disability Questionnaire Index score improved from 28 (18-44; interquartile range) to 17 (10-35) (P = .045). Mean Numeric Rating Scale for back pain improved from 7.7 ± 1.8 to 3.3 ± 3.1 (P < .0001). CONCLUSION: At 6 months, patients with CNSLBP undergoing home-based therapy with footwear-generated biomechanical manipulation and perturbation training demonstrated significant improvement of objective gait parameters, pain, and function. LEVEL OF EVIDENCE: IV.

Point-of-Care Ultrasonography Findings and Care Use Among Patients Undergoing Ultrasound-Guided Shoulder Injections.

OBJECTIVE: The aims of the study were to assess the overall reduction of pain in patients undergoing ultrasound-guided shoulder injections and to characterize the preinjection point-of-care ultrasound findings and use of clinical services postinjection including the use of magnetic resonance imaging and surgeries. DESIGN: Data of 172 patients who underwent ultrasound-guided subacromial subdeltoid injection or glenohumeral joint injection were reviewed for preinjection point-of-care ultrasound findings, change in pain intensity at 2 mos from baseline, and use of care at 6 mos' postinjection. Pain intensity was measured by the numeric rating scale and a dichotomous report of global impression of significant improvement in pain. Responders were defined as those with 50% or more reduction in numeric rating scale or those with global impression of 50% or more improvement. RESULTS: There were 141 responders among the 172 patients analyzed. Full-thickness rotator cuff tears were higher in the ultrasound-guided subacromial subdeltoid injection group when compared with the glenohumeral joint injection group (P = 0.038) and abnormal bicipital tendon findings higher in the glenohumeral joint injection group (P = 0.016). There were no significant differences in specific abnormal U findings between responders versus nonresponders. Twelve patients had a shoulder magnetic resonance imaging and four patients underwent operative interventions after the injection. CONCLUSIONS: Overall pain reduction after ultrasound-guided shoulder injections was favorable in the short term. There was no specific preinjection point-of-care ultrasound findings associated with clinical pain reduction after injection. Additional imaging and operative intervention after ultrasound-guided shoulder injections seemed to be relatively low.