Interventional Spine Course: Improving Fluoroscopic Safety and Procedural Efficacy Among Physical Medicine and Rehabilitation Residents Using a Lecture and Model-Based Curriculum.

ABSTRACT: Therapeutic interventional techniques using fluoroscopy are often used in the management of spinal pain. Currently, there are no standardized means of instruction and assessment of fluoroscopic interventional spinal procedures for physiatry trainees. The aim of our study is to evaluate the utility of an interventional spine training course for physical medicine and rehabilitation residents in improving safety and efficacy when performing these procedures. We performed a prospective multiple cohort study analyzing interventional spine knowledge and procedural ability among physical medicine and rehabilitation residents after implementing a training course that used lectures, hands-on training, and video-recorded objective structured clinical examination self-assessments. Of the total of 28 physical medicine and rehabilitation residents over the 2-yr study period, each class saw a statistically significant improvement in mean objective structured clinical examination scores from pre-examination to postexamination ( P < 0.05). Written examination scores also had a statistically significant preimprovement to postimprovement in the postgraduate years 2 and 3 classes. Our study supports the use of an interventional spine course for physical medicine and rehabilitation residents, and by following the existing cohorts and adding more cohorts in the future, we will continue to demonstrate valuable and comprehensive results.

A Novel Approach for Fluoroscopic Guided Intra-articular Hip Injections: Technique Description and Case Series.

ABSTRACT: Fluoroscopic guided intra-articular hip injections generally utilize a standard anterior-posterior view. However, this approach can expose patients to inadvertent femoral nerve or vessel infiltration owing to the proximity of the neurovascular bundle to the joint space. This case-series study describes a novel technique using fluoroscopic ipsilateral oblique angulation and caudal tilt of the image intensifier. With this view, the clinician can advance the needle in a lateral to medial trajectory to obtain intra-articular access and minimize the risk of complications. This method was performed in five patients with refractory chronic hip osteoarthritis, which resulted in notable pain improvements and no reported adverse events. The suggested technique could provide a safer alternative to the anterior-posterior imaging technique for intra-articular hip injections by avoiding the femoral neurovascular bundle, limiting needle repositioning, and offering a satisfactory postprocedural analgesic effect.

Medical Comorbidities and Complications Associated with Poliomyelitis and Its Sequelae.

Survivors of poliomyelitis may experience long-term sequelae that put them at increased risk for injury, pain, cardiovascular deconditioning, and functional decline. Osteoporotic fractures and entrapment neuropathies, in particular, may result in greater impairments in one's mobility and ability to perform activities of daily living. Dysphagia may necessitate the use of compensatory swallow strategies to minimize aspiration risk. Comorbid conditions, including hypertension, dyslipidemia, obesity, and stroke, are also very prevalent in this population. Risk factor modification, including diet, exercise, and medication compliance, is essential to achieve optimal health and function among survivors of poliomyelitis.

Football (soccer)-related spinal cord injury-reported cases from 1976 to 2020.

STUDY DESIGN: An analysis of reported cases. OBJECTIVES: To analyze the existing data on soccer (international football)-related spinal cord injury (SCI). SETTING: Cases of soccer (international football)-related SCI that were reported globally. METHODS: PubMed/MEDLINE, EMBASE, and online news publication databases were searched. RESULTS: Fourteen cases of football-related SCI that occurred between 1976 and 2020 were found. Average age at the time of injury was 19 and 86% of individuals were males. Eight of 14 individuals had vertebral fracture/dislocation, whereas two individuals had concomitant traumatic brain injury. Neurologically, 54% had tetraplegia, 39% had paraplegia, and 8% each suffered from hemiplegia and sensory deficit. Two cases could regain ability to walk with orthosis and four had full mobility with "Return to Play" (RTP). The mortality was 14%. CONCLUSIONS: Younger males were most commonly affected. The most common etiology, vertebral level of injury, and neurological manifestation was fall, cervical spine, and tetraplegia respectively. More than 50% of the individuals with football-related SCI were able to walk or RTP after rehabilitation. Further studies are required to establish universal RTP criteria and formulate preventive measures.

The emerging use of platelet-rich plasma in musculoskeletal medicine.

Platelet-rich plasma (PRP) is one of many new developments within the expanding field of regenerative medicine. Specialists in areas such as orthopedics, physical medicine and rehabilitation, and rheumatology have been exploring the benefits of this novel therapy. Although PRP therapy remains controversial and has minimal clinical trial support, the use of orthobiologics such as PRP continues to advance as patients seek nonsurgical approaches to acute and chronic musculoskeletal injury and disease. However, academic acceptance as well as insurance reimbursement remain reliant on solid and repeatable positive results from large clinical trials. The authors summarize the evolution of PRP therapy and report on its status.

Hypothermia as a clinical neuroprotectant.

Applying therapeutic hypothermia (TH) for the purposes of neuroprotection, originally termed "hibernation," started nearly 100 years ago. Because TH cooling systems have improved to the point where it is practical and safe for general application, interest in providing such treatment in conditions such as spinal cord injury, traumatic brain injury, stroke, and cardiac arrest has increased. This article reviews the mechanisms by which TH mitigates secondary neurologic injury, the clinical scenarios where TH is being applied, and reviews selected published studies using TH for central nervous system neuroprotection.

Use of glucosamine and chondroitin in persons with osteoarthritis.

Glucosamine and chondroitin are members of a group of dietary supplements often termed "complementary agents," "disease-modifying agents," or "disease-modifying osteoarthritis drugs" (DMOADs). They are among the best-selling dietary supplements in the United States. DMOADs are thought to act by affecting cytokine-mediated pathways regulating inflammation, cartilage degradation, and immune responses. Given the results of recent studies, investigators have begun to question whether the popular combination of glucosamine and chondroitin alleviates disease progression or pain in people with mild to moderate knee osteoarthritis. Reasons proposed for the lack of benefit include incorrect dosing, suboptimal compound manufacture, and a lack of complete understanding of when and how to apply the compounds. In addition, adjuvant medications also could augment the therapeutic potential of these agents. Although these agents are considered safe, some uncommon and minor adverse effects have been reported, including epigastric pain or tenderness (3.5%), heartburn (2.7%), diarrhea (2.5%), and nausea (1%). In conclusion, although some questions have arisen about whether DMOADs are as effective as has been claimed, a trial should be considered in in selected patients with sustained refractory cases of osteoarthritis.

Imaging in radiculopathy.

All patients presenting with signs and symptoms of lumbar radiculopathy must undergo a thorough history taking and physical examination. Often, however, the diagnosis remains unclear; it is accurate anatomically, but the underlying cause of the lesion is not confirmed, or the symptoms are so severe that more information on the anatomy is required. Therefore, the next step in the diagnostic process is imaging studies. This article discusses imaging modalities, including plain radiographs, magnetic resonance imaging, computed tomography (CT), CT myelogram, selective nerve root block, and bone scan.

Elite male adolescent gymnast who achieved union of a persistent bilateral pars defect.

An adolescent 15-yr-old male competitive gymnast presented to a university-based multidisciplinary spine institute with a persistent low-back pain for 18 mos. Although the results of x-rays were negative, his pain rendered him unable to compete in his sport any longer. A computed tomography scan was performed, which showed a bilateral pars fracture at L5, without spondylolisthesis. A nuclear medicine bone scan revealed negative findings, confirming chronic nonunion. The patient completed a 4-wk course of physical therapy 6 mos before our intervention, without any relief of pain or radiologic evidence of healing. The patient was treated with a bone stimulator for 4 hrs/day and was recommended to wear a warm-and-form-type brace. Isometric core trunk exercises were also initiated. Only after 6 wks of treatment, the subject showed clinical improvement at the follow-up visit. Computed tomography scan performed 12 wks after the initial scan showed complete union of the fracture correlating with clinical improvement. Two years later, the athlete remains completely pain-free, is training regularly, and is able to compete on a national and, possibly, international level.

Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury.

OBJECTIVE: Test effects of pushrim-activated power-assisted wheelchairs (PAPAWs) on the energetics and perceptual responses to steady-state and intensity-graded wheelchair propulsion in persons with paraplegia and tetraplegia having chronic shoulder pain. DESIGN: Test, retest with a control condition. SETTING: Academic medical center. PARTICIPANTS: Subjects (N=18) aged 19 to 70 years with chronic, motor-complete paraplegia and tetraplegia having confirmed shoulder pain. INTERVENTIONS: Study participants underwent testing on 4 randomized nonconsecutive days during either 6 minutes of steady-state or 12 minutes of intensity-graded wheelchair propulsion on stationary rollers. Participants used their own manual wheelchair and either their customary wheels or power-assist wheels attached with an axle bracket. MAIN OUTCOME MEASURES: Oxygen consumption (V(.)O2, L/min), distance (m), energy cost (L/m), and ratings of perceived exertion (RPE; Borg Categorical 6-20 Scale) were measured during propulsion. RESULTS: Significant main effects of testing were observed for V(.)O2, heart rate, and RPE in both subject groups. Distances propelled were significantly increased in both groups across both tests and in each of their 2-minute exercise stages. CONCLUSIONS: Use of PAPAWs by persons with paraplegia and tetraplegia having shoulder pain significantly lowers energy cost responses and perceived exertion compared with manual wheelchair propulsion while significantly increasing the distanced propelled.

Symptomatic cervical disc herniation following a motor vehicle collision: return to work comparative study of workers' compensation versus personal injury insurance status.

BACKGROUND CONTEXT: Patients with approved workers' compensation injuries receive guaranteed compensation for the duration of their injury, whereas patients with personal injury claims are only compensated, if at all, at the time of a successful settlement or trial verdict at a time point distant from their injury. PURPOSE: This study compares the financial impact and loss of work patterns due to a workers' compensation (WC) claim or personal injury in patients with a symptomatic cervical disc herniation resulting from a motor vehicle collision. STUDY DESIGN: A prospective study of patients who were seen by a single spine specialist between 1/2/96 and 9/1/01. PATIENT SAMPLE: A consecutive evaluation of 531 patients who were treated for a cervical pain syndrome caused by a motor vehicle collision. OUTCOME MEASURES: Mechanism of injury and insurance type, ie, workers' compensation or personal injury, was recorded for each patient as well as treatment response and return to work patterns. The data were analyzed using the two-way Z test. METHODS: All patients were managed in a similar manner with noninvasive treatment initially, followed by injections, and finally surgical intervention in those who failed conservative measures. Return to work rates and work disability were determined at either final follow-up or at the last doctor's visit before loss to follow-up. RESULTS: 270 of 531 patients were diagnosed with a symptomatic one or two level disc herniation by a cervical magnetic resonance imaging scan. Fifty-four patients were insured through the workers' compensation board, and 216 reported their crash as a personal injury claim. In the WC group the work disability at 3 months follow-up revealed a cumulative 2,262 total lost days of work (average 37.1 days per person). At the point of maximal medical improvement (MMI) or 2-year follow-up, total days lost from work were 7,107 (average 131.6 days per person.) In the personal injury non-WC group, the 3-month follow-up of lost days of work was 1,093 days (average 5.1 days per person.) At 2 years follow-up, the total lost days of work were 6,206 (average 28.7 days per person.) CONCLUSIONS: Participants compensated through the workers' compensation system demonstrated a significant loss of days of work as compared with injured patients who received compensation by other means. This may be a reflection of the guaranteed method of compensation afforded to WC patients as opposed to patients who receive no form of financial support (i.e., personal injury) during the recuperative process. Further analysis as to injury severity and a stratification of non-workers' compensation reimbursement methods are needed to further improve the validity of this study.

Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes.

BACKGROUND AND PURPOSE: Body weight supported (BWS) locomotor training improves overground walking ability in individuals with motor-incomplete spinal cord injury (SCI). While there are various approaches available for locomotor training, there is no consensus regarding which of these is optimal. The purpose of this ongoing investigation is to compare outcomes associated with these different training approaches. SUBJECTS AND METHODS: Twenty-seven subjects with chronic motor-incomplete SCI have completed training and initial and final testing at the time of this preliminary report. Subjects were randomly assigned to 1 of 4 different BWS assisted-stepping groups, including: (1) treadmill training with manual assistance (TM), (2) treadmill training with stimulation (TS), (3) overground training with stimulation (OG), or (4) treadmill training with robotic assistance (LR). Prior to and following participation we assessed walking-related outcome measures including overground walking speed, training speed, step length, and step symmetry. RESULTS: Data pooled across all subject groups showed a significant effect of training on walking speed. While the differences between groups were not statistically significant, there was a trend toward greater improvement in the TS and OG groups. Post hoc subgroup analysis of outcomes from subjects with slower initial walking speed (< 0.1 m/s; n = 15) compared to those with faster initial walking speeds (> or = 0.1 m/s; n = 12) identified meaningful differences in outcomes with walking speed increasing by 85% in the slower group and by only 9% in the faster group. Step length of both stronger and weaker limb increased in all groups with the exception of those in the LR group. Step symmetry was increased in the TM and LR groups. DISCUSSION AND CONCLUSION: These results represent preliminary findings of changes in walking-related function associated with different forms of BWS locomotor training for individuals with chronic, motor-incomplete SCI. Early data indicates that locomotor outcomes in these individuals appear to be comparable across training approaches. For the individuals in this study sample, those with the greatest deficits in walking function benefitted the most from locomotor training.

Prevention and treatment of heterotopic ossification after spinal cord injury.

BACKGROUND/OBJECTIVES: Heterotopic ossification (HO) is a frequent, irreversible complication after spinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management. ETIOLOGY: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO. PREVENTION: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3. MANAGEMENT: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein levels return to normal range. Surgery is indicated in a subset of patients, and a regimen that includes radiation therapy may prevent postoperative recurrence. CONCLUSION: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.

Sport-specific shoulder injuries.

This article reviews basic shoulder anatomy and biomechanics and discusses the impact these have on the etiology of shoulder injuries in sports. Four types of sport activities lead to shoulder injuries:muscle and tendon overuse, acute tears of the dynamic stabilizers,impingement and overuse injury. Most shoulder injuries initially are treated nonoperatively with rehabilitation. Rehabilitation protocols are successful in most patients. This article also discusses why postoperative rehabilitation is vital to the ultimate success of patients who require operative treatment.

The value of serum creatine kinase in early diagnosis of heterotopic ossification.

BACKGROUND: Heterotopic ossification (HO) is a complication of spinal cord injury (SCI) characterized by formation of ectopic bone. Early diagnosis is critical, but available diagnostic methods have drawbacks. Serum creatine kinase may be a marker for the development and severity of HO. PARTICIPANTS: 18 SCI patients with diagnosed HO based on clinical findings and bone scintigraphy. METHODS: Serum creatine kinase levels were taken at the time of diagnosis of HO and during subsequent etidronate therapy. RESULTS: Of the 14 patients with normal creatine kinase values, 13 had no evidence of HO on follow-up radiographic examination. Of the 4 patients with elevated creatine kinase, all developed radiographic signs of HO. CONCLUSION: Elevated serum creatine kinase may be associated with a more aggressive course of HO as well as resistance to etidronate therapy. Further studies are needed to determine whether creatine kinase may serve as a marker for early, active HO.