Differences in Acute Metabolic Responses to Bionic and Nonbionic Ambulation in Spinal Cord Injured Humans and Controls.

OBJECTIVES: To (1) compare energy expenditure during seated rest, standing, and prolonged bionic ambulation or bipedal ambulation in participants with spinal cord injury (SCI) and noninjured controls, respectively, and (2) test effects on postbionic ambulation glycemia in SCI. DESIGN: Two independent group comparison of SCI and controls. SETTING: Academic Medical Center. PARTICIPANTS: Ten participants with chronic SCI (C7-T1, American Spinal Injury Association Impairment Scale A-C) and 10 controls (N=20). INTERVENTIONS: A commercial bionic exoskeleton. MAIN OUTCOME MEASURES: Absolute and relative (to peak) oxygen consumption, perceived exertion, carbohydrate/fat oxidation, energy expenditure, and postbionic ambulation plasma glucose/insulin. RESULTS: Average work intensity accompanying 45 minutes of outdoor bionic ambulation was <40% peak oxygen consumption, with negligible drift after reaching steady state. Rating of perceived exertion (RPE) did not differ between groups and reflected low exertion. Absolute energy costs for bionic ambulation and nonbionic ambulation were not different between groups despite a 565% higher ambulation velocity in controls and 3.3× higher kilocalorie per meter in SCI. Fuel partitioning was similar between groups and the same within groups for carbohydrate and fat oxidation. Nonsignificant (9%) lowering of the area under a glucose tolerance curve following bionic ambulation required 20% less insulin than at rest. CONCLUSION: Work intensity during prolonged bionic ambulation for this bionic exoskeleton is below a threshold for cardiorespiratory conditioning but above seated rest and passive standing. Bionic ambulation metabolism is consistent with low RPE and unchanged fuel partitioning from seated rest. Bionic ambulation did not promote beneficial effects on glycemia in well-conditioned, euglycemic participants. These findings may differ in less fit individuals with SCI or those with impaired glucose tolerance. Observed trends favoring this benefit suggest they are worthy of testing.

Long-Term Retention of Musculoskeletal Ultrasound Training During Residency.

The Accreditation Council for Graduate Medical Education and the American Board of Physical Medicine and Rehabilitation developed milestones for evaluation of resident physicians that include proper musculoskeletal ultrasound examination of major joints. To date, there have been no published data demonstrating acquisition and retention of these skills and correlation with the milestone evaluation. The investigators developed and implemented a curriculum in musculoskeletal ultrasound examination for Physical Medicine and Rehabilitation residents at a large academic medical center. The investigators chose the following six joints for training and evaluation: ankle, elbow, hip, knee, shoulder, and wrist/hand. The program included: (1) didactic lectures on anatomy and ultrasound technique; (2) peer-led demonstrations of the procedure on a standardized patient (SP); (3) individual practice on standardized patients; (4) faculty observation and feedback; (5) review sessions and additional practice; and (6) assessment of skills in an objective structured clinical examination. From 2013 to 2017, 30 physical medicine and rehabilitation residents were trained and evaluated. The results, based on objective structured clinical examination scores, showed that most residents achieved the appropriate level of competency for their year. A blended, standardized curriculum in musculoskeletal ultrasound instruction with assessment by an objective structured clinical examination can be used to evaluate musculoskeletal ultrasound skills and can help align this education with residency milestones.

Two Unique Cases of Ciprofloxacin-Associated Avulsion of Ligament and Tendon.

Ciprofloxacin is recognized to have a deleterious relationship with tendons, particularly Achilles tendinopathy, which makes up most case reports. Tendinopathy seems to occur because of induction of collagen-degrading enzymes causing damage and ischemia of the poorly vascularized regions preventing repair. The focus on the relationship of ciprofloxacin and the Achilles tendon leaves patients on fluoroquinolones with non-Achilles tendinopathy symptoms at risk of misdiagnosis. There have not been any documented instances of ligament damage with ciprofloxacin administration in the literature, although ligament and tendon compositions are similar and should have similar susceptibility. This report includes two cases, one presenting with right lateral thumb pain and a medical history of gastroenteritis treated with ciprofloxacin. Physical examination showed swelling of the right metacarpophalangeal joint and ultrasound confirmed disruption of the radial collateral ligament at insertion on first metacarpal; the second case is of a woman presenting with right hip pain in setting of chronic recurrent diverticulitis treated with ciprofloxacin. She received work-up for lumbar disc disease and spondylosis. After standard therapy with pharmacotherapy and physical therapy for radiculopathy failed, magnetic resonance imaging was performed showing near complete avulsion of the right hamstring tendons from the ischial tuberosity.

Increased Reliability of Quantitative Ultrasound Measures of the Supraspinatus Tendon Using Multiple Image Analysts and Analysis Runs.

Quantitative ultrasound (QUS) is an inexpensive and promising tool for sensitive measurement of tendon pathology. However, few studies have reported the psychometric properties of measurements obtained using this technique for assessments of the supraspinatus tendon. The present study was undertaken to determine the variance contributed by several sources of error (participant, ultrasound operator, image analyst, analysis session) to QUS measures of the supraspinatus tendon. Transverse images of the supraspinatus tendon were captured from eleven subjects (22 shoulders) by two ultrasonographers, and each image was analyzed by two image analysts who each completed two analysis runs. Generalizability theory and intraclass correlations were used to assess the reliability of seven QUS metrics. Measures of tendon/cartilage thickness demonstrated the greatest degree of overall dependability (ϕ = 0.84), followed by echogenicity (ϕ = 0.56), variance (ϕ = 0.55), and entropy (ϕ = 0.47), suggesting that these measures of the supraspinatus tendon may be promising metrics for assessing differences in tendon health. Interrater reliability between ultrasound operators ranged from low to moderate for different QUS metrics, but using more than one image analyst and performing repeated measurement analysis runs on each image help increase reliability of QUS measures for the supraspinatus tendon.

Assessment of neuromuscular conditions using ultrasound.

Upper extremity pain in persons with spinal cord injury is a common cause of morbidity. Ultrasound of nerve, muscle, and tendon has the potential to become a valuable modality in assessing this population, and has the advantage of reduced health care costs, portability, and use in populations that cannot tolerate MRI. It has the potential to detect issues before the onset of significant morbidity, and preserve patient independence. Upper extremity ultrasound already has many studies showing its utility in diagnosis, and newer techniques have the potential to enhance its use in the diagnosis and management of musculoskeletal conditions.

Neurosarcoidosis presenting as mononeuritis multiplex.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology, with prevalence ranging from 1 to 50 per 100,000. Neurologic involvement occurs in up to 5% of patients but can be the initial presentation of sarcoidosis in 50% of those affected by neurosarcoidosis. The authors report a case of mononeuritis multiplex of the ulnar and then the radial nerve that subsequently led to a diagnosis of sarcoidosis in a patient 8 mos after initial presentation. It is important that neurosarcoidosis be in the differential diagnosis of mononeuritis multiplex when other causes cannot be found because early treatment could help prevent progression to other nerves.

Age, body mass index, and gender differences in sacroiliac joint pathology.

OBJECTIVE: To evaluate the correlation between age, gender, and body mass index as they relate to sacroiliac joint pathology diagnosed by dual comparative local anesthetic blocks. DESIGN: This was a retrospective review of patients at a university spine center from August 2001 until August 2004. RESULTS: One hundred fifty-eight patients underwent sacroiliac joint (SIJ) injections with average symptom duration of 34.0 mos. Of those patients, 26.6% were found to have SIJ pain by dual injections. The average age of this group was 53.3 yrs old; for those who had negative injections, it was 46.8 yrs old (P = 0.0025). The body mass indexes for the positive and negative SIJ pain groups were 30.2 and 29.3 kg/m2 (P = 0.40), respectively. The gender makeup of the positive and negative groups showed 64.3% female and 62.1% female (P = 0.85), respectively. Smoking tobacco status was not statistically significant between the two groups, with 29.6% of smokers having a positive block and 26.1% having a negative block (P = 0.35). CONCLUSIONS: Our results suggest an age difference for those patients who have SIJ pain. These patients tend to be older than those without. Gender, age, and smoking status were not found to correlate with SIJ pathology.

Industrial medicine and acute musculoskeletal rehabilitation. 2. Medications for the treatment of acute musculoskeletal pain.

UNLABELLED: This self-directed learning module highlights medications used in the treatment of acute musculoskeletal pain in the context of industrial rehabilitation. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article compares various skeletal muscle relaxants, addresses issues related to nonsteroidal anti-inflammatory medications, provides an algorithm for acute pain management in an injured worker, and discusses topical medications for the treatment of pain. OVERALL ARTICLE OBJECTIVE: To summarize medication options in the treatment of acute musculoskeletal pain in the setting of injured workers.

Industrial medicine and acute musculoskeletal rehabilitation. 3. Work-related musculoskeletal conditions: the role for physical therapy, occupational therapy, bracing, and modalities.

UNLABELLED: This chapter focuses on the use of modalities, therapeutic exercise, and orthotic devices in the treatment of lateral epicondylitis, carpal tunnel syndrome, plantar fasciitis, neck pain and low back pain. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To review the medical literature that may help clinicians make treatment decisions regarding modalities, therapeutic exercise, and orthotic devices for treating common work-related conditions in the upper and lower limbs.

Industrial medicine and acute musculoskeletal rehabilitation. 4. Interventional procedures for work-related cervical spine conditions.

UNLABELLED: This self-directed learning module outlines the use of interventional techniques in the treatment of neck pain with and without referred pain into the arm. It is part of the supplement on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on interventions used to diagnose or treat the conditions commonly seen in patients with neck pain or referred pain into the upper limb. Techniques reviewed include the use of botulinum toxin injections in the treatment of myofascial pain, cervical zygapophyseal joint injections and radiofrequency neuroablation in the treatment of posterior column disorders, and epidural steroid injections in the treatment of cervical radicular and referred upper-limb pain. OVERALL ARTICLE OBJECTIVE: To give an overview of the current state of the art regarding diagnostic and nonsurgical invasive treatment procedures for neck pain with and without referred upper-limb pain.

Industrial medicine and acute musculoskeletal rehabilitation. 5. Interventional procedures for work-related lumbar spine conditions.

UNLABELLED: This chapter emphasizes the importance of establishing a differential diagnosis for low back pain (LBP) with and without referred lower-limb pain and outlines potential interventional treatments appropriate for each diagnosis. It is part of the study guide on industrial rehabilitation and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The article specifically focuses on the various interventions used to diagnose or treat those conditions commonly seen in patients with work-related LBP or referred pain in the lower limb. Current criterion treatments for lumbar disk pain, including surgical options, are reviewed. OVERALL ARTICLE OBJECTIVE: To give an overview of the current state of diagnosis and treatment options for low back pain with or without referred leg pain focusing on interventional procedures.

Industrial medicine and acute musculoskeletal rehabilitation. 6. Upper- and lower-limb injections for acute musculoskeletal injuries and injured workers.

UNLABELLED: This self-directed study module focuses on the use of corticosteroids and other injections in the treatment of lateral epicondylitis, de Quervain's tenosynovitis, carpal tunnel syndrome, Achilles' tendinitis, and plantar fasciitis. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. OVERALL ARTICLE OBJECTIVE: To review the medical literature to help clinicians make treatment decisions regarding corticosteroid and other injections in the upper and lower limbs in injured workers.

Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal injuries.

UNLABELLED: This self-directed learning module reviews the history and physical examination of common acute musculoskeletal conditions that occur in the occupational setting. It is part of the industrial medicine and acute musculoskeletal rehabilitation study guide in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article presents case vignettes to review the diagnostic evaluation of heel pain, whiplash, repetitive strain injuries, and low back pain. OVERALL ARTICLE OBJECTIVE: To understand the important components of a history, physical examination, and concise diagnostic testing when evaluating acute industrial and musculoskeletal injuries.

Industrial medicine and acute musculoskeletal rehabilitation. 7. Acute industrial musculoskeletal injuries in the aging workforce.

UNLABELLED: This learning module highlights the unique challenges faced by physicians treating the aging workforce. It is part of the industrial medicine and acute musculoskeletal rehabilitation study guide in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Factors intrinsic and extrinsic to the patient that increase the risk of injury with aging are outlined. Low back injuries are the most common musculoskeletal complaint in the aging workforce. A conceptual framework for low back pain with aging, a differential diagnosis, and appropriate laboratory and radiographic investigations are also presented. Determination of causation in the setting of comorbid medical conditions and rehabilitation strategies are reviewed. OVERALL ARTICLE OBJECTIVE: To recognize diagnosis and treatment issues that are unique to the aging worker.

Concomitant sacroiliac joint pain in patients with lumbar disc herniation: case series.

Recent studies have shown that not all lumbar disc herniations are symptomatic and that when followed longitudinally, these patients develop back pain independent of the previous imaging study. This is a case report of two patients with radicular symptoms and lumbar disc herniations that underwent diagnostic injections to locate their pain generator. Both patients failed to respond to transforaminal epidural steroid injections. Transforaminal injections can be diagnostically sensitive for radicular pain but not specific. This is a direct result of the spread of medication to other levels in the epidural space, thus affecting multiple levels of innervation. Follow-up with two sacroiliac injections gave significant relief of their pain. They were both treated conservatively for sacroiliac joint pain and did well. One remained pain free after several months and the second remained with minimal pain until she presented again in her 3rd month of pregnancy with return of her pain. The differential diagnosis of lumbar radicular pain is discussed as well as the authors' experience in using diagnostic injections.