1/14. Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management.This is a self-directed learning module that reviews medical complications associated with spinal cord injury (SCI). It is part of a chapter on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article includes discussion of common medical complications that impact rehabilitation and long-term follow-up for individuals with SCI. Issues addressed include the rehabilitation approach to SCI individuals with pressure ulcers, unilateral lower-extremity swelling (deep venous thrombosis, heterotopic ossification, fractures), along with the pathophysiology, assessment, and treatment of spasticity, autonomic dysreflexia, orthostatic hypotension, and pain. overall ARTICLE OBJECTIVE: To describe diagnostic and treatment approaches for medical complications common to individuals with SCI.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/14. cyproheptadine for intrathecal baclofen withdrawal.OBJECTIVE: To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal. DESIGN: Descriptive case series. SETTING: University hospital with a comprehensive in- and outpatient rehabilitation center. PARTICIPANTS: Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion. INTERVENTIONS: patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases. MAIN OUTCOME MEASURES: Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise). RESULTS: The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing. DISCUSSION: Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin. CONCLUSION: cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/14. phenol block for hip flexor muscle spasticity under ultrasonic monitoring.Hip flexor spasticity, which is often associated with central nervous system (CNS) diseases, is a major impediment in rehabilitation. In order to cope with this problem, lumbar nerve blocking techniques developed by Meelhuysen and major and minor psoas muscle blocking techniques developed by Awad have been used in combination with physical therapies. Based on these techniques, we conducted major and minor psoas muscle phenol block (motor point block or intramuscular nerve block) under ultrasonic monitoring. phenol block was conducted in nine patients with cerebral infarction (13 blocking procedures) and three with spinal cord injuries (six blocking procedures) while keeping them in a lateral position with the operation side upside. The beginning of the femoral nerves and part of the lumbar artery were visualized by ultrasound in some patients. As a result of the improvement of hip flexor spasticity, the range of hip joint motion (determined by the Mundale technique, prone hip extension and Thomas test) improved shortly after blocking. When physical therapy was conducted after blocking, improvement of skin care management was observed in eight cases, ability to keep in a stable sitting position in nine, improvement of a standing posture in three, increases in the ability to walk in two and alleviation of pain in three. Although nerve block is reported to result in hematoma, decreases in muscle force, pain, cystic/rectal disorders and hypogonadism, we have observed no such complication in our patients.- - - - - - - - - - ranking = 2keywords = physical (Clic here for more details about this article) |
4/14. Successful treatment of childhood spasticity secondary to cerebral palsy using Botox.Spasticity resulting from cerebral palsy can reduce the quality of life in affected children and can eventually cause more severe impairments, such as joint dislocation and scoliosis. Botulinum toxin type A (Botox) is widely used to temporarily alleviate the increased muscle tone associated with spasticity, and when combined with a comprehensive physical therapy regimen can result in permanent improvement. This report documents the successful use of Botox over a two-year period to treat spasticity secondary to cerebral palsy in a preschool-age child. Botox was used in conjunction with a specific physical therapy regimen in order to reach a functional goal of independent ambulation.- - - - - - - - - - ranking = 2keywords = physical (Clic here for more details about this article) |
5/14. Unique use of botulinum toxin to decrease adductor tone and allow surgical excision of vulvar carcinoma.Here, we present the case of an 86-year-old woman with vulvar carcinoma requiring surgical resection and with Parkinson's disease with severe spasticity and contractures of the lower extremities. Because of the patient's severe contractures and spasticity (her knees could only be separated by 2 cm with sustained abducting force), surgical positioning and access to the vulva were impossible. The patient was admitted, intending to undergo surgery after injection with botulinum toxin (BTX) to hip adductors and intensive physical therapy. After confirmed healed hip arthroplasty, the patient underwent BTX injection (400 U) to her bilateral adductor brevis, adductor longus, adductor magnus, and semimembranosus and semitendinosus muscles on day 2 of her hospital stay. On day 3, a physical therapist began a twice-a-day stretching program. An adjustable abduction brace was custom-made to provide sustained stretching. On day 9, the patient underwent wide local excision of vulvar carcinoma with the abductor brace in place. The patient tolerated the surgery well and was discharged home on day 11 with continuous physical therapy. Upon discharge, the distance between the patient's knees was 14 cm. This unique case demonstrated a new indication for BTX treatment in the preoperative setting to allow surgical positioning and access.- - - - - - - - - - ranking = 3keywords = physical (Clic here for more details about this article) |
6/14. Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity.An originally ambulatory 18-yr-old woman with spastic left hemiplegic cerebral palsy developed left plantar fasciitis with a gradual loss of function requiring use of a wheelchair. Her symptoms were resistant to physical therapy. Two hundred units of botulinum toxin A was diluted in 4 mL of saline and injected into the gastrocnemius. Three milliliters of autologous blood was injected into the plantar fascia. She reported decreased pain at 3 days postinjection. At 10 days, she had no pain on walking. Dorsiflexion increased and Ashworth and Tardieu improved. A stretching program was taught and a better-fitting night splint was obtained. At 21 days, she exhibited no pain and increased dorsiflexion. Autologous blood injection combined with botulinum toxin A may be an alternative treatment for resistant plantar fasciitis accompanied by spasticity. Our hypothesis is that chronic plantar fasciitis is a degenerative condition and thus is relieved when a mild inflammatory process is created that leads to healing.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/14. Acute fright induces onset of symptoms in vanishing white matter disease-case report.Vanishing white matter disease is a newly recognised leukoencephalopathy of identified genetic background, characterised by cystic degeneration and progressive vanishing of white matter. The characteristic clinical symptoms are spasticity and ataxia with relatively preserved cognitive functions. A characteristic feature of the disease is the occurrence of the symptoms after a physical stress situation such as mild head trauma or febrile infection. We would like to present a case of a 6-year-old girl whose first symptoms of the disease occurred after being frightened by a horse.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
8/14. Hip instability in spinal cord injury patients.Seventeen children with spinal cord injuries that occurred before the age of 9 years were followed at the Alfred I. duPont Institute for a mean of 13.2 years (range 3-32 years). Fourteen of these patients (82%) developed subluxation or dislocation in one or both hips. patients with spastic spinal cord injury (SCI) developed hip flexion and adduction contractures and had symptoms that tended to mimic those of cerebral palsy. patients with flaccid SCI mirrored the "flail" hips of myelomeningocele. Pelvic obliquity occurred in spastic and flaccid children. Only one patient developed pain, and three had deformities suggesting avascular necrosis of the femoral head. At final follow-up, no patient had physical problems relating to the hip dysplasia.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/14. Intrathecal baclofen for severe spasticity.The intrathecal administration of baclofen by way of an implanted subcutaneous drug delivery system is described in a patient with a severe spastic paraparesis due to multiple sclerosis. Intrathecally-administered baclofen is proposed as another therapeutic dimension and adjunct to physical therapy in the management of patients with severe spasticity that is unresponsive to antispasticity agents administered by mouth.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
10/14. behavior modification in physical therapy.Behavioral techniques reported to improve ambulation skills among physically handicapped persons include both reward and desensitization procedures. This report describes the application of other behavior modification principles to two patients who resisted physical therapy (PT) designed to educate them in the use of orthopedic assistive devices. Peer modeling was used with case 1, a 2 1/2-year-old girl with complete L4 spina bifida who cried frequently when wearing her brace, and refused to walk except with much assistance. Case 2 was a 21-year-old hemiplegic man seen two years after a severe head injury. Initially, severe tantrum behavior accompanied all demands placed on him. Treatment involved a combination of contingent music for being quiet and contingent aversive auditory feedback for yelling. In both cases clinically significant behavioral changes were observed. Results are discussed with respect to the cost effectiveness of behavioral interventions and the interdisciplinary coordination of rehabilitation team members.- - - - - - - - - - ranking = 6keywords = physical (Clic here for more details about this article) |
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