This chapter briefly describes the following neurologic diseases and their electrodiagnostic findings: motor neuron diseases such as amyotrophic lateral sclerosis, X-linked spinobulbar muscular atrophy (Kennedy disease), and spinal muscular atrophy; demyelinating polyneuropathies; neuromuscular junction disorders such as myasthenia gravis and Lambert–Eaton myasthenic syndrome; and myopathy. Polymyositis and dermatomyositis are classified as inflammatory myopathies. Inclusion body myositis is the most common inflammatory myopathy in older individuals. This chapter discusses the pertinent electrodiagnostic criteria to support the diagnosis. It also reviews immunomodulatory therapy with agents such as corticosteroids, intravenous immunoglobulins, azathioprine, and methotrexate. Patients on chronic steroid therapy can develop proximal muscle weakness. Higher doses of steroids (>30 mg/d) and longer course of therapy exacerbate the risk of developing steroid myopathy.
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Falls are the leading cause of traumatic spinal cord injury (
SCI) in people over age 65. This chapter depicts the major tracts of the spinal cord. It discusses the epidemiology, classification, acute treatment, prognosis, recovery, and selected issues of SCI, and the expected functional outcomes for the average-age individual with SCI. The chapter then provides a brief description of the following clinical syndromes of SCI: central cord, Brown-Sequard, anterior cord, cauda equina, and conus medullaris. Central cord syndrome is an incomplete SCI syndrome usually seen in persons with preexisting cervical spondylosis who experience neck hyperextension injuries, typically due to falls. Currently there is no cure for SCI. Maintenance of mean arterial blood pressures of >85-90 mmHg for the first week after SCIis recommended for spinal cord perfusion and has shown improved motor outcome scores. In the acute setting, comprehensive medical treatment also includes cardiac, hemodynamic, and respiratory monitoring and support.
This chapter briefly reviews the basics of gait cycle and its components. It describes the activities of various muscles, such as the ankle dorsiflexors, ankle plantarflexors, hip abductors, hip flexors, hip extensors/hamstrings, and knee extensors, and standing during unimpaired gait. Gait deviations can stem from any combination of musculoskeletal, orthopedic, or neuromuscular changes in the body. Patients may often demonstrate distinct walking patterns. This chapter discusses gait deviations and prescriptions of muscle-deficit gait and neuromuscular impairments. Gait aids include cane basics, crutch basics, axillary crutch, forearm crutches, crutch gaits, and walker basics. Many individuals are unable to navigate their homes or communities using ambulation for a variety of reasons, including (but not limited to) muscle weakness or paralysis, impaired balance, pain, orthopedic or musculoskeletal impairments, or sensory impairments. Wheelchairs provide an alternative method of safe mobility, either on a short-term or long-term basis.
This chapter presents an overview, clinical presentation, diagnostic workup and treatment of the following conditions: facet (zygapophyseal) joint pain, sacroiliac joint dysfunction, discogenic pain, radiculopathy, and spinal stenosis. Physical therapy (
PT) should focus on restoring proper biomechanics by stretching/relaxing hypertonic shortened muscles, strengthening weakened muscles, reestablishing beneficial neuromuscular firing patterns and proprioception, and breaking kinesiophobic habits. If pain is acute, a short period of rest is appropriate before initiation of PT. Pharmacologic considerations include initiation of nonsteroidal anti-inflammatory drugs and acetaminophen. If appropriate, a short course of muscle relaxants and/or neuropathic agents such as gabapentin can be considered. Alternative treatments include acupuncture, massage therapy, transcutaneous electrical nerve stimulation unit, ice/heat, myofascial release, and mindfulness/meditation. Spine interventions include epidural injections, radiofrequency nerve ablation, and vertebroplasty/kyphoplasty. Vertebroplasty/kyphoplasty aims at treating pain and instability from acute or subacute vertebral compression fractures from the age of 2 weeks to 6 months.
A concussion represents a low-velocity injury caused by brain “shaking” resulting in clinical symptoms that are not necessarily related to a pathologic injury. This clinical syndrome of biomechanically induced alteration of brain function typically affects memory and orientation, which may involve loss of consciousness. Symptoms that may arise include posttraumatic headaches, vision issues, sleep disturbances, mood changes, cognitive changes, and an overall change in a person’s quality. The diagnosis of concussion is made based on history and physical, including assessment of the biomechanics of the injury and acute injury characteristics, and evaluation of the clinical signs and symptoms. In sports-related concussion,
CTimaging is used to evaluate for more serious intracranial injuries. It is essential to provide enough time at the end of the physical examination to discuss the exact time frames for rest to recommend, the expected symptoms, reassurance of recovery, proper hydration, and self-care.
This chapter discusses the clinical manifestations, laboratory and imaging findings, and treatment for the following rheumatologic disorders: osteoarthritis, rheumatoid arthritis, gout, calcium pyrophosphate deposition disease (
CPPD), seronegative spondyloarthropathies, fibromyalgia, and osteoporosis. Osteoarthritis is one of the leading causes of disability and the most common type of arthritis. Rheumatoid arthritis is an autoimmune, inflammatory joint disease that can lead to significant disability. Gout is a commonly seen crystal-associated arthropathy caused by monosodium urate crystal deposition precipitated by hyperuricemia. The other major crystal deposition disorder is CPPD. Pseudogout refers to the symptomatic arthropathy resulting from CPPD. Seronegative spondyloarthropathies are a group of multisystem inflammatory disorders affecting the spine, peripheral joints, and periarticular structures, and are associated with distinguishing extra-articular manifestations. The hallmark symptoms of fibromyalgia are chronic generalized pain, sleep disturbances, fatigue, and dyscognition. Osteoporosis is a skeletal disorder characterized by compromised bone strength which predisposes patients to an increased risk of fracture.
Cancer is one of the largest causes of morbidity and mortality across the country and worldwide. Based on incidence rates, the leading cancers in the United States include breast, lung, prostate, colorectal, and melanoma. Cancer rehabilitation aims to improve function and promote physical, social, and emotional well-being to maximize one’s quality of life related to cancer or its treatment. Cancer patients suffer from a wide variety of symptoms, including fatigue, pain, neuropathy, muscle wasting, cognitive dysfunction, mobility difficulties, lymphedema, dysphagia, bowel and bladder changes, and psychosocial distress. Rehabilitation has been shown to be beneficial at all stages of cancer diagnosis and treatment and is available in clinical settings across the care continuum, including acute inpatient rehabilitation, acute consult services, subacute services, outpatient clinics, and hospice units. This chapter discusses the effects of cancer and cancer treatments such as chemotherapy, hormonal therapy, immunotherapy, radiation therapy, and surgery.
Pain is a subjective unpleasant sensory or emotional experience due to actual or potential tissue damage. The sensation of pain travels via three primary neuronal pathways that transmit noxious stimuli from the periphery to the brain. Primary afferent neurons contain cell bodies in the dorsal root ganglia, which are located in the vertebral foramina at each spinal cord level. Each of these primary afferent neurons contains a single axon that bifurcates to the periphery and to the dorsal horn of the spinal cord. The mainstay of treatment for complex regional pain syndrome involves early restoration of function. Neuromodulation techniques represent an evolving interventional approach for treating chronic pain. Intrathecal pumps have a place in the management of chronic pain as well as spasticity. There is emerging evidence that cannabinoids may have a role in pain management, particularly in the setting of chronic neuropathic pain, spasticity, and cancer pain.
To assess the musculoskeletal system, clinicians use the classic techniques of inspection, palpation, and manipulation. This chapter explains the inspection, palpation, range of motion criteria, and special tests for assessing the following musculoskeletal regions: cervical spine; shoulder; elbow; wrist and hand; lumbosacral spine and pelvis; hip and thigh; knee; and foot, ankle, and lower leg. Inspection of foot, ankle, and lower leg includes observing the weight-bearing rearfoot and forefoot posture/alignment, both anteriorly and posteriorly (neutral, planovalgus, cavovarus); observing any skin lesions, calluses, blisters, and nail abnormalities; and observing overall bony alignment, any tissue swelling, or gait abnormalities. Comparing with the contralateral side in all aspects of the examination is helpful. Special tests for assessing the acromioclavicular (
AC) joint, rotator cuff, anterior dislocation, and biceps are cross-arm adduction (Apley scarf test, ACjoint), Hawkins–Kennedy (impingement), apprehension or crank (anterior dislocation), and Speed’s test, respectively.
US) is an invaluable tool for diagnosis and treatment of various musculoskeletal conditions and has become increasingly important in the field of physiatry. Advantages of USover other imaging modalities include relative portability, low cost, high-quality spatial resolution of superficial soft tissue and neurovascular structures, no exposure to ionizing radiation, and capability for continuous needle visualization during interventions. This chapter discusses USprinciples, transducer movements, common sonographic artifacts, sonographic appearance of normal and pathologic structures, and interventional applications of US. USguidance for procedures is indicated when there is close proximity to neurovascular structures, absence of surface landmarks due to body habitus, deeper target structures, as well as in cases where the diagnostic or therapeutic injection depends on precise injectate placement. US-guidedprocedures should not be performed in patients with known allergy to the injectate or in the location of an active infection, rash, or skin breakdown.