Rehabilitative Sciences

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    Platelet Releasate Injection for a Novel Treatment of Ulnar Neuritis at the Elbow
    (2023) Bejarano, Michael; Martinez, Richard; Clearfield, Daniel
    Background: Ulnar neuritis is a common entrapment neuropathy in the upper extremity that results from chronic compression of the ulnar nerve. Typical conservative treatment includes activity modification or brace immobilization. Platelet-rich plasma (PRP), an autologous product of concentrated platelets, has yet to be thoroughly investigated as a treatment option for ulnar neuritis. Platelet releasate, the supernatant of thrombin activated PRP, has potential to accelerate healing in injured peripheral nerves by releasing growth factors that promote nerve repair. Case Report: This case presentation discusses a novel treatment of ulnar neuritis with platelet releasate injection in a 42-year-old female patient presenting with right-sided neurogenic thoracic outlet syndrome and ulnar nerve entrapment. Initial imaging at the right elbow demonstrated ulnar nerve entrapment within the Arcade of Struthers. The patient’s symptoms were first managed with home exercise and and dextrose 5% in water (D5W) hydrodissection at the elbow, which decreased but did not resolve her pain. Intraneural and perineural platelet releasate injection of the ulnar nerve at the elbow was subsequently performed. Six weeks post-procedure, the patient reported her pain was 80% better and continuing to improve. Provocative tests at the elbow were negative and imaging demonstrated a normal appearing ulnar nerve. Despite these results, the patient was not completely symptom-free; continued symptoms were attributed to her concomitant neurogenic thoracic outlet syndrome. While platelet releasate injection has not previously been explored as a treatment option for ulnar neuritis, this case demonstrates how platelet releasate injection may facilitate healing in an ulnar nerve injured by entrapment. Conclusion: This case report investigated the use of ultrasound-guided nerve hydrodissection and platelet releasate injection for treating ulnar nerve entrapment. Although D5W hydrodissection proved useful in reducing the patient’s pain and paresthesia, platelet releasate injection was instrumental in resolving the patient’s localized entrapment. As current literature supports platelet releasate as a key driver of nerve regeneration, it is likely that the platelet releasate injection played a role in reducing the patient’s pain by enhancing the healing response of the injured ulnar nerve. Further research is indicated to determine if the clinical application of platelet releasate injection may be solidified as an efficacious treatment modality for ulnar neuritis and other peripheral nerve entrapments. Given the outcome for this patient, this case illustrates the prospect for platelet releasate treatment to continue to be studied as a monotherapy or synergistically with D5W hydrodissection for ulnar nerve entrapment and similar compression neuropathies.
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    Therapeutic Effects of Bone Marrow Aspiration Injection for Refractory Osteoarthritis of the Knee: A Case Series
    (2023) Whitmire, William; LeBaron, Brendan
    Case Diagnoses: This case series includes 3 cases of patients with refractory osteoarthritis of the knee who have received bone marrow aspirate concentrate injections in office. Case Description: The case series examines the patient's perception of pain, symptoms, activities of daily living, sports/recreation, and quality of life following bone marrow aspirate concentrate injections used to treat osteoarthritis of the knee. Osteoarthritis is a challenge to treat and can be an indication for knee replacement when pain persists after treatments with available therapies. Bone marrow aspirate concentrate injection is a type of therapy that uses regenerative cells found in the patient’s own bone marrow. Bone marrow is extracted from the pelvis of the patient, then placed into a centrifuge to separate regenerative cells from the other blood products. The bone marrow is then injected into the knee. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to evaluate each patient's perception of pain, symptoms, activities of daily living, sports/recreation, and quality of life. The survey was administered retrospectively, and patients were asked to complete the survey based on their perceptions before and after receiving the injection. The score is calculated on a scale of 0 to 100, with 0 representing extreme problems and 100 representing no problems. Results/Discussion: The KOOS scores for each patient were calculated before the injection and after the injection. On average, the results of the case series showed 53% decrease in pain, 70% decrease in symptoms, 36% improvement in activities of daily living, 150% improvement in sports/recreation, and 132% improvement in qualities of life. All 3 cases reported an increased score in each of the 5 measured outcomes. While this is a small case series with only 3 cases, it shows promising results. These patients have also shown clinical improvement following the injection, which correlates well with the improvements in KOOS score. The findings are relevant, as bone marrow aspirate concentrate injections could be an option for patients who desire to avoid knee replacement with refractory osteoarthritis of the knee. Conclusions: Based on the results of the case series, bone marrow aspirate concentrate injections may be an appropriate recommendation for patients with refractory osteoarthritis of the knee. More research is indicated in this regard. We are planning to investigate these results further with a cross-sectional descriptive design survey.
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    The Perplexing Plexus: An In-Depth Look at Post-Trauma Brachial Plexopathy
    (2023) Rauf, Ali; Martinez, Richard; Bejarano, Michael; Selod, Omar
    Background: Lower trunk pathologies are a subset of brachial plexus injuries involving the C8 and T1 nerve roots. These lesions can affect all the downstream components that receive input from C8-T1, including the medial cord, median nerve, ulnar nerve, and radial nerve. Lower trunk injuries can diminish both motor and sensory components of the affected upper extremity. Common etiologies for lower trunk lesions typically involve hyperabduction trauma such as motor vehicle accidents, falls, shoulder dislocations and obstetrical traction injury. Along with a thorough history and physical, brachial plexus injuries are typically diagnosed through Nerve Conduction Study (NCS), Electromyography (EMG), and imaging. Case Presentation: A 61-year-old male with a history of bilateral carpal tunnel release and bilateral ulnar nerve decompression presented to a physiatry clinic with left hand weakness following a fall on his left elbow three months prior. The patient also reported intermittent numbness in both hands involving all digits. NCS and EMG were completed and suggested mild left and severe right carpal tunnel syndrome, respectively. Two months following the initial visit, the patient returned to the clinic presenting with improved numbness in both hands, but weakened left grip strength and persistent left elbow pain. A posterior interosseous nerve (PIN) lesion was suggested due to elbow involvement. Physical exam of the left upper extremity revealed 4/5 strength in wrist extension, extensor indicus proprius (EIP), interossei, and abductor pollicis brevis (APB). Left hand interossei atrophy was also noted on examination. Repeat NCS showed left mild carpal tunnel syndrome, consistent with his previous visit. To evaluate for a PIN lesion, the left EIP and extensor carpi radialis brevis (ECRB) was tested via EMG. The EIP showed decreased recruitment, but ECRB was normal. Further testing revealed decreased recruitment of the left first dorsal interossei (FDI) and left APB. To further specify the location of the lesion, the medial antebrachial cutaneous (MAC) nerve was tested, but NCS revealed normal findings. With clinical judgment, the patient was diagnosed with a left lower trunk brachial plexopathy due to trauma. Despite an affected EIP, a PIN lesion was ruled out due to a normal ECRB. While the APB and FDI were affected, a medial cord lesion was ruled out due to an affected left EIP, which suggested a lower trunk lesion due to radial nerve involvement. An MRI of the elbow revealed lateral epicondylitis with 25-50% intrasubstance partial thickness tearing; while shoulder MRI results are currently pending. Conclusion: This case illustrates an atypical presentation of a lower trunk brachial plexus injury following trauma. The utilization of diagnostic and clinical tools in our case proved instrumental in the differentiation of lower trunk lesions from medial cord and PIN lesions and may provide a valuable reference for physicians evaluating similar cases. Furthermore, this case demonstrates the importance of continued monitoring of upper extremity nerve injuries for progression of symptoms, especially following trauma.