Physical Medicine / OMM

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    The Measurement of Postural Sway and Dynamic Gait Index as a Indication of Balance Before and After Vestibular Rehabilitation Therapy: A Case Study
    (2023) Hartley, Kristina; Patterson, Rita; Lee, Yein; Kennedy, Shawn
    Background: When managing patients with Benign Paroxysmal Positional Vertigo (BPPV), many clinicians follow patients' rehabilitation outcomes by tracking the patients' subjective symptoms, such as a sense of disequilibrium, postural imbalance, and gait disturbances. Postural sway data measurements are used to evaluate static and dynamic balance capacity in various contexts, including symptoms of vertigo. In comparison, Dynamic Gait Index (DGI) is a functional measure of dynamic balance often used in vestibular rehabilitation therapy (VRT). This case study examines the possible correlation of the patient's postural sway data with their subjective onset, symptoms resolution, and DGI score. Case Presentation: A 58-year-old female presented to the outpatient office with a new symptom of dizziness and subjective gait disturbances. The patient described the dizziness as similar to "room spinning." Symptoms worsened with head movement and resolved after a few seconds of no head movement. She also noticed the dizziness while lying down and turning in bed at night. Associated symptoms included a right-sided temporal headache and hearing difficulty. The patient's physical exam revealed normal findings except for the following. The patient's gait showed flexed forward posture and a broad base of support. Speed was slow, with uneven stride lengths. The neurological exam showed new onset nystagmus only 1-2 beats bilaterally. The pursuit was slow without apparent saccadic movements. The left hallux showed dorsiflexor movement, while the right displayed plantar flexor movement with Babinski. With the physical exam findings, BPPV was diagnosed, but before starting VRT, MRI was performed due to the new neurological findings. The MRI revealed a chronic lacunar infarct in the right caudate nucleus of unknown onset since her last visit. The patient was referred to her primary care physician for appropriate neurology referral and secondary prevention. Meanwhile, the patient was cleared to start VRT to address persistent vertigo. DGI was obtained two times during VRT, and an objective evaluation of sway was collected each time patient presented to the clinic before and after VRT. The sway data was collected by asking the patient to quietly stand on a Bertec force plate (Bertec, Columbus, Ohio) for 30 seconds with their eyes open (EO) and eyes closed (EC). A total of 21 sway measurements were calculated to evaluate objective changes in balance. The variables derived from the patient's Bertec force plate data were graphed per visit and analyzed via t-test for significance in comparison to DGI, age (age bracket [50-70]), height (1.67 m range, +-10%), and weight (90.45 kg range, +-15%) matched control data from the Human Performance Lab at UNTHSC. Significant changes in sway measurements were found in EC data over 7 weeks of therapy. Conclusions: The DGI displayed minimal change throughout VRT. The DGI evaluation time (15 minutes) prevents it from being implemented during a clinic visit, whereas postural sway collection (2 minutes) can be integrated into the patient intake. This report indicates the possible utility of outpatient collected sway data as an objective measure of balance in evaluating and managing patients presenting with balance and gait difficulties.
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    Cervical Myelopathy secondary to Hirayama Disease in 16-year-old male
    (2023) Rodgers, Abigail; Tandon, Saloni
    16-year-old male with past medical history of asthma presented to the ED with a chief complaint of months of persistent numbness, tingling and twitching sensations in his left calf and toes. The patient also noted weakness, paresthesia and loss of muscle mass of his left hand and wrist, and inability to straighten his fourth and fifth digit. Physical exam showed weakened hand grip and wrist flexion/extension with left forearm and intrinsic hand muscle atrophy. Patient had a positive Hoffman sign and brisk reflexes with no other neurologic deficits. CK elevated at 296. MRI of the brain showed volume loss with signal abnormality and enhancement in the lower cervical spinal cord (C4-C7). Findings were consistent with a non-acute, non-expansile myelopathy. Hirayama Syndrome (HS) is a rare condition caused by anterior movement of the posterior dural sac of the cervical spine during neck flexion, resulting in cord compression. Although a self-limiting condition, HS can cause chronic motor disabilities, including weakness of the extremities and loss of fine motor movements: resulting in diffuse muscle atrophy and contractures. Early interventions are key to preventing complications. Cervical collars have shown to be very effective. Nerve conduction studies can show the extent of nerve loss and possibility for reinnervation. If not treated early, cervical fusion is the only remaining intervention for HS, resulting in severe loss of cervical mobility, leading to functional, social and occupational disability. Education on prognosis and prevention of motor deficits will facilitate informed decision making, expedite diagnosis, and encourage patient compliance. Physical therapy has shown to not only reduce long term complications, but also help patients with residual motor deficits reach functional independence.
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    Case Study on the Effect of Osteopathic Manipulation on Gallbladder Ejection Fraction
    (2023) Lin, Emily; Montalvo, Emily; Adams, Natalie; Garcia Garcia, Diana; Sparks, Clarence
    Background: There is minimal research regarding the effects of osteopathic manipulative treatment (OMT) upon biliary emptying. Despite the limited research, OMT has been used to treat gallbladder dysfunctions in clinical practice. Case Information: The purpose of this case study was to examine the effects of OMT on gallbladder ejection fraction (EF) as measured by ultrasound and to determine if there was sufficient evidence of OMT-influenced biliary emptying to base a larger study. OMT was performed by a neuromusculoskeletal medicine board certified osteopathic physician on a medical student, who was acalculous and asymptomatic of any biliary disorder. Interventions included OMT targeting sympathetic and parasympathetic innervation levels, Chapman points, visceral myofascial release, and Sphincter of Oddi release. Results included gallbladder EF as measured by ultrasound. Blinded analysis demonstrated a 8.88% increase in average gallbladder EF following OMT, with a statistically significant difference in mean ejection fraction between OMT (M=46.95, SD=19.83) and no OMT (M=38.07, SD=19.13) conditions (paired t(4)=2.828, p=0.047). Conclusions: A limitation in the design of this study is that the comparison EF was measured 15 days after the OMT intervention. In future studies, we would first measure the EF and then perform OMT and measure the EF at least 4 weeks later. The results of this case study provide an enhanced understanding of OMT’s effect on gallbladder EF. Future studies should apply the biliary OMT protocol to a diverse clinical population with and without functional gallbladder disorder to determine if OMT could be used as an alternative treatment.