Rehabilitative Sciences

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    Platelet Releasate and ESWT for Treatment of a Partial Supraspinatus Tear in an Adolescent Baseball Player
    (2024-03-21) Bibi, Yasser; Al-Khabbaz, Omar; Clearfield, Daniel
    Background: Rotator cuff injuries are a prevalent orthopedic concern, often arising from repetitive overhead activities, traumatic events, or age-related degeneration with the supraspinatus muscle being the most frequently injured. As the muscle responsible for initiating abduction of the arm, the supraspinatus is particularly susceptible to strain and tears, contributing to the majority of rotator cuff injuries. The incidence of rotator cuff tears in the general population is 5-30%, the prevalence of the condition is about 25% in people over age 65 and above 50% in individuals over age 80. Case Presentation: An 18-year-old right-hand dominant male baseball player who plays the catcher position presents to the clinic with right shoulder pain. The patient reports that they had a rotator cuff injury in his anterior shoulder area about 9 months prior which led to him sitting out of his previous season. On ultrasound imaging, the supraspinatus muscle showed a twenty-five percent partial tear on the bursal surface of the anterior aspect, with no retraction seen on dynamic exam. There was no other tendinosis or tear noted, with normal muscle appearance without any atrophy or fatty infiltration, or evidence of impingement with dynamic imaging. The ESWT was conducted before the Platelet Releasate injection procedure. With the patient in a supine crass position, 3000 total pulses at 15 MHZ were applied to the affected area using 2.6-3.6 bars of energy with a D-Actor C15 tip. The patient portrayed good tolerance to treatment, with a reported decrease in pain and improved range of motion. Following ESWT, a platelet releasate procedure was conducted on the right shoulder. On imaging, the patient’s supraspinatus muscle showed significant improvement in the tear, with only ten percent of the tear in the anterior supraspinatus still apparent (15 percent reduction total in the supraspinatus tear). There was evidence of acute supraspinatus tendinitis, with no impingement on dynamic testing. There was also some newly acquired bursitis in the subacromial bursa. There was no other noted tendinosis or tear, with a normal-looking muscle appearance. Conclusion: Generally, it can be difficult to highlight specifics and attribute them to the therapeutic effects of a treatment that facilitates various regenerative and healing properties. The main point of this case is to surface a less popular therapy compared to PRP: platelet releasate/ESWT and their therapeutic effects for MSK-related injuries. Platelet releasate paired with ESWT is a minimally invasive outpatient procedure and should be presented as a potential therapeutic treatment option to patients before considering invasive alternatives.
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    Trigger Point Injections as a Potential First Line Therapy for Persistent Myofascial Pain Syndrome
    (2024-03-21) Srikalyani, Sathvik; Clearfield, Daniel; Patel, Arpan
    Background Myofascial pain syndrome (MPS), characterized by pain from myofascial trigger points in skeletal muscles, often responds to conservative treatments. However, in this case, the patient's persistent symptoms resisted conservative methods but found relief only with trigger point injections. Using trigger point injections as the primary treatment method for MPS is unique. While trigger point injections are documented, their role as a first-line treatment for MPS is underexplored. This case reinforces the potential of trigger point injections for patients unresponsive to conventional treatments and underscores the importance of personalized management for myofascial pain. Teaching points in this case highlight the significance of clinical expertise in the diagnosis and the role of advanced diagnostic tools like ultrasonography, emphasizing meticulous diagnosis in cases where traditional treatments fall short. Case Summary A 58 year old male ex-Army Ranger presented with persistent bilateral posterior leg pain and tightness after failed conservative treatments such as massages, stretching, and NSAIDs for more than a year. A preliminary differential diagnosis included chronic exertional compartment syndrome, vascular claudication, as well as myofascial trigger points. Ultrasound-guided trigger point injections were administered, significantly reducing pain, increasing function, and improving their range of motion. This success highlights the efficacy of trigger point injections in treating MPS that resists conservative methods. Conclusion Literature on MPS primarily focuses on non-invasive treatments and explores trigger point injections as an adjuvant to other treatments. However, this case is different because it features a patient with chronic lower extremity MPS unresponsive to conventional therapies. The case challenges the traditional view that non-invasive methods suffice for MPS and highlights trigger point injections as a potential first-line treatment. For similar unresponsive MPS cases, future management should consider the early use of trigger point injections, particularly with ultrasound guidance for safety and precision. This case stresses the importance of individualized care, encouraging healthcare practitioners to explore alternative treatments when conventional ones fall short.
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    Post-traumatic Range of Motion Loss in a Professional Pianist: A Multimodal Approach
    (2024-03-21) Mahasamudram, Prathyusha; Wegehaupt, Kailee
    Background: Pathological scarring is a fibroproliferative condition that occurs after abnormal tissue repair following a lesion or infection. Treatment is typically seen in post-operative or burn patients with common scarring distributions along the face, shoulders, and trunk. However, in the case of accidental, superficial injury to the hands of a musician, there exists a unique opportunity for treatment of post-traumatic scarring. For a professional musician, music is not just a career but a profound and inseparable part of their identity that is significantly threatened by what may appear as minor scarring. Pathogenesis of scarring is unclear and complex, involving disordered angiogenesis, inflammation, and tissue deposition. For this broad pathology, there are many therapy options based in pharmacology, pressure, immobilization, photoelectricity, radiation, cryotherapy, and surgical techniques. Of these, corticosteroid injections are frequently attempted because they are not only anti-inflammatory, but also repress transcription and fibroblastic factors while promoting extracellular matrix remodeling. These properties can directly improve scar volume and elasticity. Given the extensive array of treatment options and targets, adopting a multifaceted therapy approach is vital. Case Presentation: A 35 year old male musician with a past medical history of cervical stenosis at C3-C6 presented with a primary concern of decreased dexterity in his right hand, secondary to direct trauma sustained in a motor vehicle accident six months prior. He also experienced dull, burning pain across his right hand that was worse in the thenar area and exacerbated by use. As a musician he practiced up to 8 hours daily and thousands of hours yearly. He saw multiple physicians and surgeons who primarily focused on pain. He had been splinted since his injury, failed trials of high dose duloxetine and anti-inflammatories, received minimal therapy and received CMC and PIP corticosteroid injections, without relief. His ROM was functionally limited on exam, with 1-2 centimeters of difference upon right thumb opposition, flexion and extension as compared to his left. His neurologic exam was unremarkable. Ultrasound showed a slightly thickened edge of his palmar aponeurosis and 2.5 mg of Kenalog was injected into this fascial plane. Additional treatments included retraining of central pain sensitization, nitroglycerin patches, anti-inflammatory and methyl-based topicals, kinesiotaping, electroacupuncture, Feldenkrais education, and arranging regular occupational therapy, soft tissue manipulation, and psychosocial counseling. This comprehensive rehabilitation approach helped the patient regain hand dexterity and ROM that was lost secondary to prolonged immobilization and scarring, ultimately facilitating his goal of returning to his prior level of playing. Conclusion: A multimodal treatment strategy and the use of corticosteroid injection in an atypical setting was significant to this case. Treatment of pathological scarring that occurs outside an operative or burn setting is less commonly seen or needed. The indication for this treatment strategy was decided with recognition that a centimeters level of change in ROM carried substantial meaning for this professional musician. His life was his art. As such, our approach acknowledged the profound physical and psychological impacts of his scarring and the value of comprehensive treatment and rehabilitation throughout this unique encounter.
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    Integration of psychosocial and medical factors in the care of a 17-year-old with GSW at T5 – a case study
    (2024-03-21) Oliver, Madelyn; Taylor, Kristen; Wolfe-Christensen, Cortney
    Background: Rehabilitation psychology involves the application of psychological knowledge in the care of individuals with disabilities and chronic health conditions. This specialty involves ongoing evaluation of a patient’s mental and psychological status and the formation of positive coping skills and behaviors to help the patient achieve a satisfactory and productive life, as defined by the individual patient. Individuals with spinal cord injuries (SCIs) have an increased risk for poor physical, psychological, and social health. This trend is even more pronounced in vulnerable populations, including the poor, racial and ethnic minorities, older adults, and pediatric patients. Case information: A 17-year-old male presented to Care Now with a gunshot wound (GSW) to the back. The patient was transferred to JPS. CXR showed that the bullet fractured T5 and remained lodged. The patient was diagnosed with incomplete SCI and paraplegia and treated for pulmonary and hepatic lacerations and diaphragm injury. The patient was transferred to Cook Children’s RCU for long-term management. Psychology was consulted to discuss patient’s dissatisfaction with catheterization and concerns on sexual functioning. Conclusions: The incorporation of rehabilitation psychology in the care of patients with SCIs, particularly in vulnerable populations, has been shown to improve long-term success and independence. It is essential to implement a multi-factorial approach that considers both medical and psychosocial variables in a patient’s treatment plan. Emphasis must be placed on individual priorities of the patient to help the patient achieve acceptance and long-term satisfaction.