Andrew L. Sherman

Prevention and Treatment Of Heterotopic Ossification After Spinal Cord Injury

Abstract Background/Objectives: Heterotopic ossification (HO) is a frequent, irreversible complication afterspinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management. Etiology: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO. Prevention: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3. Management: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein Ieveis return to normal range. Surgery is indicated in a subset of patients, and a regimenthat includes radiation therapy may prevent postoperative recurrence. Conclusion: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.

Mesenchymal Stem Cell Therapies in the Treatment of Musculoskeletal Diseases

The application of regenerative strategies to musculoskeletal ailments offers extraordinary promise to transform management of the conditions of numerous patients. The use of cell-based therapies and adjunct strategies is under active investigation for injuries and illnesses affecting bones, joints, tendons, and skeletal muscle. Of particular interest to the field is the mesenchymal stem cell, an adult stem cell found in bone marrow and adipose tissue. This cell type can be expanded ex vivo, has allogeneic application, and has the capacity for engraftment and differentiation into mesodermal lineages. Also of major interest in the field is the use of platelet-rich plasma, a strategy to concentrate endogenous cytokines and growth factors with reparative potential. Here we review the biological basis, clinical studies, safety, and current state of mesenchymal stem cell and platelet-rich plasma therapies in the treatment of musculoskeletal disease.

Use of Glucosamine and Chondroitin in Persons With Osteoarthritis

Glucosamine and chondroitin are members of a group of dietary supplements often termed “complementary agents,” “disease‐modifying agents,” or “disease‐modifying osteoarthritis drugs” (DMOADs). They are among the best‐selling dietary supplements in the United States. DMOADs are thought to act by affecting cytokine‐mediated pathways regulating inflammation, cartilage degradation, and immune responses. Given the results of recent studies, investigators have begun to question whether the popular combination of glucosamine and chondroitin alleviates disease progression or pain in people with mild to moderate knee osteoarthritis. Reasons proposed for the lack of benefit include incorrect dosing, suboptimal compound manufacture, and a lack of complete understanding of when and how to apply the compounds. In addition, adjuvant medications also could augment the therapeutic potential of these agents. Although these agents are considered safe, some uncommon and minor adverse effects have been reported, including epigastric pain or tenderness (3.5%), heartburn (2.7%), diarrhea (2.5%), and nausea (1%). In conclusion, although some questions have arisen about whether DMOADs are as effective as has been claimed, a trial should be considered in in selected patients with sustained refractory cases of osteoarthritis.

Power-Assisted Wheels Ease Energy Costs and Perceptual Responses to Wheelchair Propulsion in Persons With Shoulder Pain and Spinal Cord Injury

OBJECTIVE Test effects of pushrim-activated power-assisted wheelchairs (PAPAWs) on the energetics and perceptual responses to steady-state and intensity-graded wheelchair propulsion in persons with paraplegia and tetraplegia having chronic shoulder pain. DESIGN Test, retest with a control condition. SETTING Academic medical center. PARTICIPANTS Subjects (N=18) aged 19 to 70 years with chronic, motor-complete paraplegia and tetraplegia having confirmed shoulder pain. INTERVENTIONS Study participants underwent testing on 4 randomized nonconsecutive days during either 6 minutes of steady-state or 12 minutes of intensity-graded wheelchair propulsion on stationary rollers. Participants used their own manual wheelchair and either their customary wheels or power-assist wheels attached with an axle bracket. MAIN OUTCOME MEASURES Oxygen consumption (V(.)O2, L/min), distance (m), energy cost (L/m), and ratings of perceived exertion (RPE; Borg Categorical 6-20 Scale) were measured during propulsion. RESULTS Significant main effects of testing were observed for V(.)O2, heart rate, and RPE in both subject groups. Distances propelled were significantly increased in both groups across both tests and in each of their 2-minute exercise stages. CONCLUSIONS Use of PAPAWs by persons with paraplegia and tetraplegia having shoulder pain significantly lowers energy cost responses and perceived exertion compared with manual wheelchair propulsion while significantly increasing the distanced propelled.

The emerging use of platelet-rich plasma in musculoskeletal medicine.

Platelet-rich plasma (PRP) is one of many new developments within the expanding field of regenerative medicine. Specialists in areas such as orthopedics, physical medicine and rehabilitation, and rheumatology have been exploring the benefits of this novel therapy. Although PRP therapy remains controversial and has minimal clinical trial support, the use of orthobiologics such as PRP continues to advance as patients seek nonsurgical approaches to acute and chronic musculoskeletal injury and disease. However, academic acceptance as well as insurance reimbursement remain reliant on solid and repeatable positive results from large clinical trials. The authors summarize the evolution of PRP therapy and report on its status.

Musculoskeletal Education for Medical Students

Mayer RS, Baima J, Bloch R, Braza D, Newcomer K, Sherman A, Sullivan W: Musculoskeletal education for medical students.Musculoskleletal conditions comprise the second most common reason for physician visits and have the greatest negative impact on health-related quality of life in the industrialized world. Therefore, all medical schools should provide education for their students in these disorders. Physiatrists play a unique role in musculoskeletal care and hence, should play a leading role in medical student education. The Association of Academic Physiatrists formed a task force in 2007 to make recommendations as to how physiatrists could contribute to musculoskeletal education for medical students. This report contains those recommendations.

The value of serum creatine kinase in early diagnosis of heterotopic ossification.

Abstract Background: Heterotopic ossification (HO) is a complication of spinal cord injury (SCI) characterized by formation of ectopic bone. Early diagnosis is critical, but available diagnostic methods have drawbacks. Serum creatine kinase may be a marker for the development and severity of HO. Participants: 1 8 SCI patients with diagnosed HO based on clinical findings and bone scintigraphy. Methods: Serum creatine kinase levels were taken at the time of diagnosis of HO and during subsequent etidronate therapy. Results: Of the 1 4 patients with normal creatine kinase values, 1 3 had no evidence of HO on follow-up radiographic examination. Of the 4 patients with elevated creatine kinase, all developed radiographic signs of HO. Conclusion: Elevated serum creatine kinase may be associated with a more aggressive course of HO as well as resistance to etidronate therapy. Further studies are needed to determine whether creatine kinase may serve as a marker for early, active HO.

Elite male adolescent gymnast who achieved union of a persistent bilateral pars defect.

An adolescent 15-yr-old male competitive gymnast presented to a university-based multidisciplinary spine institute with a persistent low-back pain for 18 mos. Although the results of x-rays were negative, his pain rendered him unable to compete in his sport any longer. A computed tomography scan was performed, which showed a bilateral pars fracture at L5, without spondylolisthesis. A nuclear medicine bone scan revealed negative findings, confirming chronic nonunion. The patient completed a 4-wk course of physical therapy 6 mos before our intervention, without any relief of pain or radiologic evidence of healing. The patient was treated with a bone stimulator for 4 hrs/day and was recommended to wear a warm-and-form-type brace. Isometric core trunk exercises were also initiated. Only after 6 wks of treatment, the subject showed clinical improvement at the follow-up visit. Computed tomography scan performed 12 wks after the initial scan showed complete union of the fracture correlating with clinical improvement. Two years later, the athlete remains completely pain-free, is training regularly, and is able to compete on a national and, possibly, international level.

1. Head and spine injuries

This self-directed learning module focuses on head, neck, and spine injuries that are frequent occurrences in sporting activity. It is part of the chapter on musculoskeletal rehabilitation and sports medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The physiatrist must be able to recognize not only the cause of the acute injury but also the functional consequences of the impairment. This article will discuss some of the more common head, neck, and spine injuries in patients engaged in sports activity and will suggest typical management options for these patients.

Imaging in Radiculopathy

All patients presenting with signs and symptoms of lumbar radiculopathy must undergo a thorough history taking and physical examination. Often, however, the diagnosis remains unclear; it is accurate anatomically, but the underlying cause of the lesion is not confirmed, or the symptoms are so severe that more information on the anatomy is required. Therefore, the next step in the diagnostic process is imaging studies. This article discusses imaging modalities, including plain radiographs, magnetic resonance imaging, computed tomography (CT), CT myelogram, selective nerve root block, and bone scan.