Elena J. Jelsing

Biomarkers, genetics, and risk factors for concussion

It is estimated that between 1.6 and 3.8 million concussions occur annually in the United States. Although frequently regarded as benign, concussions can lead to multiple different adverse outcomes, including prolonged postconcussive symptoms, chronic traumatic encephalopathy, cognitive impairment, early onset dementia, movement disorders, psychiatric disorders, motor neuron disease, and even death. Therefore it is important to identify individuals with concussion to provide appropriate medical care and minimize adverse outcomes. Furthermore, it is important to identify individuals who are predisposed to sustaining a concussion or to having an adverse outcome after concussion. This article will discuss the current research on serum biomarkers for concussion, genetic influence on concussion, risk factors associated with concussion predisposition and poor outcome, and practical suggestions for the application of this information in clinical practice.

Adult-onset autosomal dominant leukodystrophy presenting with REM sleep behavior disorder

Adult-onset autosomal dominant leukodystrophy (ADLD) is a slowly progressive hereditary disease of the white matter caused by duplication of the nuclear lamina protein lamin B1 on chromosome 5q23.2.1 Patients usually present in the 4th–5th decade with autonomic symptoms followed by pyramidal and cerebellar dysfunction.2 In ADLD, MRI head reveals symmetric T2-signal hyperintensities in the subcortical white matter, brainstem, and middle cerebellar peduncles.2 REM sleep behavior disorder (RBD) is a parasomnia characterized by dream enactment behavior and REM sleep without atonia.3 It has been reported most commonly with synucleinopathies such as Parkinson disease and may precede the diagnosis by decades.3 To our knowledge, RBD has not been reported with leukodystrophies. Herein we report a case of ADLD presenting with RBD as the initial symptom.

A simple technique to restore needle patency during percutaneous lavage and aspiration of calcific rotator cuff tendinopathy.

Calcific rotator cuff tendinopathy caused by symptomatic calcium hydroxyapatite crystal deposition is a well‐established cause of shoulder pain. In refractory or acutely symptomatic cases, sonographically guided percutaneous lavage and aspiration can significantly reduce pain in approximately 60%‐92% of cases. Although the complication rate of sonographically guided percutaneous lavage and aspiration is apparently low, needle clogging attributable to impacted calcific debris has been described by several authors and in our experience can occur in daily practice. Traditionally, an inability to relieve the obstruction via needle repositioning or increased syringe plunger pressure has required needle removal and replacement. In this article, we outline a simple technique that can be used to restore patency of the obstructed lavage needle without necessitating needle removal and replacement.

Video fluoroscopic analysis of the effects of three commonly-prescribed off-the-shelf orthoses on vertebral motion.

Study Design. Fluoroscopic assessment of the effects of commercially available spinal orthotics on lumbar vertebral motion as subjects performed flexion and extension maneuvers. Objective. To quantitate the effects of 3 commonly available, off-the-shelf, soft, and semirigid spinal orthoses on lumbar spinal motion. Summary of Background Data. Commercially available soft and semirigid orthoses are widely prescribed for patients with low back pain and, at times, following surgery. Despite this use, surprisingly little is known about the magnitude of their effects on lumbar vertebral motion. Methods. Ten subjects (6 men and 4 women) with an average age of 27.0 ± 5.3 years, underwent videofluoroscopic imaging as they performed a full flexion/extension cycle. Assessments, during which the subjects were unbraced or wearing either a soft lumbrosacral orthosis (LSO), a semirigid LSO, or a semirigid thoracolumbrosacral orthosis (TLSO) were performed in random order. Images were obtained at a rate of 3.75 Hz and digitally processed to determine the sagittal rotation of the L3–L5 vertebral bodies. Results. Each of the braces produced a statistically significant reduction in overall lumbar motion during the flexion maneuver (P = 0.007) but none had a detectable effect during extension. Relative effectiveness varied by vertebral level. At the L3–L4 level, only the TLSO had a statistically significant effect on intervertebral flexion movement (32%, P = 0.003). At the L4–L5 level all the orthoses were effective (and statistically indistinguishable) in their ability to reduce intervertebral flexion movements ranging from 48% for the semirigid TLSO to about 15% to 20% for the 2 LSOs. No effects were noted for any of the orthoses at the L5–S1 level. Conclusion. Commercially available soft and semirigid orthotics can have significant effects on lumbar vertebral body motion at the L3–L4 and L4–L5 levels.

The Prevalence of Fluid Associated With the Iliotibial Band in Asymptomatic Recreational Runners: An Ultrasonographic Study

To evaluate the prevalence and distribution of fluid associated with the iliotibial band (ITB) in asymptomatic recreational runners.

Advanced Ultrasound-Guided Interventions for Tendinopathy

Tendinopathy is increasingly recognized as an important cause of musculoskeletal pain and disability. Tendinopathy is thought to be principally a degenerative process, rather than inflammatory as was traditionally believed. Consequently, traditional tendinopathy treatments focused solely on decreasing inflammation have often been ineffective or even harmful. The advancement of ultrasonography as for guidance of outpatient musculoskeletal procedures has facilitated the development of novel percutaneous procedures for the treatment of tendinopathy, mostly by using mechanical intervention to stimulate regeneration. Several of these techniques, including percutaneous needle tenotomy, percutaneous ultrasonic tenotomy, high-volume injection, and percutaneous needle scraping, are reviewed in this article.

Musculoskeletal Ultrasound in Physical Medicine and Rehabilitation

This review article discusses the current role of ultrasound in the modern physiatric practice, both as a complementary diagnostic tool and as a modality for intervention guidance. Indications, limitations, techniques, guidelines for utilization, new training and credentialing initiatives, and potential for future research are discussed. Indications include the role of diagnostic ultrasound and ultrasound-guided interventions in the different areas of physical medicine and rehabilitation (PM&R) including musculoskeletal, pain, neuromuscular medicine/electrodiagnosis, pediatrics, and central nervous system rehabilitation. Guidelines for utilization including recently published articles pertaining to the role of ultrasound in diagnosis of musculoskeletal conditions are reviewed. Training and credentialing are reviewed, specifically the introduction and evolution of ultrasound training in PM&R residency programs as well as recently introduced practitioner certification and practice accreditation processes. Potential for research is discussed including the need for further evaluation of cost-effectiveness, accuracy and efficacy of these techniques when compared to current standards of practice.

Sonographic Visualization of the Posterior Cutaneous Nerve of the Forearm: Technique and Validation Using Perineural Injections in a Cadaveric Model

To determine the ability to sonographically identify the posterior cutaneous nerve of the forearm (PCNF) and its distal epicondylar branches using sonographically guided perineural injections in an unembalmed cadaveric model.

External Iliac Artery Vasospasm in an Elite Female Runner.

A 33-year-old elite female runner presented to a tertiary care sports medicine clinic with a 2-year history of progressive anterior thigh and circumferential leg pain with associated foot paresthesias brought on by high-intensity running. She had both external iliac artery vasospasm and chronic exertional compartment syndrome. External iliac artery vasospasm is a rare cause of exertional leg pain, particularly in the running population. This case highlights the unique features of this condition, addresses the multidisciplinary approach that led to the accurate diagnoses, and demonstrates that more than 1 etiology for exertional leg pain can coexist in an athlete.

Poster 264: Nonoperative Management of a Complete Adductor Longus Tendon Tear in a Collegiate Football Player: A Case Report

Disclosures: Kelly Smith: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: 44-year-old woman with Holt Oram Syndrome, the congenital absence of bilateral thumbs including thenar eminences, presented to rule out bilateral carpal tunnel syndrome. Description: Patient with congenital absence of bilateral thumbs and thenar eminences presented 10-month history of bilateral hand numbness, weakness, mild edema greater in right hand, positive nighttime symptoms, and dropping objects. Symptoms present in all four fingers without alleviating or aggravating factors. Physical exam was noteworthy for asymmetric length of upper extremities, irregular muscle contouring of forearms, and widened neck. Patient uses index fingers for grasping, has decreased active/passive range of motion of wrists in extension, but has 5/5 strength in bilateral upper extremities, with negative Phalen’s and positive Tinel’s sign. Xray imaging revealed congenital absence of the thumb and absence of normal flaring of the distal radius with fusion of the scaphoid and lunate bilaterally. MRI was unavailable; US evaluated musculoskeletal aspects and median nerve size. Patient also had a history of diabetes and hypothyroidism. Setting: Outpatient electromyography (EMG) clinic. Results: Nerve conduction studies (NCS) demonstrated bilateral median sensory mononeuropathy at the wrist with no response on the right and decreased amplitude on the left. A complete electrodiagnostic evaluation was not possible due to atypical anatomy. No electrodiagnostic evidence of ulnar mononeuropathy or generalized peripheral neuropathy was noted. Data were consistent with bilateral median mononeuropathy at the wrist. Discussion: Holt Oram Syndrome affects approximately 1:100,000 live births. The patient’s clinical presentation and NCS were consistent with median mononeuropathy at the wrist, despite congenital anatomic variation of missing bilateral thumbs and thenar eminences. Conclusions: This case demonstrates how to diagnose median neuropathy at the wrist without the ability to test median motor recording from the abductor pollicis brevis muscle in a patient with missing thumbs due to Holt Oram Syndrome. Level of Evidence: Level V