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Poster 159 Adverse Childhood Experiences, Musculoskeletal Disorders and Disability
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with normal flexor hallucinus longus, but concurrent cysts and edema within the anterior calcaneus. The patient was prescribed physical therapy with an occupation/ballet-focused therapist and told to follow-up as an outpatient. Setting: Quaternary care academic hospital. Results: The patient had an isolated posterior tibialis tenosynovitis without concurrent flexor hallucis longus injury that improved with focused therapy to strengthen her kinetic chain through strengthening of ankle inversion, intrinsic foot muscles, and external hip rotation to prevent pronation or “rolling out of foot.” Discussion: In ballet, posterior tibialis tendinopathy often arises from a combination of excessive pronation during jumping/propulsion and decreased peroneus longus strength which leads to “rolling out of foot.” Ballet dancers are classically known to have FHL “dancer’s tendinitis” injuries secondary to repetitive plantar flexion push-off maneuvers of the forefoot. Conclusions: To our knowledge, this is a unique case of an isolated posterior tibialis tenosynovitis causing the ballerina’s symptoms instead of the more common flexor hallucis longus injury with relief with focused therapy. Poster 157 Evaluation of the Role of Ultrasonography in the Diagnosis of the Myofascial Neck Pain. Antonio Stecco, MD (University of Padua, Padua, Italy); Marta Imamura, MD, PhD; Carla Stecco, MD. Disclosures: A. Stecco, No Disclosures. Objective: Myofascial pain is a very common pathology and the most frequent localization of this pain is the neck region. The diagnosis is actually only clinical. With this study, we tried to objectify the diagnosis of myofascial pain with ultrasonography. Setting: We compared the morphometric and clinical data of 25 healthy subjects and 28 patients with chronic neck pain. We analyzed with 10Mhz ultrasonography the fascia thickness of sternal ending of the SCM and of scalene medio muscle. Some authors have described the deep fascia as a multilayer structure. These sub-layers are possible to recognize in most regions of the body, but not in the SCM. All subjects were analyzed also with the goniometer (for the active and passive cervical ROM) and administered the Neck Pain Questionnaire before treatment, after physiotherapy and at 3- and 6-month follow up. Results: In the patients, the mean value of the fascial thickness in the upper and lower side were respectively, 0.157 cm and 0.124 cm in the left SCM; in the left scalene were respectively, 0.1 cm and 0.105 cm; in the right SCM were respectively, 0.151 cm; 0.114 cm; in the right scalene were respectively, 0.118 cm; 0.130 cm. There were significant statistical differences with the normal subject in the thickness of the upper side of the SCM fascia (P value .06 lf; .035 rt) and of the lower and upper side of the rt scalene fascia (P⫽.031; P⫽.031). At the end of the treatment and at 3- and 6-month follow up, the patients refer a significant decrease of the pain. We observed a significant decrease in the thickness of the fascia at the end of the treatment (P⬍.05) and at 3 (P⬍.005) and 6 months (P⬍.005). The analysis of the thickness of the sub-layers of the fascia showed a statistical decrease of the loose connective tissue at the end of the treatment (P⫽.0001) at 3 months (P⫽.0003) and at 6 months (P⫽.0003). There wasn’t any variation in the thickness of the collagen layers of the fascia. Conclusions: Ultrasonography is helpful in the diagnosis of myofascial pain. Visualizing a thickness of the SCM fascia bigger
PRESENTATIONS
then 0.15 cm is correlated with stiffness and myofascial etiology of chronic neck pain. The increase of the fascia thickness is correlated only at the thicker layer of loose connective tissue. Poster 158 Isolated Teres Minor Atrophy in Quadrilateral Space Syndrome: A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); Madhuri Dholakia, MD. Disclosures: A. Sinha, No Disclosures. Case Description: A 56-year-old man presented with a 2-year history of neck and right shoulder pain. He denied any upper extremity radicular pain but did report mild paresthesias in his hands. He denied any bowel, bladder, or balance disturbance. On examination, the patient was neurologically intact without evidence of upper motor neuron signs. He did have mild weakness in right shoulder strength along with positive shoulder impingement signs. MRI of the cervical spine showed evidence of C6-7 foraminal stenosis. The patient had undergone physical therapy and cervical epidural injections with marginal improvement of his symptoms. MRI of the right shoulder revealed mild supraspinatus tearing and fatty atrophy of the teres minor. Setting: Outpatient orthopedic practice. Results or Clinical Course: Electrodiagnostic testing of the right upper extremity showed normal nerve conduction and needle studies, except for denervation found only in the teres minor; there was no denervation noted in the cervical paraspinals or remainder of the right upper extremity. Discussion: Quadrilateral space syndrome (QSS) is caused by compression of the posterior humeral circumflex artery and axillary nerve or one of its major branches in the quadrilateral space. Symptoms include a dull intermittent ache localized in the posterior and lateral shoulder. These symptoms are exacerbated by active and resisted abduction and external rotation of the humerus. Paresthesias may occur in the cutaneous sensory distribution of the axillary nerve, overlying the deltoid muscle. Diagnosis can be made by MRI of the shoulder, electrodiagnostic studies, and CT arteriogram. Treatment includes rest, physical therapy, and NSAIDs, but surgical decompression may be considered in refractory cases. Conclusions: We present a rare case of right shoulder pain and weakness secondary to isolated teres minor atrophy from axillary nerve injury within the quadrilateral space. Clinicians should consider this syndrome in patients with shoulder pain and weakness, and should order MRI and electrodiagnostic studies for further evaluation. Poster 159 Adverse Childhood Experiences, Musculoskeletal Disorders and Disability. C. Miryam Schussler-Fiorenza, MD, PhD (Thomas Jefferson University, Philadelphia, PA, United States); Margaret Stineman, MD; Dawei Xie. Disclosures: C. Schussler-Fiorenza, No Disclosures. Objective: To examine the effect of childhood adversity on musculoskeletal disorder prevalence rates and self-reported musculoskeletal-related activity limitations and participation restrictions. Design: We analyzed Behavioral Risk Factor Surveillance System (2009-2010) data, a population-based telephone survey. Statistical analyses accounted for the complex survey design to obtain appro-
PM&R
priately weighted prevalence and odds ratio estimates. The Adverse Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional) and family dysfunction (exposure to domestic violence, living with mentally ill, substance abusing, or incarcerated family member). Setting: Six U.S. States: Arkansas, Louisiana, New Mexico, Tennessee, Washington, Wisconsin. Participants: Community-dwelling adults ages ⱖ18 (n ⫽ 30,059). Interventions: Not Applicable. Main Outcome Measures: Self-reported musculoskeletal (MSK) disorder prevalence; MSK-disorder- related disability measured as: activity limitations, work and social participation restrictions. Results: The prevalence of any ACE was 59% and of 4⫹ ACEs was 15%. The age-adjusted MSK-disorder prevalence increased from 21% for those with no ACEs to 36% for those with 4⫹ ACEs. In those with MSK-disorders (n⫽9354), the percent reporting activity limitations increased from 46% (no ACEs) to 59% (4⫹ ACEs.). The percent reporting work and social restrictions increased from 25% (no ACEs) to 44% (4⫹ ACEs) and from 40% (no ACEs) to 57% (4⫹ ACEs) respectively. In logistic regression analyses adjusting for demographic factors (sex, age, education, marital status, income), those reporting 1, 2, 3, and 4⫹ ACEs had an increased OR (95% confidence interval) of MSK disorders of 1.14 (1.05-1.24), 1.53 (1.33-1.76), 1.84 (1.58-2.13), 2.43 (2.15-2.74) respectively, compared to those reporting no ACEs. Those with MSK-disorders and 4⫹ ACEs also had an increased adjusted odds of MSK-related activity limitations [1.6 (1.4-2.0)], work [1.9 (1.5-2.4)] and social [1.6 (1.3-2.0)] participation restrictions compared to those with no ACEs. Conclusions: Adverse childhood experiences have a graded effect on musculoskeletal disorder prevalence and also magnify the disability associated with these disorders. A better understanding of this link will help physicians improve functioning in those affected by childhood adversity and musculoskeletal disorders. Poster 160 Prolotherapy in Charcot-Marie-Tooth Disease to Relieve Pain and Stabilize the Lateral Ankle Ligaments: A Case Report. Christopher Karam (Medstar National Rehabilitation Hospital, Washington, DC, United States); Victor Ibrahim, MD; Dane Pohlman, DO; Vikramjeet Saini, MD; Parag Shah. Disclosures: C. Karam, No Disclosures. Case Description: The patient is a 44-year-old woman with ankle pain secondary to Charcot-Marie-Tooth disease (CMT). She received prolotherapy injections to her left lateral ankle to improve pain and gait stability. She failed several months of conservative management bracing and physical therapy, and was experiencing progressive functional decline. The anterior talofibular ligament, the posterior talofibular ligament and the calcaniofibular ligament were each injected with 2.5 mL of 25% dextrose solution under ultrasound guidance. She had a total of four treatments with prolotherapy over the span of 3 months, each procedure identical to the first. During the procedure, in addition to the standard precautions, the peroneal tendons and cuboidal nerve were avoided to prevent injury.
Vol. 4, Iss. 10S, 2012
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Setting: Free standing rehabilitation hospital. Results or Clinical Course: Following the series of injections she reported near complete resolution of pain and resolution of her subjective ankle instability. Serial ultrasound examination showed a gross increase in cross-sectional area of all three ligaments injected, with improved fibrillar patterning. She was able to return to her activities of daily living following treatment. These included exercising five times a week, playing baseball with her children and swing dancing. Discussion: This case illustrates the patient continued to have pain secondary to joint laxity. This was the result of inadequate repair of the fibrous connective tissue in the ankle. Prolotherapy lead to an increase in the tensile strength of the joint and decrease in its laxity. This off-loaded nearby tissue, decreasing activation of pain receptors, resulting in functional gain and decreased pain. Conclusions: Prolotherapy can provide a significant improvement in patients with CMT regarding overall functionality and quality of life in a safe and effective manner. Poster 161 Large Dorsally Directed Communicating Zygapophyseal Joint Cyst as a Novel source of LBP: A Case Report. Christopher Sahler (Mt. Sinai Hospital, New York, NY, United States); Tanvir Choudhri, MD; Donna D’Alessio, MD; Parag Sheth, MD. Disclosures: C. Sahler, No Disclosures. Case Description: The patient is a 64-year-old man with chronic axial low back pain (LBP) worsening over the past 1 year, which is now severely limiting his ability to ambulate. MRI demonstrated severe facet changes at L4/5 and L5/S1 foraminal stenosis at L4/L5 and L5/S1, and DDD, without significant central canal stenosis or nerve root impingement. A large dorsally directed facet cyst was noted extending from the joint capsule of the right L4/L5 facet joint. The right L4/5 facet was localized under fluoroscopy, and palpation of the area reproduced the patient’s primary pain complaint. A lateral view of contrast injection under fluoroscopy demonstrated contrast flow into the cyst. He underwent bilateral L4-L5 and L5-S1 facet steroid injections under fluoroscopic visualization for pain control. Program Description: 64- year-old man with chronic axial LBP secondary to facet cyst. Setting: Hospital faculty practice outpatient office. Results or Clinical Course: The patient reported complete relief of usual pain immediately after the injection and on subsequent follow-up phone calls at 6 weeks. Discussion: This is the first reported case, to our knowledge, of large dorsally directed zygapophyseal cyst as a potential source of axial LBP. Conclusions: Dorsally directed zygapophyseal cyst may be a potential contributing source of LBP. Poster 162 Sonographically Assisted Diagnosis of Left Rectus Femoris Tendon Tear in a Patient with a Total Knee Arthroplasty: A Case Report. Dane Pohlman, DO (Medstar National Rehabilitation Hospital, Washington, DC, United States); Robert D. Bunning, MD; Victor Ibrahim, MD; Christopher Karam; Cynthia G. Pineda, MD; Fabiolla Siqueira, MD.
with normal flexor hallucinus longus, but concurrent cysts and edema within the anterior calcaneus. The patient was prescribed physical therapy with an occupation/ballet-focused therapist and told to follow-up as an outpatient. Setting: Quaternary care academic hospital. Results: The patient had an isolated posterior tibialis tenosynovitis without concurrent flexor hallucis longus injury that improved with focused therapy to strengthen her kinetic chain through strengthening of ankle inversion, intrinsic foot muscles, and external hip rotation to prevent pronation or “rolling out of foot.” Discussion: In ballet, posterior tibialis tendinopathy often arises from a combination of excessive pronation during jumping/propulsion and decreased peroneus longus strength which leads to “rolling out of foot.” Ballet dancers are classically known to have FHL “dancer’s tendinitis” injuries secondary to repetitive plantar flexion push-off maneuvers of the forefoot. Conclusions: To our knowledge, this is a unique case of an isolated posterior tibialis tenosynovitis causing the ballerina’s symptoms instead of the more common flexor hallucis longus injury with relief with focused therapy. Poster 157 Evaluation of the Role of Ultrasonography in the Diagnosis of the Myofascial Neck Pain. Antonio Stecco, MD (University of Padua, Padua, Italy); Marta Imamura, MD, PhD; Carla Stecco, MD. Disclosures: A. Stecco, No Disclosures. Objective: Myofascial pain is a very common pathology and the most frequent localization of this pain is the neck region. The diagnosis is actually only clinical. With this study, we tried to objectify the diagnosis of myofascial pain with ultrasonography. Setting: We compared the morphometric and clinical data of 25 healthy subjects and 28 patients with chronic neck pain. We analyzed with 10Mhz ultrasonography the fascia thickness of sternal ending of the SCM and of scalene medio muscle. Some authors have described the deep fascia as a multilayer structure. These sub-layers are possible to recognize in most regions of the body, but not in the SCM. All subjects were analyzed also with the goniometer (for the active and passive cervical ROM) and administered the Neck Pain Questionnaire before treatment, after physiotherapy and at 3- and 6-month follow up. Results: In the patients, the mean value of the fascial thickness in the upper and lower side were respectively, 0.157 cm and 0.124 cm in the left SCM; in the left scalene were respectively, 0.1 cm and 0.105 cm; in the right SCM were respectively, 0.151 cm; 0.114 cm; in the right scalene were respectively, 0.118 cm; 0.130 cm. There were significant statistical differences with the normal subject in the thickness of the upper side of the SCM fascia (P value .06 lf; .035 rt) and of the lower and upper side of the rt scalene fascia (P⫽.031; P⫽.031). At the end of the treatment and at 3- and 6-month follow up, the patients refer a significant decrease of the pain. We observed a significant decrease in the thickness of the fascia at the end of the treatment (P⬍.05) and at 3 (P⬍.005) and 6 months (P⬍.005). The analysis of the thickness of the sub-layers of the fascia showed a statistical decrease of the loose connective tissue at the end of the treatment (P⫽.0001) at 3 months (P⫽.0003) and at 6 months (P⫽.0003). There wasn’t any variation in the thickness of the collagen layers of the fascia. Conclusions: Ultrasonography is helpful in the diagnosis of myofascial pain. Visualizing a thickness of the SCM fascia bigger
PRESENTATIONS
then 0.15 cm is correlated with stiffness and myofascial etiology of chronic neck pain. The increase of the fascia thickness is correlated only at the thicker layer of loose connective tissue. Poster 158 Isolated Teres Minor Atrophy in Quadrilateral Space Syndrome: A Case Report. Anupam Sinha, DO (Rothman Institute, Philadelphia, PA, United States); Madhuri Dholakia, MD. Disclosures: A. Sinha, No Disclosures. Case Description: A 56-year-old man presented with a 2-year history of neck and right shoulder pain. He denied any upper extremity radicular pain but did report mild paresthesias in his hands. He denied any bowel, bladder, or balance disturbance. On examination, the patient was neurologically intact without evidence of upper motor neuron signs. He did have mild weakness in right shoulder strength along with positive shoulder impingement signs. MRI of the cervical spine showed evidence of C6-7 foraminal stenosis. The patient had undergone physical therapy and cervical epidural injections with marginal improvement of his symptoms. MRI of the right shoulder revealed mild supraspinatus tearing and fatty atrophy of the teres minor. Setting: Outpatient orthopedic practice. Results or Clinical Course: Electrodiagnostic testing of the right upper extremity showed normal nerve conduction and needle studies, except for denervation found only in the teres minor; there was no denervation noted in the cervical paraspinals or remainder of the right upper extremity. Discussion: Quadrilateral space syndrome (QSS) is caused by compression of the posterior humeral circumflex artery and axillary nerve or one of its major branches in the quadrilateral space. Symptoms include a dull intermittent ache localized in the posterior and lateral shoulder. These symptoms are exacerbated by active and resisted abduction and external rotation of the humerus. Paresthesias may occur in the cutaneous sensory distribution of the axillary nerve, overlying the deltoid muscle. Diagnosis can be made by MRI of the shoulder, electrodiagnostic studies, and CT arteriogram. Treatment includes rest, physical therapy, and NSAIDs, but surgical decompression may be considered in refractory cases. Conclusions: We present a rare case of right shoulder pain and weakness secondary to isolated teres minor atrophy from axillary nerve injury within the quadrilateral space. Clinicians should consider this syndrome in patients with shoulder pain and weakness, and should order MRI and electrodiagnostic studies for further evaluation. Poster 159 Adverse Childhood Experiences, Musculoskeletal Disorders and Disability. C. Miryam Schussler-Fiorenza, MD, PhD (Thomas Jefferson University, Philadelphia, PA, United States); Margaret Stineman, MD; Dawei Xie. Disclosures: C. Schussler-Fiorenza, No Disclosures. Objective: To examine the effect of childhood adversity on musculoskeletal disorder prevalence rates and self-reported musculoskeletal-related activity limitations and participation restrictions. Design: We analyzed Behavioral Risk Factor Surveillance System (2009-2010) data, a population-based telephone survey. Statistical analyses accounted for the complex survey design to obtain appro-
PM&R
priately weighted prevalence and odds ratio estimates. The Adverse Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional) and family dysfunction (exposure to domestic violence, living with mentally ill, substance abusing, or incarcerated family member). Setting: Six U.S. States: Arkansas, Louisiana, New Mexico, Tennessee, Washington, Wisconsin. Participants: Community-dwelling adults ages ⱖ18 (n ⫽ 30,059). Interventions: Not Applicable. Main Outcome Measures: Self-reported musculoskeletal (MSK) disorder prevalence; MSK-disorder- related disability measured as: activity limitations, work and social participation restrictions. Results: The prevalence of any ACE was 59% and of 4⫹ ACEs was 15%. The age-adjusted MSK-disorder prevalence increased from 21% for those with no ACEs to 36% for those with 4⫹ ACEs. In those with MSK-disorders (n⫽9354), the percent reporting activity limitations increased from 46% (no ACEs) to 59% (4⫹ ACEs.). The percent reporting work and social restrictions increased from 25% (no ACEs) to 44% (4⫹ ACEs) and from 40% (no ACEs) to 57% (4⫹ ACEs) respectively. In logistic regression analyses adjusting for demographic factors (sex, age, education, marital status, income), those reporting 1, 2, 3, and 4⫹ ACEs had an increased OR (95% confidence interval) of MSK disorders of 1.14 (1.05-1.24), 1.53 (1.33-1.76), 1.84 (1.58-2.13), 2.43 (2.15-2.74) respectively, compared to those reporting no ACEs. Those with MSK-disorders and 4⫹ ACEs also had an increased adjusted odds of MSK-related activity limitations [1.6 (1.4-2.0)], work [1.9 (1.5-2.4)] and social [1.6 (1.3-2.0)] participation restrictions compared to those with no ACEs. Conclusions: Adverse childhood experiences have a graded effect on musculoskeletal disorder prevalence and also magnify the disability associated with these disorders. A better understanding of this link will help physicians improve functioning in those affected by childhood adversity and musculoskeletal disorders. Poster 160 Prolotherapy in Charcot-Marie-Tooth Disease to Relieve Pain and Stabilize the Lateral Ankle Ligaments: A Case Report. Christopher Karam (Medstar National Rehabilitation Hospital, Washington, DC, United States); Victor Ibrahim, MD; Dane Pohlman, DO; Vikramjeet Saini, MD; Parag Shah. Disclosures: C. Karam, No Disclosures. Case Description: The patient is a 44-year-old woman with ankle pain secondary to Charcot-Marie-Tooth disease (CMT). She received prolotherapy injections to her left lateral ankle to improve pain and gait stability. She failed several months of conservative management bracing and physical therapy, and was experiencing progressive functional decline. The anterior talofibular ligament, the posterior talofibular ligament and the calcaniofibular ligament were each injected with 2.5 mL of 25% dextrose solution under ultrasound guidance. She had a total of four treatments with prolotherapy over the span of 3 months, each procedure identical to the first. During the procedure, in addition to the standard precautions, the peroneal tendons and cuboidal nerve were avoided to prevent injury.
Vol. 4, Iss. 10S, 2012
S245
Setting: Free standing rehabilitation hospital. Results or Clinical Course: Following the series of injections she reported near complete resolution of pain and resolution of her subjective ankle instability. Serial ultrasound examination showed a gross increase in cross-sectional area of all three ligaments injected, with improved fibrillar patterning. She was able to return to her activities of daily living following treatment. These included exercising five times a week, playing baseball with her children and swing dancing. Discussion: This case illustrates the patient continued to have pain secondary to joint laxity. This was the result of inadequate repair of the fibrous connective tissue in the ankle. Prolotherapy lead to an increase in the tensile strength of the joint and decrease in its laxity. This off-loaded nearby tissue, decreasing activation of pain receptors, resulting in functional gain and decreased pain. Conclusions: Prolotherapy can provide a significant improvement in patients with CMT regarding overall functionality and quality of life in a safe and effective manner. Poster 161 Large Dorsally Directed Communicating Zygapophyseal Joint Cyst as a Novel source of LBP: A Case Report. Christopher Sahler (Mt. Sinai Hospital, New York, NY, United States); Tanvir Choudhri, MD; Donna D’Alessio, MD; Parag Sheth, MD. Disclosures: C. Sahler, No Disclosures. Case Description: The patient is a 64-year-old man with chronic axial low back pain (LBP) worsening over the past 1 year, which is now severely limiting his ability to ambulate. MRI demonstrated severe facet changes at L4/5 and L5/S1 foraminal stenosis at L4/L5 and L5/S1, and DDD, without significant central canal stenosis or nerve root impingement. A large dorsally directed facet cyst was noted extending from the joint capsule of the right L4/L5 facet joint. The right L4/5 facet was localized under fluoroscopy, and palpation of the area reproduced the patient’s primary pain complaint. A lateral view of contrast injection under fluoroscopy demonstrated contrast flow into the cyst. He underwent bilateral L4-L5 and L5-S1 facet steroid injections under fluoroscopic visualization for pain control. Program Description: 64- year-old man with chronic axial LBP secondary to facet cyst. Setting: Hospital faculty practice outpatient office. Results or Clinical Course: The patient reported complete relief of usual pain immediately after the injection and on subsequent follow-up phone calls at 6 weeks. Discussion: This is the first reported case, to our knowledge, of large dorsally directed zygapophyseal cyst as a potential source of axial LBP. Conclusions: Dorsally directed zygapophyseal cyst may be a potential contributing source of LBP. Poster 162 Sonographically Assisted Diagnosis of Left Rectus Femoris Tendon Tear in a Patient with a Total Knee Arthroplasty: A Case Report. Dane Pohlman, DO (Medstar National Rehabilitation Hospital, Washington, DC, United States); Robert D. Bunning, MD; Victor Ibrahim, MD; Christopher Karam; Cynthia G. Pineda, MD; Fabiolla Siqueira, MD.