UMEM Educational Pearls - By Brian Corwell

The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis

Concussions make up 70% to 90% of all traumatic brain injuries

During the recovery process, prolonged rest has been shown to slow recovery and precipitate secondary symptoms of fatigue, reactive depression, anxiety and physical deconditioning.

As a result, a gradual increase in low-level activities has been encouraged after 24-48 h of rest.

23 articles for a total of 2547 concussed individuals, 49% female, both kids and adults. Included both sport related and non-sport related concussion.

None of the studies reported any adverse events in symptomatic participants after subthreshold exacerbation aerobic exercise.

Duration ranged from 15-20 minutes per session or until symptom exacerbation.

Subthreshold activity generally targeted 80% of max heart rate achieved during a graded symptom threshold test.

Every study showed improved concussion symptom scores with a physical activity intervention.

Most common treatment duration was 6 weeks (Range 1-12 wk)

Best outcomes if initiated with 2-3 weeks after injury but intervention beneficial in chronic phases of recovery as well.

The intervention of physical activity decreases post concussion symptom scores and the overall effect across studies was large and positive.

Optimal intensity, duration and time to initiation of exercise intervention needs further investigation.

Exercise effect is likely multifactorial including:

1. Improvement in cerebral autoregulation
2. Increases levels of brain-derived neurotrophic factor which promotes neuron growth and repair
3. May reduce fear of exercise and perception of illness and injury
4. Reintegration with social environments and support

One of the best effects I have seen in treating these patients is that active exercise allows a proactive approach to patient recovery. Patients become less focused on every minor symptom or irregularity.

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Exertional Heat Stroke at the Boston Marathon

Study goal: To assess for possible associations between exertional heat stroke (EHS) and sex, age, prior performance and environmental conditions

Data sourced from 2015-2019 Boston Marathon races.

Why Boston:  The Boston marathon is one of the only marathons that require qualifying times for entry for a majority of runners which yields a high proportion of faster than average runners. The race is frequently characterized by extreme weather conditions, including warm and humid days.

Results: 136,161 race starters. Incidence of EHS was 3.7 cases per 10,000 starters.

                Note: Twin Cities Marathon found 3 cases per 10,000 runners.

Mean age of runners was 43.3. Female 45%, male 55%.

Significant associations between sex and age, sex and start wave and age group and start wave.

Sex not associated with increased EHS incidence.

Age < 30 and assignment to the first 2 waves (faster runners) was significantly associated with increased EHS.

All cases of EHS occurred with average wet bulb globe temperatures (WBGT) were 17° – 20° C.

Linear correlation between EHS and incidence in addition to increases in WBGT from start to peak.

72.5% of cases were race finishers. Non finishers presented after mile 18.

Almost 30% developed post treatment hypothermia.

Almost 2/3rds were discharged directly, the remainder required hospital transport.

Authors estimate needing at least 4 ice water immersion tubs per 10,000 runners with potential of needing 8-10 if race day is humid.

Conclusions: Overall, EHS represented a small percentage of medical encounters but required significant resources.

Younger and faster runners are at high risk of EHS.

Greater increases in heat stress from start to peak worsens risk.

Definitions: WGBT - The Wet Bulb Globe Temperature (WBGT) is a measure of the heat stress in direct sunlight, which takes into account: ambient temperature, relative humidity, wind speed, sun angle and cloud cover (solar radiation). This differs from the heat index, which takes into consideration temperature and humidity and is calculated for shady areas. 

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Study Question:  A recent study investigated whether a history of concussion caused greater disturbances in cerebral blood flow and cerebral white matter after subsequent concussions.

Background:  Researchers used changes in blood flow in the cingulate cortex and white matter microstructure in the corpus callosum as evidence of underlying brain injury.

Population:  228 athletes with an average age of 20.  Divided into 2 groups, recent and non-recent concussion.

61 athletes had a recent (uncomplicated) concussion and 167 did not. Within the first group, 36 had a history of concussion. Within the second group, 73 had a history of concussion.

Note: researchers used “self-reported” history of concussion in study.

Intervention: Researchers took up to 5 MRI scans of each recently concussed athlete. This encompassed the acute phase of injury (1 to 7 days post-injury), the subacute phase (8 to 14 days), medical clearance to return to sport, one month post return and one year post return.

The sport concussion assessment tool (SCAT) was also used to evaluate effects of history of concussion on symptoms, cognition and balance.

Results:  One year after a recent concussion, those athletes with a history of concussion had sharper declines in blood flow within one area of the cingulate cortex compared to those without a history of prior concussions.

Athletes with a history of concussion had an average cerebral blood flow of 40 mL per minute, per 100 grams of brain tissue.

Athletes without a history of concussion had an average cerebral blood flow of 53 mL per minute, per 100g of brain tissue.

In the weeks following concussion, those athletes with a prior history of concussion had microstructural changes in the corpus callosum.

 Effects were seen in the absence of differences in SCAT domains or time to return to sport.

Conclusion:  Athletes with a history of concussion experience identifiable injury to their brains as evidenced by changes in blow flow and white matter microstructure.  Athletes “cleared” for return to play following concussion may be at greater risk of subtle patterns of brain injury versus their peers.

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Chronic Exertional Compartment Syndrome (CECS)

Similar pathology to acute compartment syndrome except symptoms are related to activity (frequently running) and abate with rest.

95% involve lower extremity

Inappropriately elevated tissue pressure in one or more lower leg compartments associated with exercise

Anterior compartment most frequently involved

As tissue pressure increases, local perfusion is decreased. This leads to symptoms of pain, pressure, cramping and paresthesias.  

Also commonly associated with team sports such as soccer, lacrosse and field hockey.

More likely in competitive athletes than recreational.

Patient will be symptom free at time of ED evaluation

Make diagnosis of CECS with history

1. Pain must be induced with exercise
2. Usually limited to a single compartment, frequently the anterior
3. Pain occurs at predictable time in exercise and forces athlete to stop running
4. Pain resolves with rest
5. If witnessed, tenderness is present only in the involved compartment and not elsewhere

Diagnosis with compartment pressure measurements done in office with treadmill exercise.

Non operatively, gait retraining programs have been shown to help symptoms. Appropriate if symptoms are mild.

Surgical treatment involves a minimally invasive fasciotomy

Post surgery success rates are between 63-100% with recurrence rates up to 20%

Low dose ketamine was compared  to morphine for the treatment of patients with long bone fractures

126 patients with upper and lower extremity long bone fractures were divided into two treatment groups

1. IV morphine at a dose of 0.1 mg/kg
2. IV ketamine at a dose of 0.5mg/kg

Pain scores were compared pre and at 10 minutes post treatment

Pain severity significantly decreased in both groups to a similar degree

Increase adverse effects (emergence phenomenon) noted in ketamine group but all effects resolved spontaneously without intervention.

Conclusion:  Analgesic effect of ketamine is similar to morphine in patients with long bone fractures.

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NSAIDs for lower back pain (LBP)

NSAIDs are recommended for first line treatment of lower back pain.

Ibuprofen (600mg), ketorolac (10mg) and diclofenac (50mg)  were compared.

3 arm, double-blinded study in an ED population with musculoskeletal LBP.

66 patients in each arm.

Outcomes via telephone interview 5 days later

Primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ).

Lower scores indicate better LBP functional outcomes.

Secondary outcomes:  Pain intensity and the presence of stomach irritation.

Baseline characteristics similar in 3 groups.

Results:  No significant differences between 3 arms in primary outcome.

Ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34).

Ketorolac group reported less overall pain intensity at day 5.

Ketorolac group reported less stomach irritation that the other drugs ((p < 0.01).

While there was no differences in terms of functional outcomes, there may be a benefit of using ketorolac in terms of overall pain intensity and stomach irritation. This would benefit from further study in a larger population in order to draw definitive conclusions.

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You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.

You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.

While you may be right, there is increasing recognition of an alternative diagnosis

Exercise-induced laryngeal obstruction (EILO)

During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.

This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.

While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.

Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.

Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.

In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.

Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.

Hand elevation test

• Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.

• This phenomenon prompted the idea of developing a simple hand elevation test to diagnose carpal tunnel syndrome. 

• To perform: Ask the patient to elevate both arms in the air for one minute. Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose.

• A positive test reproduces symptoms of carpal tunnel syndrome. 

• The hand elevation test has a high sensitivity (75-86%) and specificity (89-98.5%) and may be comparable to or likely better than other provocative tests.

https://www.youtube.com/watch?v=IO2qC5qHVFE

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Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are highly sensitive (84-100%) for spinal infections and are observed in >80% with vertebral osteomyelitis and epidural abscesses.

ESR 

Most sensitive and specific serum marker, usually elevated in both spinal epidural abscess (SEA) and vertebral osteomyelitis.  

ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients

Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)

CRP 

Not highly specific

Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR (elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA)

Better used as a marker of response to treatment.  

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Erythrocyte sedimentation rate (ESR) for spinal infection

Sensitive for spinal infection but not specific

Elevated ESR is observed in greater than 80% of patients with vertebral osteomyelitis and epidural abscess

ESR is the most sensitive and specific serum marker for spinal infection

               Usually elevated in acute presentations of SEA and vertebral osteomyelitis

ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients

Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)

Infection is unlikely in patients with an ESR less than 20 mm/h.

Incorporating ESR into an ED decision guideline may improve diagnostic delays and help distinguish patients in whom MRI may be performed on a non-emergent basis

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Study Question:  A recent study investigated whether adult patients presenting to the ED with a diagnosis of mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms.

Setting:  Randomized controlled trial conducted in three Canadian EDs. Consecutive, adults (18–64 years) seen in ED with a mTBI sustained within the preceding 48 hours.

The intervention group received discharge instructions prescribing 30 minutes of daily light exercise.

The control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution.

Outcome:  The primary outcome was the proportion of patients with postconcussion symptoms at 30 days,

A total of 367 patients were enrolled. Median age was 32 years Male 43%/Female 57%.

Result:  There was no difference in the proportion of patients with postconcussion symptoms at 30 days. There were no differences in median change of concussion testing scores, median number of return PCP visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35).

Conclusion

Prescribing light exercise for acute mTBI, demonstrated no differences in recovery or health care utilization outcomes.

Extrapolating from studies in the athletic population, there may be a patient benefit for light exercise prescription.

Make sure that the patient is only exercising to their symptomatic threshold as we recommend with concussed athletes. Previous studies have shown that athletes with the highest post injury activity levels had poorer visual memory and reaction time scores than those with moderate activity levels.

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Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures

A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to

1. Home removal of splint and physician follow-up as needed (home management)  

Versus

2. Prescribed PCP follow-up in 1-2 weeks

Noninferior study

Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children

This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention

Outcome: functional recovery at 3 weeks

Randomized controlled trial at a tertiary care children’s hospital

All radiographs reviewed by pediatric radiologist with MSK specialization

149 patients. Mean age 9.5 years. 54.4% male

Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer

Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks

Outcomes:  Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.

Conclusion:  Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.

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What time of day is best for exercise to achieve weight loss goals?

Working out in the morning has traditionally held the edge, especially if done on an empty stomach.

Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.

Switching to a morning workout may also decrease appetite throughout the day.

Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain. 

Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.

However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.

Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.

Study:  32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:

In the morning (8.00–10.00 a.m., N = 12) OR

In the afternoon (3.00–6.00 p.m., N = 20)

Test: Graded cycling test with ECG monitoring until exhaustion

Results:  Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.

Conclusion:  Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.

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Exercise and Covid-19

The majority of COVID-19 cases fall into the mild-to-moderate category, with symptoms lasting less than 6 weeks on average.

The disease presents a challenge for clinicians seeking to offer counsel for patients wishing to return to exercise.

A recent cohort study in Germany looked at 100 patients (avg. age 49, 53% male) who had recovered from Covid-19 infection.

Most had been healthy, with no pre-existing medical conditions, before becoming infected. 

The group had cardiac MRI (CMR) performed.

Average time interval between Covid-19 diagnosis and CMR was 71 days.

Cardiac involvement was seen in 78% of patients and ongoing myocardial inflammation in 60%.

Evidence based return to activity guidelines being developed are more conservative than in the past with other viral infections

https://link.springer.com/article/10.1007/s11420-020-09777-1/tables/1

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A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.

Outcome data is very interesting for our practice, deviates from traditional teaching.

Population:  1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)

Antibiotics queried:  Seven total oral antibiotics of mixed class:

1. Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)
2. Other:  Amoxicillin, amoxicillin-clavulanate, azithromycin and cephalexin.

Outcome measures:  all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)

Results:  Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk

Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.

The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!

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Chief complaint:  “My hip snaps when I exercise”

Both athletes and non-athletes may report a “snapping” sound with certain movements

This may affect up to 10% of the population

May be associated with activities than involve repetitive hip flexion

Symptoms may be due to an internal or an external cause

External causes are usually due to a tendon passing over a bony prominence

This can be felt as either an audible sensation and/or even a palpable snap

This may or may not involve pain or discomfort

This is most commonly due to a benign cause

During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.

Alternatively, the hamstring tendon may pass over the ischial tuberosity

There are several other causes with similar mechanisms

Symptoms are usually minimal and not serious

This can be reproduced on bedside clinical exam

               Ask the patient to identify the area of snapping with one finger which will help with anatomic localization

First line therapy is physical therapy which focuses on:

Improving muscle length if muscle is too tight   OR

Improving neuromuscular activation if problem is due to excessive muscle activation

The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested. 

This test is not very sensitive overall, but especially in concussed athletes.

Many concussed athletes are able to stand relatively stable despite their neurologic injury.

In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).

A) Romberg

B) Single leg stance

21. Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
21. NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg

C) Tandem Stance

https://www.researchgate.net/profile/Boaz_Saffer/publication/309591285/figure/fig2/AS:669641529626644@1536666390860/Balance-Error-Scoring-System-BESS-performed-on-firm-surface-A-C_W640.jpg

Have patient stand quietly with hands on hips

Have patient close eyes and start 20 second trial

If error occurs tell patient to return to start as quickly as possible

Examples of errors: opening eyes, lifting hands, falling out of position

A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

How do we evaluate for biceps tendonitis?

1. Tenderness to palpation in the bicipital groove
2. Speed’s test
3. Yergason’s test

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

• Arm is supinated and extended and elevated against examiner’s  downward resistance
• https://youtu.be/N00gA4Pvsbw

Yergason’s test

• Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
• Patient attempts to supinate and externally rotate arm against resistance
• https://youtu.be/rQ2Mp6aSi88

Ulnar Collateral ligament injuries of the elbow

Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow

This can lead to valgus instability similar to what can occur in the knee

Overhead throwing places a significant valgus stress on the elbow

Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports

In the acute setting may be seen after an elbow dislocation

History includes a “pop” and medial elbow pain following throwing activities

In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.

The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion

One classic test for UCL instability is the milking maneuver

Patient may be sitting or standing

Patient’s forearm is supinated and elbow flexed at 90 degrees

A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line. 

Instability, pain or apprehension at the UCL is considered a positive test

https://www.youtube.com/watch?v=gbn24X_qqn0

Carpal Tunnel Syndrome (CTS)

The hallmark of classic CTS:  pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.

The symptoms of CTS are typically worse at night and often awaken patients from sleep.

Fixed sensory loss is usually a late finding

Involves the median-innervated fingers BUT spares the thenar eminence.

This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.

Consider a more proximal lesion in cases involving sensory loss in the thenar eminence

            Example: pronator syndrome