Phorest & Trees 2020-10

Phorest & Trees Sharing the things I’m reading (for better or worse) Hope you enjoy the new look!

AANEM Guidance on the upcoming 2021 CODING CHANGES

Some of you are probably already aware of the upcoming changes to E&M office visit coding. If you’re interested in their take on it, there is a comment by them from earlier this month and this recent Q&A by AANEM. That article led me to this link at the AMA. I plan to do a summary of the new coding in the future but for now, if you’re wondering how it will affect your electrodiagnostic coding, heeeeere’s Carrie!

Physiatrist’s Coding Cheat Sheet

And even though the timing couldn’t be worse (see above), I’ve finally completed a coding cheat sheet that I’ve been slowly putting together. It’s weird because the front is bifold and the back is trifold. So you will have to pick how many folds are important to you. Also, it’s not super easy to understand without some explanation but I offer it anyway. See attached

Pulley my Finger

I know everyone gets jazzed about seeing things on ultrasound, but how cool is it when you can see things intra-operatively… Attached are pictures of the A1 pulley (often attributed to triggering) and the tendon after release. Just for fun.

Goodbye Dr. Weinberger

Those of you who have rotated at the VA may remember Dr. Larry Weinberger, neuropsychologist who performed many of the comprehensive TBI evaluations. He’s been a close friend of us physicians and we are going to miss him as he leaves for retirement. Attached are a few pictures of us (temporarily removing our masks) posing for pictures.

Injectology stuff

This study of PRP + HA is making the Doximity rounds. I really liked what they measured and found but can’t say I totally agree with the conclusions   This study on PRP for RTC disease did not show superiority to corticosteroid injections. It’s always interesting to me that most of these studies have some form of “steroids don’t offer long-term benefit.” I personally never expect them to do so but rather use them as a way of offering temporary relief so that the patient can fully enroll themselves in the therapy which will actually address the underlying issues. We already know that muscle, tendon, and even ligament will remodel if forces are applied through them. I suppose the advocates of “PRP vs steroid” want to kickstart that process.

MILESTONES & BOARD Scores

I remember when my good friend/mentor, Susan Garstang was tasked with coming up with milestones as mandated by the ACGME. Personally, I thought it was an upgrade from what we had before. A recent publication by some reputable names in our field tell us that they do have some predictive value for board scores.

AANEM Meeting 2020

it was fantastic. They set a high bar for what a virtual meeting can be. Residents were asking for the link where is here. I believe you have till the 9th or you can purchase 3 years of access to the lectures. Devin Rubin’s “You make the call” series has everything you need to know about needle emg. I attended a session with Larry Robinson where I directly got to ask him questions that are going to change my practice. (Ben Levy, let’s talk about inching again!)

MUSCLE ULTRASOUND

Other than MSK, there is a lot of research into muscle in various conditions. Attached is an early look at a review from Muscle and Nerve

Natural Medicines

After watching a 1 hour info session on this, the bottom line is this website.

Trees

Burn pit exposure gets some attention. Unfortunately many of my veterans express consternation with this so I found it a good read. An attempt to offer objective benefit of Cupping. Doesn’t matter if you don’t address the underlying issue. DMARD switching and mood disorders Recently a book came out on mental health in musicians reviewed in Mix magazine. I attached a screenshot of that article. Are you stuck in Act1 of your life, or are you ready to take the red pill? The residents shared the cute attachment on the etymology of well-known candy bars.

 

Phorest & Trees 2020-09 B

 

HI all,

Hope everyone is doing well. If you are on Spotify, enjoy some music from my band.  Otherwise, here’s what I’ve been reading.  Hope you enjoy.

-gautam

 

Journal of Bone and Joint Surgery Summaries

4 paragraph Summaries with references to get a quick sense of the current knowledgebase

• Rehab strategies in THA. Is formal PT needed? Does prehabilitation work?
• Adhesive capsulitis Is stretching enough>? Which stretches? Injection?
• CMC OA etc

Injections

• Attached is an editorial critically addressing the role of intra-articular placebo and limitations of existing guidelines in answering the question of whether to inject or not to inject.
• Nothing has really changed in terms of practice based on 20% response rate from 3400 ASSM surveyed: It appears that triamcinolone and methylprednisolone are the most commonly‐used corticosteroids for sports medicine physicians; most physicians use 21‐40mg of corticosteroid for all injections, and lidocaine is the most‐often used local anesthetic; very few use ropivacaine. Over a third of respondents used high‐dose (>40mg triamcinolone or methylprednisolone) for at least one joint or bursa.
• Trigger point injections are safe…aren’t they?
• Degenerated meniscus? Stick some fat in it. Thoughts?
• Did you ever notice that some of these veterans with bone on bone OA have no pain? Well it aint just veterans… residents will benefit from reading the lit review in the background section to understand the long-standing (no pun intended) issues with imaging in OA

Hematoma Risk after Needle EMG with NOAC

Attached is a study looking at risk of Hematoma after newer oral anticoagulant use

 

AANEM STUFF  You guys specifically asked for more AANEM updates. So here they are.

• The 2020 annual meeting is full of interesting stuff, is virtual, and is super affordable this year. Our residents should be able to attend for free. Here are the details of the schedule.
• There is a new ultrasound certification through the AANEM
• I will follow up with things learned at the conference

Evaluation of persons with suspected lumbosacral and cervical radiculopathy part II

• Attached is part 2 of the Dillingham et al Monograph
• See prior emails for part 1

ADA Issues New Guidelines for Pharmaceutical Management of Type 2 Diabetes

This is a quick read and very high yield. Being diabetic myself, I was interested to know what has now become the standard. Us old guys didn’t learn in medical school about SGLT2 inhibitors, GLP-1 Ras, and DPP-4 inhibitors. But these medications have changed the face of diabetes.

 

The Empathy Gap

To some extent this is what we are taught — to compartmentalize and dissociate in order to stay focused on the delivery of care — but is it doing us any favors?

 

Fellowship is popular among physiatrists:  The results of this survey demonstrate that majority of graduating residents are matriculating into fellowship training with pain, spine, and/or sports medicine being among the top choices.

 

Opening for Chief of SCI Position Memphis TN VA: For any further information, please contact Anita R. Patel via email @ Anita.Patel1@va.gov or via phone @ 901-577-7346.

Please send CV/Resumes of interested candidates to L’Keyla.Walker@va.gov.

 

 

 

Gautam Malhotra MD

Physical Medicine & Rehabilitation Service - VANJ Health Care System

Director of Strategic Development

Director of VANJ Polytrauma

NJ Liaison to VA Amputee System of Care

Clinical Associate Professor, Rutgers New Jersey Medical School

Diplomate, American Board of Physical Medicine & Rehabilitation

Certified by American Board of Electrodiagnostic Medicine

Certified in Subspecialty of Neuromuscular Medicine

Certified in Subspecialty of Brain Injury Medicine

Phorest & Trees 2020-09

 

Hope you all had a wonderful labor day weekend.

 

Phorest

 

• Attached are 2 summaries of the VA’s “OWN THE MOMENT” initiative offering seemingly easy but important points to consider as we move through our day.
• Attached is an excellent introduction to peripheral neuropathies by on of the greats (Dyck) for a practical approach to diagnosis and management.
• The AMA has published an update to CPT that includes two new codes associated with the pandemic. See here for the AANEM description.

 

Trees

• The C-Brace is ottobock’s passive hydraulic microprocessor orthosis. Allows any orthosis design as long as the C-brace is attached. It is sealed but no water proof. Contraindicated in >10 deg hip flexion contracture, excessive knee flexion contracture, in ability to translate femur anteriorly. Variable stance and swing. Allows for walking backwards, slopes, descending stairs. Adjustment via app. 225 pound limit.
• At the 2019 AANEM, during a “Challenging Cases” roundtable discussion, the “Neck Tornado Test” was brought up as a supplement to the Spurling maneuver. Attached is my summary of the article describing it (Juyeon Park et al International Journal of Medical Sciences 2017; 14(7): 662-667. doi: 10.7150/ijms.19110)
• Antidiabetics, Statins, and the Risk of Amyotrophic Lateral Sclerosis (ALS) !!

Antioxidants, although great in general, could be getting in the way of the beneficial effects of exercise.
Vitamin D seems to have a beneficial effect on falls. # needed to treat is 15 (to prevent 1 fall) and the dose is 800IU.

gene involved in nerve breakdown?
learning about Resveratrol for my uncle.

Vertebral Endplate

A great review of vertebral endplate
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16816945#CR15

Introduction and conclusion From Bone. 2009 Feb;44(2):372-9. Epub 2008 Nov 11

The cranial endplate of thoracolumbar vertebrae is injured more often than the caudal [1], [2], [3], [4], [5] and [6], and anterior wedge fractures in elderly patients usually involve the cranial rather than caudal endplate [7] and [8]. Schmorl's nodes, which represent a bony reaction to endplate defects, are also more common in the cranial endplate [4]. Mechanical experiments on cadaveric spines suggest that the cranial endplate is more vulnerable to compressive damage than either the caudal endplate or the intervertebral disc [9], and indentation experiments on isolated endplates suggest that cranial are weaker than caudal [10] even though there is little difference in their bone density [11]. These curious facts have been reported, but not explained. Cranial and caudal endplates of adjacent vertebrae are subjected to the same compressive loading by the intervertebral disc that lies between them, and cranial endplates tend to fail in-vitro even if specimens are tested upside down [9]. Therefore this asymmetry in fracture pattern suggests an underlying structural asymmetry in the vertebrae.

In the human thoracolumbar spine, pedicles join the vertebral body at above mid-height. Bone mineral density (BMD) is higher in the pedicles than in the vertebral body [1], and trabecular arcades from the pedicles appear to reinforce the lower endplates more than the upper, at least at some spinal levels [12]. However, the neural arch largely resists axial rotation [13] and [14] and shear [15] B.M. Cyron and W.C. Hutton, Articular tropism and stability of the lumbar spine, Spine 5 (2) (1980), pp. 168–172. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (35)[15] acting on the spine, and there is no obvious reason why trabeculae from the neural arch should be deployed to enhance the compressive strength of the vertebral body.

Structural asymmetry may lie in the endplate itself rather than in its trabecular support. A vertebral endplate consists of perforated cortical bone with a layer of hyaline cartilage bonded to its disc surface. The cortical bone layer contains a radiating anastomosing network of small marrow cavities [16] which allow bone marrow to lie adjacent to calcified hyaline cartilage for approximately 10% of the central endplate area [17], and this is widely regarded as an important route for metabolite transport into the avascular intervertebral discs [18]. Certainly, calcification and blocking of the endplate route is associated with disc degeneration [6] and [19]. It seems reasonable to suppose that the nutritional demands of the discs, which are the largest avascular structures in the body, ensure that vertebral endplates are as thin and porous as possible. This may explain why endplate fracture is so common, but it does not explain why cranial endplates should be more vulnerable than caudal.

This is an important clinical problem because endplate fractures and Schmorl's nodes are associated with back pain [20], [21] and [22], even though both lesions often go unidentified so that the scale of the problem may be underestimated [21], [23], [24], [25] and [26]. Typical recovery periods from acute episodes of back pain are consistent with bony injury, as are the protective and accelerated recovery effects of exercise [27] and [28]. Endplate fracture may cause chronic as well as acute back pain because it can lead to disc degeneration, both in humans [29] and [30] and in experimental animals [31]. In elderly people, damage to vertebral endplates and their supporting trabeculae is so common [23] that it largely explains why old endplates develop a concave deformity facing the disc [32]. Damaged endplates decompress the nucleus pulposus of the disc [33] and [34], lead to abnormally-high load-bearing by the annulus fibrosus and neural arch [33] and [34], and probably contribute to pain and disability in patients with senile kyphosis [35]. A greater understanding of the factors that contribute to the increased fragility of the cranial endplate may help to reduce the risk of injury, and to optimise treatments such as vertebroplasty.
...

Vertebral compressive failure usually affects the cranial endplate because it is thinner and supported by less-dense trabecular bone. This relative weakness may reflect the fact that most spinal compression arises from muscle tension [37], which is transmitted to the vertebral body via the pedicles. This causes compressive loading to increase down the spine in stepwise fashion, at the level of each pedicle. Each cranial endplate is compressed by the disc above it, whereas the caudal endplate of the same vertebra is also compressed by muscles attached to its pedicles. Hence the structural asymmetry. Unfortunately, this fine match between loading and strength is lost if the spine is compressed by external forces, such as in a fall on the buttocks with the spine flexed, because then the same force passes through both endplates, damaging the weaker (cranial) one. This could explain the preponderance of cranial endplate fractures in the present experiment, where the same compressive force passed through both endplates. It could also explain their preponderance in life, because falls contribute greatly to vertebral fractures [55].

Reduced thickness and density in the central regions of vertebral endplates (Fig. 6) may reflect the precarious supply of nutrients to the adjacent intervertebral discs. Discs rely on the thinness and porosity of endplates for the transportation of metabolites from blood vessels within the vertebral body [18] J.P. Urban, S. Smith and J.C. Fairbank, Nutrition of the intervertebral disc, Spine 29 (23) (2004), pp. 2700–2709. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (57)[18], and nutritional demands are greatest in the disc nucleus [18]. Impairment of this supply is associated with disc degeneration [19] and [56]. Cranial endplates may not thicken in lumbar vertebrae (as caudal endplates do) as a concession to the nutritional demands of the largest discs. Cranial endplates could possibly be singled out for this “sacrifice” because of asymmetries in blood supply to the vertebral bodies although information on this is lacking. Low optical density in the central endplate probably represents a greater concentration of marrow contact channels in the region which is known to be most porous [39]. In the cervical spine, where discs are thinner and have less acute metabolite transport problems, cranial and caudal endplates are equally thick [57].

The apparent weakness of endplates compared to intervertebral discs may have carried little evolutionary disadvantage when average lifespans were short. Longevity in modern humans exaggerates sarcopaenia and osteopaenia, which appear to reduce vertebral strength more than disc strength [58]. Longevity also increases disc degeneration which intensifies focal loading on vertebral endplates [52] and may facilitate fracture. The need to resist focal loading from degenerated discs may explain why BMD in older spines is greater in trabecular bone adjacent to the endplates compared to central regions of the vertebral body [59] and why BMD is greater in the posterior vertebral body, opposite the high stress concentrations which are commonly found in the posterior annulus of the disc [46].

Shoe inserts and PFS

1. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

2. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: A randomised clinical trial
3. http://d-med.com/orthaheel/Knee_Pain.html#

• secrets of medical success: this was a great set of advice that may seem obvious.
• Slower recovery after 2-incision surgery

Hyperdense bones can be the result of

• osteopetrosis
  
• hypervitaminosis D,
  
• hypoparathyroidism,
  
• myelofibrosis,
  
• Paget disease,
  
• lead toxicity,
  
• diffuse skeletal metastasis of breast or prostate cancer,
  
• pseudohypoparathyroidism,
  
• fluoride toxicity,
  
• beryllium toxicity,
  
• sickle cell disease,
  
• leukemia.
  
• 1 case report describes abnormal bone modeling and increased bone density, with histologic features of drug-induced osteopetrosis, in a 12-year-old boy treated with bisphosphonates.

Completely unrelated to medicine are
hulk vs wolverine
chevelle
folliculitis (eeewwww)

Uhthoff's phenomenon

Thanks to dr. patel for pointing this out.

C7 to Flexor Carpi Ulnaris?

According to Dumitru, there are two "communicating branches" in the majority of brachial plexi. One of them is a connection between the medial and lateral pectoral nerves. The second is referred to as "lateral root of the ulnar nerve" which is present in 43 to 92% of brachial plexus dissections. This suggests that it is not an anomaly but a major portion of the brachial plexus ignored in standard descriptions. This arises from the lateral cord, communicates with the medial branch of the medial cord to the median nerve, and the continuation of this connection to the ulnar nerve itself. This is an explanation for the contribution from C7 to the ulnar.

NESS L300

Effects of a New Radio Frequency–Controlled Neuroprosthesis on Gait Symmetry and Rhythmicity in Patients with Chronic Hemiparesis

Claimed to have improved gait rhythm and symmetry over 5 years after the stroke. Could be effective for our patients?

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder

"Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation."

Bisphosphonate Therapy Linked to Risk for Severe Musculoskeletal Pain

January 8, 2008 — Temporary or permanent discontinuation of bisphosphonate therapy should be considered in patients who present with severe musculoskeletal pain, the US Food and Drug Administration (FDA) warned healthcare professionals yesterday. Overlooking bisphosphonate therapy as a causal factor may delay diagnosis, thereby prolonging pain and/or impairment and the use of analgesics. In contrast with the acute-phase response that sometimes accompanies initial exposure to bisphosphonate therapy, some patients experience severe and sometimes incapacitating bone, joint, and/or muscle pain that begins months or years later.

Autoimmune effects of medications.

It's common medical knowledge that autoantibodies are associated with the use of certain medications. We memorize the small list of board relevant meds that cause lupus-like symptoms. More have been reported and they're common: minocycline, tnf alpha biologics, aromatase inhibitors, sulfasalazine and statins.

Although many patients develop autoantibodies, only a minority develop autoimmune-like diseases. The development of autoantibodies alone is not sufficient reason to discontinue the medication. Patients treated with medications such as tumor necrosis factor inhibitors and minocycline who develop an apparent 'flare' of the disease should be evaluated for the possibility of drug-related lupus. Rechallenge with minocycline might be useful in order to confirm a diagnosis of minocyclinerelated lupus. Clinical trial data indicate that patients who receive aromatase inhibitors can develop arthralgias and arthritis, although no data regarding the development of autoantibodies have been reported. Patients with pre-existing thyroid autoantibodies are more likely to develop autoimmune thyroid disease when treated with interferon-α than patients with no pre-existing condition.

Memories of Jim (Off topic)

It's now 1:30 a.m. on January 21, 2008. I received two phone calls from my buddy Gary. I missed both of them. Maybe it was fortunate. The voicemail said that Jim McLean had passed this weekend during the snowboarding accident in Colorado. I saw that Jim's brother Justin had also left a message so I called him back. I actually started to get just a slight bit of emotion coming through my voice. I told him that I would be available at any time to help the family and to pass on the information to his residents and programs.

Jim and brother Justin. I came upstairs and replayed Gary's voicemail on speakerphone. Monica began sobbing loudly. I comforted her and then walked away so that I could talk Gary and clear my head. Gary sounded a little lost in his voice. It seemed he had all this emotion and intention but no clear outlet with which to produce something. We spoke in tones and inflections as if nothing had happened. But the content was clearly corrupted by the news we had just taken in. Gary had taken care of calling all of Jim’s co-residents etc. At this point he was trying to figure out how to pay tribute to Jim McLean as an outlet. I figured I would try to do the same.

Jim's residency-class picture. I first was aware of Jim during residency when he was approaching the insurance reps during our Kessler resident lunch hour. I heard him say that he lives in the same town as me and in no time we became study partners. He had become habituated to studying at Starbucks so I honored his request the first time. He was determined to read the Braddom textbook from cover to cover within his first year. He was working on understanding/memorizing the anatomy of the limbs. I was studying an article by Asa Wilbourne on radiculopathy. In order to understand something I have to be able to teach it, and he was soaking up every bit of what I was telling him. I think he was sold on the idea of studying with me and therefore respected my wishes to try studying at my parents house.

What really sealed the deal for our studying there, were the endless bountiful meals offered by my parents. Even they were impressed with the frequency and amplitude of portions ingested by Jim with a huge grin on his face. My parents used to love feeding him. It seemed to all of us that his gut was an inexhaustible infinite receptacle of food. His classmate Gary, was known to be a competitive eater in his pre-medical life. It was widely accepted that everyone should get their food from the buffet table before Gary and Jim had a chance to deplete the resources. (I suppose he had to eat like a champ in order to do the training of a champ.)

Whatever we studied that first day in my basement, required that I printed out my notes. Jim found this to be a bit excessive and he did not hesitate to tell me so. I showed him the process that I went through and he was doubly sure that this was not something he was going to explore. To him, it just did not seem to justify the time spent. The next day he showed me what he had studied in a handout format. He had completely co-opted my style and was taking it to the next step. He went handout crazy after that and served as the source of positive competitive spirit for me.

He took in all of my advice but was very careful not to let any of the negative aspects of it slow him down. I remember being amazed at how diplomatically he could get me to do things without my knowledge of it at the time for example, it is well known that I am physically quite lazy. But somehow he got me to help him move out of his apartment with two other people who clearly were not averse to physical activity. I still can’t believe that happened in retrospect.

Jim and Sally at an event (photo by Casey ODonnell).

I remember one day when we were studying in my parents basement and he sat down at my drum kit. He started to play something that caught my attention. He had played percussion in his middle school band. I immediately saw the potential rock drummer in him. By treating rock drumming as a math problem, I was able to teach him enough to play a few songs at the program's graduation party. He attacked this task with the same intensity, drive, and comprehensiveness that he did everything else. No one could believe that he was holding his own on a stage with a bunch of musicians with years of experience.

Jim drumming at Kessler graduation (photo by Jenfu Cheng)

Jim was an excellent multitasker. He simultaneously participated in a number of potentially publishable research projects, trained for the Ironman competition, set up the Ironman as a fundraiser for children, worked on a curriculum to teach electrodiagnostic evaluation to residents, tutored medical students and still made the time to talk on the phone with friends, have a relaxed dinner with my family, and keep his dating life active. He somehow did all of this without spreading himself too thin. His reputation was so ingrained among the people who knew him that it was not uncommon to hear people say "Look, I'm no Jim McLean" when trying to imply that a specific task or number of tasks seemed potentially overwhelming.

I designed this cover for the last of many manuals/study guides created by Jim.
It's hard to explain to people outside our field what it means to be prolific
in this way. Most of us don't even read a full manual, let alone write more than one.

I remember one day that he rang my doorbell and was soaking wet. I remarked that I didn't realize how torrentially it must've been raining. He corrected me, told me it was beautiful outside, the dripping wetness was actually his perspiration after riding his bike from four towns over. He then laid down on my new microfiber sofa which now has a Jim McLean body sized discoloration where he had lain. J

Jim Mclean displaying an impressive hematoma after a biking accident
(ie sliding at god knows how many mph on a metal grate bridge).

He was truly fearless. To call him a gentle soul would be a mischaracterization. He had a gentle aura which contrasted his aggressive physique and assertive ambition. We had very different backgrounds and aesthetics yet he was able to see beyond those things when dealing with me. In that way I was able to gain a strong friendship in my life.

Jim and I were very close for two years. This is the kind of closeness that one rarely finds in adulthood... it's the kind that requires many hours a week spent in the same room, with the same goals, and the same urgency to achieve them. People knew this. One friend joked when he saw our new house "which of these is Jim's bedroom?" I enjoy the guilty vice of taunting my friends to the point of aggravation. Jim never let this get to him. There was only one time that I was really able to get under his skin but I can't count it as a victory because we later found out that he was severely hypoglycemic at that moment.

Happy smiling Jim AFTER the hypoglycemia was sated by
chocolatey goodness (yes, those are girlscouts cookies)
BEFORE it he was going to unleash on me
the wrath of his front headlock!

Right now I'm a little numb. It hit me very very hard when I heard of his passing but seconds later it was gone. His life was already packed with twice the experiences and accomplishments at the end of most people's lives. Despite this, there was so much more that Jim had left to give to the world. This is the definition of tragic. I'm really going to miss him.

2 noteworthy articles:

• Daily Record.com
  
• Video from Fox
  

Other Links to the Story:

• Link to first Local Newspaper Announcement in Rocky Mountain News
• Denverpost.com
• Kansas City.com
• Summit Daily
  
• Kansas.com
• NJ.com
• Denverpost.com
• KJCT8.com
• 9news.com
• thedenverchannel.com
• gazette.com
• vaildaily.com
• bnd.com
• gazetteoutthere.blogspot.com
• kake.com
• hdnews.net
• msnbc.msn.com
• ksn.com
• Kansas.com
  
• Rutgers
• Flow Wrestling
  

• In England they found advice and manual therapy or advice alone to be more cost effective than ultrasound (duh!)
• Hemiarthroplasty was found to have better outcome compared to internal fixation in 222 femoral neck fractured patients in Norway.
• Radial contrast-enhanced CT can detect acetabular labrum injury almost as well as MRI (confirmed by arthroscopy). So go ahead and use it when MRI is contraindicated.
• Vitamin D Deficiency in Residents of Academic Long-Term Care Facilities Despite Having Been Prescribed Vitamin D. Elovic and Heath reviewed the link between Vit D deficiency and musculoskeletal pain.

Shoulder adhesive Capsulitis

I wish I could read this article in its entirety. I can't tell if there is any appreciable benefit or not.
I'm going to need to review this at some point.

Random Stuff: Lasers, Vitamins, and worthless PT

Zoledronic acid
A bisphosphonate used for hypercalcemia of malignancy.
NEJM recommends infusion to improve morbidity and mortality after hip fracture.
Has a well established safety profile.

Meta Analysis of Ca Vit D to prevent fractures and bone loss in age 50 and over:
"Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

"Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended."
Vitamin C reduces lipid peroxidation, scavenges hydroxyl radicals, protects the capillary endothelium, and inhibits vascular permeability. They assert that Complex regional pain syndrome type I or reflex sympathetic dystrophy which is treated symptomatically, and the clinical focus is on prevention. Major trauma can overwhelm homeostasis, lead to systemic inflammatory response syndrome and multiple-organ distress syndrome. This may parallel burn wounds and the development of CRPS because of the inflammatory reaction and the involved microangiopathy involving a cascade of deterioration and exaggeration of a similar process. High dose Vit C in early burn resuscitation has reportedly significantly reduced resuscitation fluid volume requirements, wound edema, severity of respiratory dysfunction, vascular permeability. This stuff reminds me of Jack's "molecular helmet."

Low level laser therapy for nonspecific low-back pain.6 reasonalbe quality RCTs showed some short-term and intermediate-term evidence of pain relief with LLLT, compared to sham therapy for subacute and chronic low-back pain. No difference disability and insufficient evidence for lumbar range of motion. Relapse rate was significantly lower than control.

Bracing after ACL reconstruction: "This study represents a systematic review of the Level I evidence (12 RCTs) to determine if appropriate evidence exists to support brace use. We found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use..."

Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial: "As compared with no therapy, physiotherapy following first-time disc herniation operation is effective in the short-term. Because of the limited benefits of physiotherapy relative to "sham" therapy, it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery, but psychological factors may contribute substantially to the benefits observed." This is quite a claim.

Jones Fx, RFA, Knee Bursae, Diabetic Amyotrophy

Jones Fracture is a frx at base of fifth metatarsal at metaphyseal-diaphyseal junction not to be confused with the much more common 5th metatarsal styloid avulsion, os peroneum, or stress fracture (chronic jones). Conservatively treat (if minimally displaced, is 3 months old, and radiographs show frx w/o evidence of non-union) with non-wt-bearing cast for 6-8 wks .

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Pes Anserine bursitis good ol emedicine does an okay job. They mention some of the 12 bursae i always talk about.
See my document about Knee Bursae

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Radiofrequency neurotomy for neck pain: an excellent study in N Engl J Med. 1996 Dec 5;335(23):1721-6. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. This paper tells you about the procedure as well.

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Diabetic Amyotrophy: One of the best reviews of this is the podcast with Dr. Dyck where he discusses his article "Diabetic and Nondiabetic Lumbosacral Radiculoplexus Neuropathies: New Insights into Pathophysiology and Ttreatment." Muscle & Nerve. 2002 Apr;25(4):477-91. It is a usually monophasic & unilateral lumbosacral radiculoplexus neuropathy associated with weight loss, begins focally with pain (excruciating in thigh, hip, buttocks muscles) but evolves into widespread, bilateral paralytic disorders. There may be prolonged pain and weakness leading to wheelchair-dependence. Nerve injury and microvasculitis seen (motor>autonomic and sensory ischemic injury). Immune-modulating therapies may be beneficial.

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Can you say Articularis Genus?

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Other Topics from Today

Parkinson's Disease:
Spinal Stenosis:
Spondylolisthesis:
Crossed Adductor Reflex:
Fibromyalgia
Proprioception
Sciatica vs. sciatic nerve injury vs. common peroneal nerve injury

Calcium and friggin Iron absorption

In an effort to understand a vegetarian family member's persistent anemia and osteopenia, i came to suspect that they could be inter-related. Nutrition was defiinitely an under-represented component in my training.

Calcium supplementation in clinical practice: a review of forms, doses, and indications.
"Most Americans do not meet the adequate intake (AI) for calcium; calcium supplements can help meet requirements...Calcium carbonate, the most cost-effective form, should be taken with a meal to ensure optimal absorption. Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or protein-pump inhibitors...The maximum dose of elemental calcium that should be taken at a time is 500 mg. U.S. ..Absorption from calcium-fortified beverages varies and in general is not equal to that of milk...The risk of advanced and fatal prostate cancer has been associated with calcium intakes from food or supplements in amounts >1500 mg/d."

The inhibitory effect of dietary calcium on iron bioavailability: a cause for concern?"high intakes of dietary calcium can inhibit iron absorption if both are present in the same meal. The mechanism for the calcium-iron interaction is not known. A recent study has demonstrated that separating foods high in calcium from meals high in iron can prevent some of the calcium-induced inhibition of iron absorption."

Effect of tea and other dietary factors on iron absorption.
Several dietary factors can influence this absorption. Absorption enhancing factors are ascorbic acid and meat, fish and poultry; inhibiting factors are plant components in vegetables, tea and coffee (e.g., polyphenols, phytates), and calcium.