radiographic findings associated with aging - ohsu

Radiographic Findings Associated with Aging: Normal or Abnormal?

Dave Pettersson, MDAssistant Professor of NeuroradiologyOregon Health & Science University

5th Annual Musculoskeletal Updatefor Primary CareSeptember 6, 2018

Sag MRISag MRI Sag MRI

Disc herniation:Protrusion

Disc herniation:Extrusion

Disc herniation:Schmorl node

Disclosures:

Nothing to disclose

Spine Imaging and Aging:

Outline:

Spine degenerative changes on imaging:• Prevalence• Appearance on MRI, CT, radiographs

Low back pain• When to image• “Red flag” conditions

Age related changes on brain MRI

Spine Imaging and Aging: Question

What percentage of asymptomatic 20 year olds havedegenerative disc findings on lumbar spine MRI?

A. 5 %B. 15 %C. 25 %D. 35 %E. 45%


What percentage of asymptomatic 80 year olds have degenerativedisc findings on lumbar spine MRI?

A. 35 %B. 55 %C. 75 %D. 95%

Spine Imaging and Aging: Answers

Disc protrusion Prevalence of degenerative findings on Lumbar MRI:• 148 volunteers• All asymptomatic at time of MRI• 46% reported never having back pain

Age under 40 years: Age under 40 60 years: Age over 60 years:

A disc protrusion (red) involves less than 25% of the disc

circumference and has a wide base of attachment.

Sag MRI

A diffusely bulging disc (red)involves greater than 25% of the

disc circumference.

Sag MRISag MRI

Axial MRIAxial MRIAxial MRI

To qualify as a disc extrusion (red) the neck of the disc

material must be narrower than the material outside the

disc space .

An intravertebral discherniation (red) aka

Schmorl node.

Sag MRI

Axial MRI

Disc herniation:Protrusion

Disc herniation:Extrusion

Disc herniation:Schmorl node

Diffuse disc bulge Facet joint degeneration

Facet joints enlarge with degeneration (red). There is central

canal stenosis (blue) from the hypertrophy.

Axial MRIAxial MRI Sag MRI

This spur/osteophyte of the facet (red) extends into the neural foramen

and encroaches on the nerve root (pink).

Fluid is bright on T2-weighted MRI (yellow). Fluid is not normally visible in the facet joint space, though can

be seen in joint degeneration.

Facet joint hypertrophy Facet joint osteophyte Facet joint effusion

Spine Imaging and Aging: Radiography, CT, MRI

Sag CT

axial CT

Sag MRI

Axial MRI

Lateral radiograph

Multilevel degenerative changes Disc protrusion, CT Disc protrusion, MRI


35 year old otherwise healthy male presents with 1week history of acute onset LBP radiating to left legalong the left L5 distribution that started while lifting aheavy box. Which is the most appropriate imaging study?

A. No imaging is indicatedB. Lumbar spine radiographsC. Lumbar spine CTD. Lumbar spine MRI


You advise him that the natural history of acute LBP isto resolve in a few weeks time with conservativetherapy and no imaging is need. He pays out of pocketfor spine MRI and it shows a disc extrusion, likelyaccounting for his radicular pain.

What is the natural history of a disc extrusion?

A. Most enlarge over timeB. Most stay the same size over timeC. Most get smaller over time

Disc extrusion

Low Back Pain: OverviewAcute low back pain (LBP) with or without radiculopathy: 1

Common: 80 85% lifetime incidence.2nd most common cause for primary care visits (after URI).Leading cause of years lived with disability

ACP & APS Classissification:2

Nonspecific LBPBack pain potentially associated with radiculopathy or spinal stenosisBack pain potentially associated with another specific cause

Acute: less than 6 weeksSubacute: 6 12 weeksChronic: greater than 12 weeks

1. Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369(5):448-457.2. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and theAmerican Pain Society. Ann Intern Med. 2007;147(7):478 491.

Radiculopathy:Symptoms due to injury of a nerve root.Myotomal/dermatomal distribution of:

• pain• paresthesia• weakness

Uncomplicated acute LBP +/ radiculopathy:• benign, self limited condition• imaging studies not warranted 1,2,3.

When to consider imaging LBP:• After 6 weeks of medical management and physical therapy with little/no improvement & intervention candidate.• patients with red flags of a serious underlying condition:

• Cauda equina syndrome (saddle anesthesia, urinary retention, bowel dysfunction, bilat leg weakness)• Malignancy (personal hx of cancer, unexplained weight loss)• Fracture (trauma, tenderness to palpation, osteoporosis, prolonged corticosteroid use)• Infection (immunocompromised, fever, IVDU, ESR)• Referred pain (pancreatitis, pyelonephritis)

Low Back Pain: When to image.

1. Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic imaging for low back pain: advice for high value health care from the American College of Physicians. Ann Intern Med.2011;154(3):181 189.2. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. Jama. 2003;289(21):28102818.3. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597604.

“Red flag” conditions InfectionDiscitisOsteomyelitisEpidural abscessSeptic facet arthritis

TumorMetastatic to spinePrimary spine tumorsLeptomeningeal carcinomatosisPrimary cord tumors

TraumaCompression fracture

Cauda Equina Syndrome

MRI spine without and with IV contrastis indicated for evaluation of suspected:• Tumor• Infection

CT/MRI spine without IV contrast isindicated for evaluation of suspected:• Degenerative disease• Trauma

Discitis-osteomyelitis Metastatic disease

Compression fractures

Cauda equina compression

Accessed from https://www.ncqa.org

Choosing Wisely: an initiative of the American Board of Internal Medicine Foundation in collaboration with more than 70 specialty society partners,promotes a “national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures” by publishing recommendations from thespecialty societies to “facilitate wise decisions about the most appropriate care based on a patient’s individual situation.”

Imaging Low Back Pain: Consensus Recs Imaging Low Back Pain: Recs

https://acsearch.acr.org/list

ACR Appropriateness criteria

Modic MT, Obuchowski NS, Ross JS et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237 (2):597 604.

Roland Morris Disability Questionnaire:• Patient questionnaire• health status measure for LBP

246 patients• acute LBP• +/ radiculopathy

Low Back Pain Imaging:The evidence behind the guidelines.

Clinical improvementby 4 6 weeks

Those with disc herniationon MRI improved more.

Those without disc herniationon MRI fared slightly worse.

Re: therapeutic decision making:MRI did not have additive valueover clinical assessment.

Low Back Pain: Guidelines. Most pt with radicular symptoms recover in several weeks1,2.

Natural history of disc herniations is spontaneous resorption1.1/3rd regress or disappear at 6 weeks2/3rd regress or disappear at 6 months

1. Modic MT, Obuchowski NS, Ross JS et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005;237 (2):597 604.2. Pengal LH, Herbert RD, Maher CG, Refshange KM,. Acute Low Back Pain. A Systematic Review of its Prognosis. BMJ 2003:326 (7401):323

L4 L5 disc extrusion

Sag T2 MRI

Annual brain volume loss:Normal aging 0.5%

Brainvolume(mL)

Age (years)

Brain volume loss in healthy controls

Changes with Age: Physiologic brain volume loss

14year old

70Year old

CT

CT

Physiologic, age-related, parenchymal volume loss

Dementia,Frontotemporal

Changes with Age: Pathologic brain volume loss

Annual brain volume loss:Normal aging 0.5%Mild cognitive impairment 1 2%Alzheimer’s disease 2 4%

Significant shrinkage!

5 years

later

Dementia,Alzheimer’s disease

Normal cognition

Changes with Age: Chronic small vessel ischemic changes

FLAIRFLAIR

14 year old 70 year old

Normal MRI FLAIR hyperintense lesions (red) appear with age. A fewspots are “allowed” in normal aging. Too many spots can bepathologic, associated with vascular dementia.

Degenerative changes on spine imagingCommon & increase with ageNot predictive of disease/symptomsMRI very sensitiveSignificance depends on clinical data (low specificity)Symptomatic disc herniations usually regress

Low back painCommonWhen to get MRI?

• Red flag conditions (tumor, infection, fracture, cauda equina syndrome• Pain same/worsened > 6 weeks & surgical candidate

Age related changes on brain imagingVolume loss is normalA few white matter spots are normal

Learning Objectives: Summary

Peace out.Ultrasound fetus

Radiographic Findings Associatedwith Aging: Normal or Abnormal?

Barry G. Hansford, MDOregon Health & Science University

Assistant Professor RadiologyMusculoskeletal Radiology Fellowship Director

Osteoporosis: Terminology

Osteopenia: Paucity of bone, increased radiolucency, descriptive term w/out causality

Osteoporosis: Bone loss/decreased density, normal quality, decreased quantity

Osteomalacia: Malformed bone

Why Is Osteopenia Preferred?• Cannot tell cause of osteoporosis radiographically• Cannot discern osteoporosis from osteomalacia• Generic term encompassing both osteoporosis and osteomalacia

Primary Osteoporosis: Most common in post menopausal females, osteoporosis of aging

Secondary Osteoporosis: Implies underlying disorder, broad DDX, only 5% of cases

Osteoporosis: Definition

World Health Organization: Bone mineral density 2.5 or more standard deviations less than thatof a young healthy adult

T Score: 2.5 SD or less as measured with dual energy x ray absorptiometry (DEXA scan) for postmenopausal women and men over 50

Z Score: Abnormal if 2 SD away from mean for age and sex matched norm, relative quantity

Clinical Utility: T score more useful for predicting fracture risk, absolute quantity

Women: Estrogen deficiency after menopause, accelerated cancellous bone loss

Men: More linear pattern of bone loss

Equivalent loss by 80 years of age

Osteoporosis: Morbidity

Common, diminished, but otherwise normal bone

Etiology: Inadequate bone formation or resorptionexceeds bone formation

May be localized (disuse) or generalized

Frequency: 13 18% women older than 50, 1 4% menolder than 50

Who Cares?Significant morbidity and mortality, 9 million fxrs year

1/3 women and 1/5 men older than 50

Most Common Locations: Forearm, hip and spineRadioGraphics 2016; 36:1871–1887

Osteoporosis

Radiography:• Second metacarpal at mid diaphysis normal cortical thickening should be approximately 1/3 to 1/4

thickness of the metacarpal

• Decreased in osteoporosis RadioGraphics 2016; 36:1871–1887

Osteoporosis

Radiography• Thinned cortices• Endosteal resorption• Decreased trabeculae• Intracortical tunneling• Subperiosteal resorption

Must have 30 50% bone loss todetect pathology

Picture frame or empty boxappearance of vertebral bodies

RadioGraphics 2016; 36:1871–1887

Osteoporosis: Morbidity

Vertebral Bodies: Weight bearing bones with little cortical bone• Vertical trabeculae thicker• Horizontal trabeculae thinner, preferentially lost earlier in disease

History of osteoporotic vertebral body fracture• Increases risk of future vertebral body fracture X5, 50% asymptomatic• Increases risk of future hip fracture X2 RadioGraphics 2016; 36:1871–1887

Insufficiency Fractures

Who: Typically > 60 y/o, post menopausal women

Definition: Abnormal bone under normal stress

Location: Pelvis, sacrum, proximal femur,thoracolumbar vertebral bodies

Presentation: Acute pain, 25% multiple sites, nohistory of trauma/low impact trauma

Management: Conservative, bed rest, reduced weightbearing, simple analgesics

Bisphosphonates: Bone protective therapy, rarely maydevelop atypical femur fractures

European Journal of Radiology 71 (2009) 398–405


Radiography insensitive but should be obtained first, MRI far superior for marrow

Pelvis/Sacrum: H shaped Honda or butterfly pattern, pubic bones and acetabulum

Radiation Therapy: Increases risk European Journal of Radiology 71 (2009) 398–405



European Journal of Radiology 71 (2009) 398–405

Atypical Femoral Fractures

Who: Strong association w/bisphosphonates,increases w/duration of use, must discontinue

Presentation: May be little to no pain

Location: Subtrochanteric lateral femoral cortex,50% bilateral must image contralateral femur

Management: If symptomatic, may be surgical

Imaging: Radiography first, if no intracorticalfracture lucency, cross sectional imaging forfurther evaluation

Radsource: Atypical Femoral Fractures

Osteoarthritis

Most common joint disorder

Etiology: Primary/idiopathic, post traumatic,metabolic bone disease, endocrine disorders

Frequency: > 50% over 65 y/o and > 80% over 75y/o have radiographic evidence

Symptoms matter! Not radiographic findings inisolation

Imaging Work up: Always start with radiographs,little to no role for MRI

Brower AC, Flemming DJ. Arthritis in Black and White3rd Edition

Osteoarthritis

Radiographic Findings:

• Osteophyte formation• Non uniform joint space loss• Normal mineralization• No erosions• Subchondral new bone formation• Cysts• Subluxations• Unilateral or bilateral asymmetrical distribution

Locations:

Hands, feet, knees and hips

Spares shoulder and elbows Brower AC, Flemming DJ. Arthritis in Black and White3rd Edition

Osteoarthritis

Herberden node:

Osteophytosis and soft tissueswellingBrower AC, Flemming DJ. Arthritis in Black and White

3rd Edition

Osteoarthritis


Osteoarthritis


Imaging of the Shoulder

Radiography should always be obtained first

MRI: Reserved for normal radiographs and persistentpain despite conservative management

US: Reserved for normal radiographs and persistentpain despite conservative management

CT: Reserved for trauma cases or evaluating bonestock

MRI may muddy water and not change management

Labral tear/degeneration very common > 40 y/o

Rotator cuff tears may be symptomatic, especially inaging population

Imaging of the Shoulder Imaging of the Shoulder

Imaging of the Knee

Radiography should always be obtained first

MRI: Reserved for normal radiographs andpersistent pain despite conservative management

CT: Reserved for trauma cases or evaluating bonestock

MRI may muddy water and not changemanagement

Meniscal tears may be asymptomatic and surgicaltreatment may precipitate osteoarthritis

Crystal Disease: Gout

Increasing frequency with aging, 20x M>F

Etiology: Monosodium urate deposition, primary andsecondary

Presentation: Hot, painful, swollen joint, can mimicinfection

Radiographic findings depend on location of crystals

Only 45% of patients have radiographic findings, takes6 8 years

Cartilage: Osteoarthritis

Soft Tissues: Tophaceous goutBrower AC, Flemming DJ. Arthritis in Black and White3rd Edition



• Tophi• Normal mineralization• Joint spaces preserved• Punched out erosions w/sclerotic borders• Overhanging edges• Asymmetric polyarticular

Locations:

Feet, ankles, knees, hands and elbows








Crystal Disease: Calcium Pyrophosphate Deposition Disease

Most common crystal arthropathy, middle age toelderly

Etiology: Chondrocalcinosis deposition in cartilage

Frequency: Up to 5% of population

Variable presentation and radiographicappearance

Most Common Locations: Knee, pubic symphysisand wrist

Appears similar to osteoarthritis in atypicaldistribution Brower AC, Flemming DJ. Arthritis in Black and White

3rd Edition


• Chondrocalcinosis• Normal mineralization• Uniform joint space loss• Variable osteophytosis• Prominent cysts• Neuropathic rare• Bilateral• Involves shoulders and

elbows









Sarcopenia

Significant muscle loss, a/w cachexia and fragility

Who Cares? Predicator of quality and quantity of life

Particularly in elderly, cancer patients or surgery

Associations: Physical disability, osteoporosis, falls,prolonged hospital stay, readmission, post opcomplications and death

May be Accompanied by Obesity

Imaging CT: May be used as a biomarker of patientsalready undergoing scan

Use to quantify surface area and density

AJR:205, September 2015

Sarcopenia

Emerging Clinical Applications: Progressive sarcopeniaafter diagnosis of colorectal cancer has significant negativeprognostic association with overall and progression freesurvival

Imaging MRI: Multiple evolving techniques

Future Directions: Best techniques and applications stilluncertain

Take Home Points: Independent risk factor for adversehealth outcomes

Muscle routinely included on standard cross sectionalimaging

Potentially valuable biomarker AJR:205, September 2015

Metastases and Multiple Myeloma

Patients > 40 y/o with osteolytic lesion withoutsclerotic borders = Metastases and multiple myeloma

Big Four: Metastases, multiple myeloma, lymphomaand leukemia > 99% of bone cancer

Breast, lung, prostate, kidney, thyroid = 85%metastases

Multiple Myeloma: Most common primary bonemalignancy

Monoclonal proliferation of plasma cells

Imaging: Punched out lytic lesions of axial skeleton

MRI, PET/CT, CT more sensitive

Metastases and Multiple Myeloma Metastases and Multiple Myeloma

Questions

SUPPLEMENTS AND THE SUPPLEMENT INDUSTRY

Kerry Kuehl, M.D., Dr.P.H., M.S.Professor of MedicineChief Health Promotion and Sports MedicineDirector Human Performance LaboratoryOregon Health & Science University

Health Promotion & Sports Medicine

RESEARCH

REHABILITATION

WILDERNESSMEDICINETEAM PHYSICIAN

WEIGHT LOSS

Human Performance LaboratoryHealth Risk AssessmentPhysician conducted H&P examBlood tests for cholesterol and diabetesBody composition analysis Cardiopulmonary exercise stress testBasal Metabolic Rate measurementDietary analysis and prescription Weight loss counselingElite athlete testing and trainingSports nutrition and supplements

Nutritional Supplement Types

VitaminsMineralsHerbs or BotanicalsSports SupplementsThermogenic or Weight Loss ProductsMeal Replacements“Healthy” Water

SPORTS SUPPLEMENTS

Sports Drinks (Gatorade, Red Bull, etc.)Bars and Gels (Powerbar, Supergel)Amino Acids (Arginine, BCAA, Creatine)Protein Powders (Whey, Casein)Minerals (Chromium, Iron, Sodium, etc)Stimulants (Ephedrine, Caffeine, etc)Anabolic Precursors (DHEA, Andro, etc)Vitamins (Vit B, C, folate, etc)

GROWTH OF AN INDUSTRY

2016

$50 billion

Consumer Use of Supplements

Dissatisfaction with limitations of conventional medicinePerception of Western model of medicine –“Drugs” only and not “natural”Medical practices of other cultures“Lifestyle” causes of diseasePrevention issues and desire to reduce medsConvenience shopping and think less costly

Dietary Supplement Health and Education Act of 1994

Congress passed into law this act which allows a supplement to be excluded from regulation as a food additive or drug.Can bring the product to market without any reports or studies or safety or efficacy of the product.

Supplement Claims

The act allows manufacturers to make nutritional benefit claims that are not disease-related claims

OK to make health claim as long as product or ingredients cannot prevent, treat, or cure a specific disease.

Cure For The Common Cold

Zinc: Inconsistent evidence 2008- $24 million fraud NEJM 2011: No effect

New Dietary Ingredients and Labeling

The act allows ingredients in supplements only if they have been present in the food supply in a natural form that is not chemically altered, or have a history of use or other evidence of safety.Ingredients and dosages must be stated on the label.

Supplement Studies on Product Purity

50% of dietary supplements tested had mislabeled ingredients (FTC, 2000)25% of sports supplements tested were contaminated with “banned” substances (USADA, Jan 2010) FTC trying to enforce supplement labels and content with USP (US Pharmacopoeia) which means product passed tests for purity.

Statements of Nutritional Safety

The act exempts, from the definition of labeling, information in the form of an article, report, safety study, book chapter, or official abstract of a peer-reviewed scientific publication used in connection with the sale of supplements.

Formula-One: The Ultimate Supplement

“all natural supplement that will make you feel better and have more energy”“control of hunger, reduced sugar cravings, burn more fat and lose weight”Contains boron, chromium, Vitamins B3, C and E, multiple herbs including Ma-huang (ephedrine), Kola Nut (caffeine), White Willow Bark (salicylate), Gingko Biloba (aspirin + Vit E), Bladderwrack (iodine).

FDA Pulls Formula One

Affiliated Consultants International has been instructed to stop marketing this product due to numerous adverse events and fatalities associated with this product.

How can this be prevented?

SAFETY BURDEN ON US

The act considers a supplement to be adulterated if it presents a significant or unreasonable risk of illness or injury under conditions of use stated on label or understood under ordinary use.

Healthcare providers have become the watchdogs of the industry.

FTC Releases Report on Dietary Supplement Advertising

Report shows 55% false claims and another 40 % misleading or deceptive ads.Two major trends in past 10 years: 1) For weight loss, shift away from exerciseto taking the diet pill only to lose weight.2) New ads much more likely to make misleading and deceptive promises.

Examples of Weight Loss Ads False Claims

Claim: Lose weight while you sleep or with a patch.

Fact: Products and programs that promise quick easy weight loss are bogus. To lose weight, you have to lower your intake of calories and increase your physical activity.

False Claim

Lose 12 pounds in 2 days, or lose 30 ponds in 30 days

Fact: The faster you lose weight, the more likely you’ll gain it back. Experts recommend a goal of 1 pound/week

Healthier Water? Healthy or Unhealthy?

On January 14, 2009, the Center for Science in the Public Interest filed a class-action lawsuit against Energy Brands alleging that the marketing of the drink as a "healthful alternative" to water is deceptive and in violation of FTCCSPI states that the 33 grams of sugar in each bottle of Vitaminwater do more to promote obesity, diabetes and other health problems than the vitamins in the drinks do to perform the advertised benefits listed on the bottles". Coca-Cola dismissed the suit as "ridiculous," on the grounds that "no consumer could reasonably be misled into thinking Vitaminwater was a healthy beverage" and was only an attempt by the group to increase its readership

Interactions of Supplements and Medications ?

“Check with your health care provider or pharmacist if there is the potential for an interaction.”

We know about drug/nutrient interactions and drug/drug interactions. Now there is thesupplement/drug interactions.

Specific Supplement Interactions

Ginkgo Biloba:Mechanism of action: antioxidant like Vitamin E and antiplatelet effect like aspirin. Interaction: with anti-coagulant medications such as Aspirin, Coumadin (Warfarin), Heparin.Adverse Event: Multiple cases of spontaneous hemorrhage (GI, Brain)

DIETARY SUPPLEMENTS TARGETING KIDS

Source Nutraceuticals “Focus Child” has over 400 items including “Rhino Pops” (Echinacea) for “colds”.Fresh Samantha “Oh Happy Day” Vitamin line contains St. John’s Wort.MLO Products, Inc. provides free creatine monohydrate supplement to Mater Dei H.S. and claims credit for “building champions”.

VIT D – Super Hormone? Strong biological and mechanistic bases indicate that vitamin D plays a role in the prevention of colon, prostate, and breast cancers.

Emerging epidemiologic data suggest that vitamin D has a protective effect against colon cancer, but the data are not as strong for a protective effect against prostate and breast cancer, and are variable for cancers at other sites.

Studies do not consistently show a protective effect or no effect, however.

Dietary Supplement Fact Sheet: Vitamin D

NIH Office of Dietary Supplements: Vitamin D is a fat-soluble vitamin naturally present in very few

foods (cod liver oil) and produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis

Vitamin D (+ Calcium) helps protect adults from osteoporosis.

Serum concentration of 25(OH)D best indicator of vitamin D status.

ANTIOXIDANTS and CANCER

Mechanism of action: inhibit oxidant formation, interfere with the oxidant activity once already formed, and repair injury caused by oxidants.Findings are from molecular and cellular experiments done on animals. Human trials ongoing (50,000 sites mentioning subject).Epidemiologic data show association of antioxidants ONLY FROM FOOD (not from supplements) in prevention of cancer.

Antioxidants and CHD

Antioxidant Supplements have not been proven to prevent heart disease by current clinical and epidemiological evidence.Recommendation: obtain antioxidants from food (mainly fruits, vegetables).US Surgeon General: Healthy People 2020

Randomized Trials of Antioxidant Supplements on Cancer and CVD

TRIAL Subject #-Linxian (Dysplasia) 4000 -Linxian (General) 30000-ATBC 29000-CARET 18000-PHS 22000-NHS (CHD) 88000-CHAOS (CHD) 2100-Northern Skin CA 1900-Southern Skin CA 1300

TREATMENT EFFECTMultivit 0E/BC/Selenium +E/BC --BC/A 0BC --Folate/B6 +E +, 0BC 0Selenium +0 = no effect+ = effect, -- = adverse effect

Fruits and vegetables derive antioxidant properties from the chemical that causes their various colors

Red - tomato, red plum, watermelon, pink grapefruit. Lycopene inhibit cancer cell growth.

Red/Purple - grapes, cherries, strawberries, raspberries, blueberries, prunes, red apples. Proanthocyanins inhibit cancer cell growth.

Green - broccoli, Brussel sprouts, cabbage, bok choy. Isothio-cyanates increase liver proteins against carcinogens.

Green/Yellow - spinach, corn, kale, avocado, mustard greens. Lutein protects vision, the heart, and inhibits cancer cell growth.

Orange - carrots, cantaloupe, pumpkin, apricots. Beta carotene (vision/immune fxn).

Orange/Yellow - oranges, lemons, papaya, peaches, nectarines, pineapple. Flavonoids inhibit tumor growth and repair DNA. Limonoids in the skin of oranges and lemon inhibit tumor growth.

Green/White - Garlic, onion, celery, chives, pears, leeks. Allyl sulfides inhibit tumor cell.

Kuehl Research on Tart Cherries

Fibromyalgia Study

Hood To Coast Runner Study

Inflammatory Osteoarthritis Study

Tart Cherries and Muscle Damage

45

Tart cherries have both antioxidant and anti-inflammatory properties. They contain flavonoids (anti-inflammatory), which inhibit cyclo-oxygenase 1 and 2, and anthocyanins with high antioxidant activities.

Why Study Tart Cherries?

46

1

48

**

**p<.01 The Tart Cherry Group had a 25 mm lower pain score

37 mm

12mm

Post-Race Pain Assessment

49

Pre and Post Inflammation BiomarkersBaseline(Day 1)

Post-Intervention(Day 21)

Change Score P value

CRP (mg/L))

7.19 (6.67)5.51 (3.32)

3.77 (4.57) 5.95 (3.56)

-3.42 (4.63)0.44 (1.16)

0.016*

IL-6 (pg/ml)) 2.44 (1.75)

2.51 (3.41)1.89 (1.36)2.47 (2.70)

-0.55 (1.44)-0.03 (0.89)

0.364

IL-10 (pg/ml)) 1.23 (0.66)

1.08 (0.35)1.32 (0.78)1.25 (0.79)

1. (0.70)0.17 (0.73)

0.830

TNF- (pg/ml)0) 1.62 (0.84)

1.07 (0.44)1.39 (0.79)1.01 (0.38)

-0.23 (0.24)-0.06 (0.29)

0.181

.

Anti-Inflammatory Food Ideas• Add in Ginger sprinkled on trail mix

• Add Turmeric on your morning oatmeal

• Daily serving of tart cherries or berries

• Green tea provide catechins and quercetin

• Frequent servings of salmon

• Red grapes or wine – 5 oz/d

Natural Anti-inflammatory Foods

• Resveratrol

• Sources: Japanese knotweed and grapes (skin)

• Role is to protect the plant from infection and UV radiation

• Anti-inflammatory Mechanism: inhibits TNF – alpha and IL-1.

• NIH Human Cancer Trials: melanoma, colon cancer

52


• Curcumin

• Source: Turmeric comes from flowering plant in the ginger family.

• Human mechanism: inhibits both Cox-1 and Cox-2 inflammatory pathways.

• Alternative to NSAIDS but may have same GI side effects. Not to be taken with NSAIDS.

53


• Omega-3 EFA

• Source: marine and plant oils (Fish oil, flax seed).

• Active ingredients: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) enhance conversion of COX to prostaglandin E3.

• P E3 inhibits arachidonic acid conversion to P E2 (highly inflammatory).

• Farm raised: Controversy of polychlorinated biphenyls (PCB’s).

54

Supplements Needed in the Pacific Northwest?

• Vitamin D – Should get Vit D level checked.

• Iron– Athletes should get serum ferritin checked for anemia.

• Calcium – Menopausal women, adolescents females, lactose intolerance patients should be assessed.

• Vitamin B12 - Vegetarians should get level checked and individuals on Proton Pump Inhibitors.

• Seasonal Affective Disorder Syndrome – Vitamin D Deficiency associated with SADS. St John’s Wort does not work. Try to supplement with a light therapy box.

CONCLUSION

Since DSHEA, explosion in nutritional supplement industry.FDA takes action on Supplement Safety in 2003.Use must be guided by scientific study of efficacy, minimum and maximum safety doses, interactions, adverse effects, and costs.

Resources

Ask the pharmacistConsumerLab.comSupplementwatch.comNutrition Action LetterFDA Supplement websiteNIH Office of Dietary SupplementsNCCAM

+

Nels Carlson, M.D.Assistant Dean

Continuing Professional Development

School of Medicine

Associate Professor

Department of Orthopaedics and Rehabilitation

Oregon Health and Sciences University

+

Physical Medicine and RehabilitationFocus on restoring functionExercise is the mainstay of treatment for most

musculoskeletal conditions

-Musculoskeletal Medicine

-- Non-operative treatment:

-- Muscles and nerves

-- Joints and bones

-- Osteoarthritis

-- Spine

- Sports

+Overview1. Benefits of Exercise

2. “Quality of Life” Insurance

3. “Quantity of Life” Insurance

4. What Does the Research Show?

5. Maintaining an ExerciseProgram

6. Recommendations and Prescription for Physical Activity

7. What’s New in Exercise Science?

+ Why Exercise?Top Ten List of Reasons to Exercise – Mayo Clinic

Exercise will reduce fatigue levels.

Aerobic exercise reduces the risk of diabetes, heart disease, cancer.

Aerobic exercise can help prevent heart attacks, and subsequent heart attacks.

Exercise activates the immune system, making you less susceptible to viral illness, such as colds and the flu.

Exercise and diet will help you lose weight and maintain weight loss.

Exercise can reduce tension, promote relaxation and decrease depression.

With long-term exercise, your heart is stronger, pumps blood more efficiently.

Aerobic exercise can favorably effect your cholesterol levels.

Aerobic exercise can help older people maintain muscle strength, maintain mobility, decrease falls, and decrease age-related cognitive decline.

People who participate in regular aerobic exercise appear to live longer than those who don’t exercise regularly.

+ Gait Speed - The Next Vital Sign?

• Predicted survival based on:• age, sex and gait speed

• was as accurate as predicted survival based on:• age, sex, chronic conditions, smoking

history, blood pressure, body mass index and hospitalization.

• “Why does walking speed predict survival? Walking requires energy, movement control, and support and places demands on multiple organ systems, including the heart, lungs, circulatory, nervous and musculoskeletal systems.”

• Studenski S, et al. Gait Speed and Survival in Older Adults. JAMA. 2011;305(1):50-58.

+

Do you have “Quality of Life” Insurance?Exercise not only helps to prevent or manage disease, exercise may be the “Fountain of Youth” that maintains independence and quality of life as we age.

+Exercise – your “Quality of Life” Insurance

People are less physically active as they age.

Nearly 40% of people age 55 or greater report no leisure-time physical activity.

Inactive people lose muscle at a rate of 3-5% every decade after age 30.

15% of muscle is lost by age 60.

Loss of strength results in:Decreased balanceIncreased fall riskDecreased ability to perform activities of daily living

Decreased exercise tolerance results in a diminished “threshold of physical ability”

A minor illness or injury may result in complete dependence for daily care

+Physical Activity Guidelines:“Quantity of Life” Insurance

Minutes per week:moderate or vigorous physical activity

Relative risk

30 1

90 0.8

180 0.73

330 0.64

420 0.615

The risk of dying prematurely declines as people become physically active.

Few lifestyle choices have as large an effect on mortality as physical activity.

40% lower risk of dying prematurely for those physically active 7 hours per week compared to 30 minutes per week.

Any age, gender, race, ethnicity, body weight will gain this benefit.

US Dept Health and Human Services

+Physical Activity for Age-Related Degeneration – The Research

Spine

Disc degeneration

Spondylosis

Spinal Stenosis

Facet Arthritis

Hip/Knee

Osteoarthritis

Improved physical functionStrengthEndurance Flexibility

Improved psychosocial parameters

Improved self-efficacyIncreased coping skillsDecreased helplessness

Decreased ill-health beliefs

Conditions Benefits

++ Imaging Studies Don’t Tell the ++ Imaging StudiWhole Storyy

Normal “Abnormalities” y

” –– Degenerative Disc Disease is NNormal AbnormalitieReally Just Gray Hair

98 asymptomatic

L-Spine MRIs

52% bulges

27% protrusions

1% herniations

14% annular ligament tear

8% facet arthropathy

38% with multilevel abnormalities

- Jensen, 1994

67 asymptomatic

L-Spine MRIs

20-39 yo:

35% disc degeneration

<60 yo:

20% herniations

>60 yo: 57% abnormal

36% herniations

21% stenosis - Boden, 1990

++ Imaging Studies Don’t Tell the Imaging StudiWhole StoryyDisc Degeneration is Found in Asymptomatic Children gDisc Degenerationas Well as Adults

Scottish study of spinal canal dimension154 asymptomatic 10 year-olds

MRIs

9% with disc abnormality

14 abnormal discs at L45 or L5S1

4 with decreased T2 signal in nucleus pulposus

10 with decreased T2 signal and posterior protrusionSmith, 2003

++ Imaging Studies Don’t Tell the Imaging StudiWhole StoryyAre Imaging Study “Abnormalities” in Asymptomatic Are Imaging Study AbnormalAre Imaging Study AbnSubjects Predictive for Pain?

Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack)

148 asymptomatic subjects (36-71 yo)MRIs at baseline and 3 years

83% disc degeneration, 64% bulge, 32% protrusion, 6% herniation

~ 67% developed back and/or leg symptoms over the 3 year period

Annular ligament tears, bulges and protrusions did not predict painSelf-described depression most important predictor

Jarvik, 2001

++ Imaging g Studies Don’t Tell the + ImagingWhole

tudiStngg e e Story

Imaging Study “y

“Normalssl ” in Symptomatic Subjects

MRI in Symptomatic20 patients with:

History of LBP with radiating leg pain

PE findings with single nerve root distributions of neurologic deficits

16 of 20 MRIs:lesion consistent with history and exam findings

Modic, 1995

Do normal studies = no pathologyMisinterpreted films

Review your own

Non-compressive radiculopathyDiabetic amyotrophy

Radiculopathy-like presentations

LS plexopathy

+

Hurley Miner

+ Exercise for Acute Low Back Pain (0-6 weeks)

Malmivaara, NEJM

Randomized controlled trial:Bed Rest vs. Exercise vs. Ordinary Activity

Exercise:Specific PT “extension” program, pain contingent

Results:Ordinary activity group had favorable pain, work and disability outcomes at 3 and 12 weeks

Linstrom, Spine

Randomized controlled trial:Passive PT vs. Graded Exercise & Activity

Exercise:Quota based, gradually increasing program

Results:Graded activity group had better back function, less symptoms, less disability, and less lost work time

+Exercise for Subacute Low Back Pain (6-12 weeks)

Indahl, Spine

Randomized controlled trial:Passive PT vs. Advice to Perform Light Exercise and Return to Normal Activities

Exercise:Not fixed, but patients encouraged to set own goals, avoid illness behaviors, not be fearful

Results:Advice group had less work disability at 1 and 3 years

Mitchell, Spine

Observation of cohorts:

Passive PT vs. Intense Active Exercise

Exercise:

Quota based, aggressive

Results:

Intensive exercise group had quicker return to work and lower cost

+Exercise for Chronic Low Back Pain (>12 weeks)

Frost, Brit Med J

Randomized controlled trial:Fitness/Exercise Program vs. Back School

Exercise:Stretching and strengthening (non-pain contingent)

Results:Exercise group had decreased disability and decreased pain

Observational Trials – Functional Restoration

Mayer, JAMA

Hazard, Spine

Estlander, Scan J Rehab Med

Manniche, Pain

Rainville, Spine

Nelson, Orthopedics

+Exercise for Hip/Knee Osteoarthritis

Kovar, et al Topp, et al


Ettinger, et al Hopman-Rock, et al


Van Baar, et al Van Baar, et al

+

Exercise AdherenceNow that you are exercising, how do you stick with a program?

+Exercise Adherence

Complex, multifactorialperceptions of personal capabilities

positive attitudes toward exercise

sense of control over exercise

level of confusion regarding exercise

attrition rates of 50% within the first 6 months

+Exercise Adherence

Jette et al102 sedentary older subjects

Home-based resistance training program

Identified adherence factors

Physical factors:

Indicators of overall exercise participation

Psychological factors:

Indicators of program adherence

+Exercise Adherence

McAuley et al114 middle-aged subjectsRandomly assigned to 5 month exercise - education vs. control groupEducation group included educational intervention focusing on increasing confidence regarding ability to exerciseEducation group had increased adherence, decreased attrition over time

+Exercise Adherence

Keeping it simple:

Get out of the house!

Peer support

Work out with someone or in a group

Do exercises that you like

Any activity is better than no activity

+

Physical Activity GuidelinesU.S. Department of Health & Human Services-Research Findings

-Types of Physical Activity

-Which Physical Activity is Best

-Recommendations for Youth, Adults, Older Adults

+Physical Activity Guidelines:Research on Health Benefits

Decreased risk of adverse health events.

Increased amount of physical activity is associated with increased benefits.

Both aerobic and resistance activities are beneficial.

Decreased risk of premature death (heart disease, some cancers).

Children

Adolescents

Adults

Older adults

Every racial and ethnic group

Disabilities

Chronic disease

What are the Benefits? Who Benefits?

+Physical Activity Guidelines:Type of exercise

Aerobic (endurance, cardio)Brisk walking

Running

Jumping rope

Cycling

Swimming

Components

Intensity

Frequency

Duration


Muscle-strengthening (resistance)

MachinesFree weightsElastic bands (theraband)Body weight (push-ups)

Components

Intensity

Frequency

Repetitions


Bone-strengtheningWeight-bearing exercisesPromotes bone growth and strength“Impact” activities

Brisk walk, weight lifting

Flexibility

Stretching

Yoga

Pilates

+Physical Activity Guidelines:Adults

AerobicAt least 3 days per weekAt least

150 minutes per week of moderateor 75 minutes of vigorous activity

For additional health benefits:300 minutes of moderateor 150 minutes of vigorous

Muscle-strengthening2 or more days per weekInvolve all major muscle groups

+Physical Activity Guidelines:Older Adults

Same as for adults, plus:If unable to do 150 minutes per week, be as active as chronic condition allows.

If at risk of falling, do exercises that maintain/improve balance.

Determine level of physical activity relative to fitness level.

Determine how chronic condition will affect ability to do regular activity.

+ A Function-Based Approach to Age-Related Degeneration and Pain

Build:

Strength

Endurance

Flexibility

Pain follows function

When function improves, pain improves

This is a process that takes months (especially as we get older), not days or weeks

Improve Function Decreae Pain

+

James Rainville, MDDept of PM&RHarvard Medical SchoolThe Spine CenterNew England Baptist HospitalBoston, MA

Rethinking Back Pain Based on

Epidemiology and Basic Science

Discoveries

+Conservative Treatment

Physical Activity

Why Self-Induced Pain Feels Less Painful than Externally Generated Pain: Distinct Brain Activation Patterns in Self- and Externally Generated Pain

Wang Y, et al.

PLoS ONE, 2011; 6(8):e23536

Prospective Cohort Study

25 subjects, asked to hold “ring” with points or spheres

Trial 1–squeeze with other handTrial 2–examiner squeezes hand

ResultsActive movement inhibited pain response in somatosensory cortexPain-inhibiting effect of voluntary activity may explain beneficial impact of exercise on pain

+NeuroscienceEffects of Exercise on PainAerobic exercise for 5 weeks

Results of exercise

Reversed mechanical sensitivity of limb

Normalized injury induced changes in dorsal ganglia and spinal cord

peripheral nerve growth factors (NGF)

brain-derived neurotrophic factor (BDNF)

phosphorylation status of PLCI-1

astrocyte and microglia hyperactivity

Almeida C, et al. Exercise therapy normalizes BDNF upregulation and glial hyperactivity in a mouse model of neuropathic pain.Pain 2015;156(3):504-13.

+NeuroscienceEffects of Exercise on PainLow intensity exercise

Results of exercise

Reduced pain behaviorsBrainstem

Increased serotonin (5-HT) production

Decreased 5-HT transport

Increased 5-HT receptors

Reduced inflammatory cytokines, tumor necrosis factor-alpha, and interleukin-1 beta

(These factors are known to modulate pain)

Bobinski F, et al. Role of brainstem serotonin in analgesia produced by low-intensity exercise on neuropathic pain after sciatic nerveinjury in mice. Pain 2015;156(12):2595-606.

+NeuroscienceEffects of Exercise on Pain

High intensity exercise

Results of exercise

Reduced withdrawal reflex

Mu-opioid receptors

Altered expression of mu-opioid receptors in brain stem and spinal cord shifting balance of pain modulation to inhibition.

This effect is blocked by opioid receptor antagonist naloxone.

Kim YJ, Byun JH, Choi IS. Effect of Exercise on Âμ-Opioid Receptor Expression in the Rostral Ventromedial Medulla in Neuropathic Pain Rat Model. Ann Rehabil Med 2015;39(3):331-9.Stagg NJ, et al. Regular exercise reverses sensory hypersensitivity in a rat neuropathic pain model: role of endogenous

opioids. Anesthesiology 2011;114(4):940-8.

+NeuroscienceEffects of Exercise on PainGraded exercise

Results of exercise

Reduced hyperalgesia in the skinNeurological changes

Prevented nerve fiber sprouting in the skin

Lowers neurotrophic factors in the sciatic nerve

Reduced NGF and BDNF in sensory neurons and spinal cord

Normalized pain disregulated ion transport in dorsal ganglia and spinal cord

Reduce microglia cell proliferation in spinal cord

Lopez-Alvarez VM, et al. Early increasing-intensity treadmill exercise reduces neuropathic pain by preventing nociceptorcollateralsprouting and disruption of chloride cotransporters homeostasis after peripheral nerve injury. Pain 2015;156(9):1812-25.

Chen YW, et al. Exercise training attenuates neuropathic pain and cytokine expression after chronic constriction injury of rat sciatic nerve. Anesth Analg 2012;114(6):1330-7.

+Neuroscience

The stimulus from exercise reverses pain sensitizing changes in the brainstem, spinal cord, dorsal ganglia and peripheral nerves.

Ossipov MH, et al. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8:143-51.

+Human studies of exercise

Exercise

+Clinical Trials – Exercise

Spinal stabilizationGeneral exercise

Improvements in pain and disability similar in both groups.

Woo SD, Kim TH. The effects of lumbar stabilization exercise with thoracic extensionexercise on lumbosacral alignment and the low back pain disability index in patients with chronic low back pain. J Phys Ther Sci (2016 Jan) 28(2):680-4


Pilates exerciseGeneral exercise


Mostagi FQ, et al. Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. J Bodyw Mov Ther (2015 Oct) 19(4):636-45


Motor control impairmentGeneral exercise


Saner J, et al. A tailored exercise program versus general exercise for a subgroup of patients with low back pain andmovement control impairment: Short-term results of a randomised controlled trial. J Bodyw Mov Ther (2016 Jan) 20(1):189-202


High load liftingLow load motor control


Michaelson P, et al. High load lifting exercise and low load motor control exercises as interventions for patients with mechanical low back pain: A randomized controlled trial with 24-month follow-up. J Rehabil Med (2016 Apr 28) 48(5):456-63


Supervised walkingFitness training


Hurley DA, et al. Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial Pain 2015;156:131-7.

+ The neurological effects of exercise are rather non-specific!

Specific exercise techniques may be less important than reaching a certain threshold of exercise needed to induce neurological changes that reduce pain stimulus threshold

“We are not responsible for what patients believes before they come to our practice.”

“We are responsible for what they believe when they leave.”

Aage Indahl, Spine 1995

+Goals: STAY FIT FOR QUALITY AND QUANTITY LIFE

The best exercise?

Meet the physical activity guidelines

Aerobic

Muscle-strengthening

Flexibility

Develop exercise buddiesPeer support

Maintain an exercise program over time

+Any activity is better than no activity!

MUSCULOSKELETAL UPDATE FOR PRIMARY CAREHans Carlson, MDAssociate Professor Physical Medicine & RehabilitationOHSU

INTERESTING CASES / PANELMaking the diagnosis with musculoskeletal pain

IF YOU’VE NEVER HEARD OF THE DIAGNOSIS…

…you can’t make the diagnosis.

IF YOU’VE NEVER HEARD OF THE DIAGNOSIS…

…you can’t make the diagnosis.Hans Carlson MS1, 1988

The prepared mind…

Where does it hurt?

What’s there that can hurt?

Musculoskeletal Injuries

TendonsMusclesLigamentsJointsBursaNervesReferred Pain

Know the patterns!

MusculoskeletalPain

• 44 y.o. female • 9 month history of progressive right hand/thumb numbness

• Complaints of grip weakness• Occasional radiation to the elbow and shoulder

• Symptoms increased at night or with driving

• No neck pain

A. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

MusculoskeletalPain

• No history of prior surgery• No prescription medications• Occasional left knee pain with jogging

• Works as teacher


MusculoskeletalPain

• Mild left APB weakness• No intrinsic atrophy • Normal interosseii and finger flexor strength

• Normal sensation• Equivocal Tinel’s at wrist and Phalen’s maneuvers


MusculoskeletalPainA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


Carpal Tunnel SyndromeA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

MusculoskeletalPain

• 59 year old male• 4 month history of moderate to severe right thoracic spine pain

• Started with housework, no trauma• Continued symptoms despite rest with progression to low back pain

• No lower extremity numbness, weakness

• Increased symptoms with forward flexion, sitting, getting out of bed

• Decreased symptoms with NSAID, sitting with arm rest

• No red flags


MusculoskeletalPain

• BPH• Hyperlipidemia• Allergic rhinitis• Meralgia paresthetica• Achilles tendon repair• No prior imaging


MusculoskeletalPain

• Decreased, painful thoracic and lumbar spine ROM

• Normal LE motor, sensory, reflexes

• Unremarkable gait, skin• Cervical spine ROM normal• Moderate to severe thoracolumbar paraspinal muscle and spinous process tenderness

• Normal, pain-free bilateral hip ROM





Multiple MyelomaA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 30 year old female• 4 week history of moderate severity left hip pain

• Running 10-12 miles/week x 3 months• Acute onset during 10K running downhill

• Unable to weight bear initially• Able to ambulate with crutch after 2-3 days

• Recent increased symptoms and crepitus with AROM

• Pain in groin without lower extremity paresthesias

• Mild associated low back pain


• No medical problems• No prescription medications• Remote history of right ACL repair


• Partial LLE weightbearing with crutches

• Using wheelchair for longer distances

• Unable to actively raise left leg while supine

• Normal BLE motor, sensation and reflexes

• Limited AROM, PROM secondary to pain



Femoral Neck StressFracture/FractureA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 41 year old male• 4 years of LBP, BLE pain - stable• No history of trauma• Several month history of progressive difficulty with walking with chronic foot drop

• Now using cane as well as AFO’s• Chronic BLE paresthesias• Polyarthralgias


• IDDM since age 6 • Recent EDX with borderline peripheral neuropathy

• Recent MRI of lumbar spine• L5-SI bilateral pars defect – no severe stenosis

• No surgery recommended• History of psoriatic arthritis


• Mildy decreased spine ROM without pain

• Decreased LE reflexes• No clonus, equivocal Babinski• Decreased sensation bilateral feet

• 4/5 left Ankle dorsiflexion, plantar flexion

• Wide based gait with decreased cadence and instability





Thoracic SyrinxA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 64 y.o. male with 13 month history of bilateral arm pain and paresthesias

• Symptoms are intermittent, stable• Has had 2 years of mild foot paresthesias w/o pain

• NIDDM x 4 years• History of remote 2 level cervical spine fusion


• Onset of symptoms shortly after ATV accident• Associated rib fractures


• Normal BUE motor strength• Normal BUE sensation to light touch

• Normal gait, balance and BLE sensation

• Negative CTS provocative maneuvers

• Negative Spurling s maneuver


• Symptoms only occur while he is urinating! Musculoskeletal

PainA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

• Remote imaging of the thoracic spine and ribs following injury

• No other work-up or treatment





Severe Cervical Stenosis with InstabilityA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

Quick Radic:Efficient and Effective Assessment for

Radiating Upper Extremity Pain

OHSU Musculoskeletal Update for Primary Care

Erik Ensrud, MDAssociate Professor, Orthopaedics and Rehabilitation, OHSU

Board Certified in PM&R/EMG/Neurology/Neuromuscular Disease

What percentage of your patients arecomplaining of radiating arm or leg pain?A. < 5%

B. 5 10%

C. 10 15%

D. 15 20%

E. > 20%

Ms.K, a 38 yo new pt, c/o 2 months right arm painthat radiates down the arm to just past the elbow.You decide to…A. Order a cervical MRI

B. Order an EMG

C. Examine 8 muscles for strength

D. Examine 6 muscles, one neck test, and 3 shoulder tests

E. Examine 4 muscles, 2 MSK tests, and 3 sensory points…and do this in< 60 sec

PAIN THAT TRAVELS ALONG A LIMB

Radiating (vs radicular) pain is a very common clinical complaint

Often assumed to be radicularradicular pain pain “radiated along a dermatome of a nerve dueto inflammation or irriation of a nerve root”

But radiating pain is often not due to nerve irritation muddles theworkup

So sometimes radiating pain can be MSK

But many DO have radicular pain from pinching ofnerve roots…how to effectively find that ?

Let’s start with what we are looking at…

Let’s back up…what Do Normal Peripheral Nerves Do?3 Functions

1. Carry a signal to muscle to contract

2. Carry normal sensation, such as light touch for skin orposition of joints

3. Carry pain signals from non nerve tissues (skin, bone,joints, soft tissue). *This message does not mean thatthe nerve is injured or abnormal.

Such as, a fire alarm going off may mean the fire alarm is injured/malfunctioning(injured nerve), or…

that the fire alarm is working as designed to carry a message that there is a fire inthis case the fire alarm/NERVE is functioning normally.

Ordering an MRI as First Step

• BENEFITS• Time saver few clicks…“Smart” Set• Likely to be abnormal

confirmation bias• Pts are always worried about their

spine, want to know• Very sensitive test• Picture for the Instagram Age

• Drawbacks• High likelihood of normal

abnormalities• Often requires pre auth, denials• Much explanation needed in f/u

about disc bulges, foraminalstenosis on wrong side

• Often low specificity test

Exam?? We’re going somewhere,but it’s foggy and old fashioned….

Amish community outside of Champaign-Urbana, IL

Is the exam relevant today?

Sun setting on that way back when windmill thing…

MOTOR EXAMINATION

• Advantages• FEE Fast, Easy, Effective in clinic• QUICK much faster than even rapid CT• Can provide valuable info regarding the longest tracks

throughout the central and peripheral nervous system• Pattern recognition allows for rapid diagnosis

• Disadvantages• Relies on pt effort/level of alertness/cooperation• Relies on examiner’s interpretation of muscle force• Difficult to learn this on the web or in a book

it’s a learned motor skill, like riding a bike

Basic Principles of Muscle Force Testing 1

• Each muscle crosses a joint and causeschanges in that joint ROM with contraction

• Try to STABILIZE the joint the muscle crosseswhenever possible, to help isolate the muscleaction


• Use your similar sized muscles only in hand muscles

• You will use your perception of the force you deliver and yourexperience of what is “normal” this is a learned motor skilland takes time to learn try to do a focused exam on pts withknown diagnoses so that you know what to expect

• In motor testing, the EXAMINER has the subjective sensationbeing judged c/w sensory where the PATIENT has thesubjective sensation

• In non hand muscles, use your additional muscles/bodyweight as needed this is not a force competition (i.e., I amstronger and therefore the pt is “weak” or vice versa)


• Muscle Strength testing =• = Force (M x A)

• Measured in Pounds/Kilograms/Newtons• Not time dependent

• Work =• = Force x Distance• Units are joules

• Power =• = Work/time• Units are units of energy divided by time,• i.e watt = one joule/second

TORQUE !

• The tendency of a force to rotate an object about anaxis (aka joint in MST)

• Physics = Torque• Mechanical Engineering = Moment

Maximize d !!


• The score assigned to the muscle is the maximumforce generated at any point in time during thetesting of that muscle

• Rapid decreases in force do not represent weakness;rather, almost without exception they representvariability in lower motor neuron drive (exceptionsevere myasthenia)

• * Do not report the average when intermittentactivation occurs report the PEAK force

Score Peak force

0

10

20

30

40

50

60

70

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Forc

e in

lbs

Time in seconds

Score this

Another look at peak strength testing

Intermittent Activation (IA):The Great Strength Confounder

• Three Reasons for IA• Pain in joint crossed

contraction of musclecompresses joint

• Poor proprioception/position sensecannot sense the

contraction ofmuscle/joint positionwell

• “Enhancement” ofweakness (somatic vs.malingering)“The Chicken Dance”

Back to MsK…consensus is examine first…

What nerve roots might be affected with radiatingpain down an arm? C6>C7>C5>C8

We know that C6 is the most common cervical radiculopathy, what isthe best muscle to check strength for C6?

A. Deltoid

B. Biceps

C. Pronator teres

D. Triceps

E. Wrist Extension

Pronator Teres most sensitive muscle for C6* the most distal C6 innervated muscle

Why is that?Unique structure of peripheral nerve cells the LONGEST cells in the body,very length dependent transport along the length of the very long cell

Nerve root compression is similar to a dam at acreek spring…where does the creekbed start to rundry? Near the spring…or downstream?Pronator teres is the most “downstream” C6 muscle

In an arm, 2+ feet long!

Why was this missed? What about ASIA (AmericanSpinal Injury Association) scales?What about wrist extension?• ASIA motor levels are based on

SPINAL CORD levels

• Motor neurons in the spinal cordare always superior/above theirnerve root exit from the spinal cord

• Because of this, spinal cord andnerve root levels do not correlatewell

4 Muscle, Side to Side Comparison, C5 8 Screen

• Infraspinatus C5

• Pronator teres C6

• Extensor Digitorum Communis (EDC) C7

• Extensor Indicis Proprius (EIP) C8

IInfraspinatus force testing C5side to side immediate comparison (also upper motor neuron advantages)

Extends and laterally rotates the humerus

Pronator Teres most sensitive muscle for C6* the most distal C6 innervated muscle

PPronator teres C6

• Shake pts hand, ask themto keep the thumbDOWN

• Pts elbow must be fullyextended (if flexed testpronator quadratus)

• Weak in ~2/3 of C6 radics• check side to side• Bend your trunk sideways

prn for additional force

EEDC (Extensor digitorum communis)highly C7

• Have pt grasp knees with all fingers,then lift up the 2 middle fingers

• Minimal force muscle, like all fingerextensors

• Don’t push too hard too fastmarshmallow analogy

• Check force side to side

EExtensor indicis propius (EIP)radial nerve, highly C8

• Have pt grasp knees withall fingers, then lift up the2 index fingers

• Slight force muscle, likeall finger extensors(finger flexors muchstronger cause oftrigger fingers)

• Check force side to side• Great advantage of not

being involved in ulnarneuropathy or CTS

SENSORY EXAM

• “CAN YOU FEEL IT” IS A…

• A. Good question to ask during the usual sensory exam

• B. 1980 epic hit single/video by The Jacksons

• C. Poor question to ask a pt with an acute spinal cordinjury

• D. Album by the innovative 1980’s Australian band,Hunters and Collectors (best known for their single,“Throw Your Arms Around Me”)

CAN YOU FEEL IT

Which circle is darker gray? PAUSE

Which of those 2 previous ovals was darkerthe 1st or 2nd?

A. FirstB. Second

DST double simultaneous testing DST double simultaneous testing

• Use to test• Distal to proximal gradients for length dependent

neuropathy.Light touch is best subserved by both systems

• Side to side distal dermatomes for radiculopathy

• Different peripheral nerve distributions for focalneuropathies

Side to side distal aspect of dermatomes forradiculopathy

Simultaneously touchBack of Left and Right hand

Thumb C6

Middle Finger C7

Pinky C8

10 sec

Different peripheral nerve distributions for focalneuropathies

Ulnar

Median

vs

Back to MsK…cervical radic muscle screennegative…

What else might be affected with radiating paindown an arm?

MSK Mimic definition

A musculoskeletal condition that presents with pain ordiscomfort suggestive of a nerve injury/neuropathic etiology

Reasons to care about MSK Mimics

Common causes of limb pain

Frequent reason for clinic referral

Pts may have radiculopathy AND mimics

Your extremity skeleton and spinal nerve roots don’t coordinate their painlike your 2 kids crying at the same time about 2 different things

”Pain in limb ? radiculopathy, ? CTS”

Treatable conditions

Musculoskeletal Exam Tests:Advantages

FAST/EASY/EFFECTIVEAbility to diagnose quickly at bedside or exam room with

appropriate physical exam

Timesavers for the Provider…keep up your clinic flow

Fewer unnecessary MRIs ordered with time consuming followup

Musculoskeletal Exam Tests:Pearls

Check bilateral limbs for side to side comparison: non involvedside first when possible

Ask, “Is that the same pain you have been experiencing?”

* Patients can have more than one condition i.e. radiculopathyand rotator cuff tendinitis

Musculoskeletal Exam Tests Pearls:Wince sign

Look for the “Wince” sign forpositive test

•Eye blink/face grimace•Not just mild discomfort

When doing an MSK test,Watch their eyes

2 High Yield MSK Mimic Tests forRadiating/? Radic Exam

• Hawkins Sign

• Lateral epicondyle tenderness

Supraspinatus/Rotator Cuff Tendonitis

Supraspinatus tendonitismimics

C3 7 radiculopathy*

Supraspinatus tendonitisSymptoms/risk factors

Pain with arm movement, esp. overhead*Difficulty sleeping when lying on affected side

Pain may radiate up towards neck and down arm, even beyond elbowRepetitive movements esp. overhead, acromion anatomy (hooked)

Especially in people with underlying neurologicdisease, due to periscapular muscle imbalance

leading to instability of glenohumeral joint

Supraspinatus Tendonitis:Hawkins Shoulder Testmost sensitive at 92%

Humerus flexed 90 degElbow flexed 90 deg

Examiner’s hand stabilizes pt’sshoulder

Examiner pulls down on pt’sforearm WITH RAPID JERK to

internally rotatehumerus…forceful enough toknock over a full pint glass on

a tabletopHead of humerus pinches

tendon under acromionPAIN when inflamed

Lateral epicondylitis

Lateral epicondylitismimics

Lower cervical radiculopathy pain can radiate distally alongforearm/ulna

Ulnar neuropathy* pain around elbow, radiates from elbow**Ulnar nerve will go into pinky and ring finger…usually different

from radiculopathy

Lateral epicondylitis exam test

• Palpate 0.5 1cm distal to the epicondyle(max . tenderness to palpation)

Practice with another participant

4 Muscle, Side to Side Comparison, C5 8 Screen• Infraspinatus C5• Pronator teres C6• Extensor Digitorum Communis (EDC) C7• Extensor Indicis Proprius (EIP) C8

L/R Light Touch C6/7/8

Hawkins and Lateral epicondyle Tests

Back to MsK…cervical radic muscle screen negative, light touchC6/7/8 L/R equal…

Markedly positive R Hawkins Test, negative lateral epicondyleTTP

Now you have options…

1. Home rotator cuff exercises2. PT Referral3. Subacromial steroid injection4. Some combination of the above

RTC 2 months…MUCH better

Review Quick Radic, Upper Extremity

• 4 muscle force screen 30 sec

• L/R light touch comparison 10 sec

• Hawkins and Lateral Epicondyle MSK Tests 20 sec

When fishing for radiating upper extremity pain…

Cervical Spine MRI

Quick Radic Exam

THE END

Larry Kanfer PhotographyChampaign-Urbana, IL

Happy to discuss a patient or see your [email protected], or text page me on OHSU system

Osteoporosis in Spinal Surgery

Clifford Lin, MDAssistant Professor

Department of Orthopaedics and RehabilitationOregon Health & Science University

OutlineDefinitions

Bone metabolism

Epidemiology

Classification

Presentation

Diagnosis

Management

Techniques in Spinal Fixation

Osteoporosis

Age-related decrease in bone mass secondary to unbalanced bonemetabolism characterized by:

Microarchitectural deterioration of bone tissue

Skeletal fragility

Increased risk of fracture

Bone Metabolism

Osteoblasts

Mononucleated cells

Osteoblasts

Mononucleated cells

Synthesize unmineralized bone matrix Type 1 Collagen

Proteoglycans

Osteoblasts

Mononucleated cells

Synthesize unmineralized bone matrixType 1 Collagen

Proteoglycans

Synthesize bone mineralHydroxyapatite

Deposited into Type 1 collagen

Osteoblasts

Mononucleated cells

Synthesize unmineralized bone matrix Type 1 Collagen

Proteoglycans



Osteoblasts embedded in the matrix become osteocytes

Maintain the bone matrix

Osteoblasts

Mononucleated cells

Synthesize unmineralized bone matrixType 1 Collagen

Proteoglycans



Osteoblasts embedded in the matrix become osteocytes

Maintain the bone matrix

Blastic phase takes 80 days

Bone Metabolism

Osteoclasts

Multinucleated cells

Bind to bone integrins to form resorption cavity (Howship lacuna)

Creates acidic microenvironment that dissolves hydroxyapatite mineral

Clastic phase takes 20 days

Regulation of Bone Metabolism

PTHSecreted in response to ionized calcium

Increases reabsorption of calcium in kidneys Activates Vitamin DStimulates bone resorption by osteoclasts

Vitamin DIncreases absorption of calcium from GI

CalcitoninInhibits osteoclast activity and favors storage of calcium in bone

Gonadal hormonesStimulate osteoblast proliferation and synthesis of bone

EpidemiologyThe Recent Prevalence of Osteoporosis and Low Bone Mass in the United States Based on Bone

Mineral Density at the Femoral Neck or Lumbar Spine

Journal of Bone and Mineral ResearchVolume 29, Issue 11, pages 2520-2526, 20 OCT 2014 DOI: 10.1002/jbmr.2269http://onlinelibrary.wiley.com/doi/10.1002/jbmr.2269/full#jbmr2269-fig-0001

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EpidemiologyThe Prevalence of Osteoporosis and Low Bone Mass in the United States Based on Bone Mineral

Density among Men and Women

Bone Health and Osteoporosis: A Report of the Surgeon General.Office of the Surgeon General (US).Rockville (MD): Office of the Surgeon General (US); 2004.

EpidemiologyMean Bone Mineral Density among Men and Women by Age and Ethnicity


Economic Impact


2002 Annual Direct Care Expenditures (Hospital and Nursing Home Care)

$17 billion dollars $47 million dollars daily7% of all healthcare costs among women 45 and older

2030 Estimates$60 billion dollars$154 million dollars daily

Economic Impact ClassificationPrimary Osteoporosis

Occurs as a result of aging

Slow phaseOccurs in both men and womenDue to impaired Vitamin D metabolism by kidneysBone mass decreases at rate of 0.3% -0.5% per year

Accelerated phaseOccurs only in post-menopausal womenDue to loss of estrogen and increased bone resorptionBone mass decreases at rate of 2% -3% per yearLasts ~5 years

Primary OsteoporosisProtective Factors

Higher peak bone mass – attained in mid 30sBalanced dietRegular exerciseGonadal hormones

Risk FactorsLate menarche or premature menopausePoor calcium intakeSedentary lifestyleTobacco and alcohol useGenderEthnicityFamily History

Secondary OsteoporosisSecondary Osteoporosis

Results from any medical condition or medication that contributes to accelerated loss of bone densityHigher prevalence in menMedical conditions

EndocrinopathiesHypogonadismHyperthyroidism

GastrointestinalInflammatory bowel diseaseCeliac sprue

HematologicalBone marrow dysplasia

Chronic nutritional deficienciesMedications

CorticosteroidsAnticonvulsants

Risk Factors

Orthobullets, - https://www.orthobullets.com/basic-science/9032/osteopenia-and-osteoporosis

PresentationAsymptomatic

Incidental compression fracturesGeneralized osteopenia without fracture

SymptomaticPainful fractures

Spine – 700,000Comprise half of all osteoporotic fracturesBack painRarely associated with neurological compromisePain resolves once fracture healsMultiple fractures can lead to progressive kyphosis and sagittal imbalance

Other locationsHip – 300,000Wrist – 250,000Other Locations – 250,000

DiagnosisDEXA

Assesses bone mineral density at areasprone to osteoporotic fractures (ie, spine and hip)

ProcedureMeasures values in lumbar spine fromL1-L4, total hip, and femoral neckComputes T score and Z score

AnalysisT score

BMD for normal healthy young controls at peak bone masEstimates the number of SDs the patient’s BMD is below this value

Z scoreBMD for healthy gender and age-matched controlsEstimates number of SDs the patient’s BMD is below expected value for ageCannot be used to diagnosis osteoporosisUseful for screening for secondary causes

Medical ManagementPrevention

Good nutritionVitamin D and calcium supplementation

1500 mg/day calcium2000 IU/day Vitamin D3

Weight-bearing, impact exercisesSmoking cessation

MedicationsBisphosphonatesEstrogen hormonal replacementCalcitoninPTH

Medical ManagementBisphosphonates

First-line drugInhibit osteoclastic activity in resorption cavityEfficacy

Increase bone mass by 5% at 2 yearsReduce risk of spinal and hip fractures by 50%

Side effectsDyspepsia, osteonecrosis of jaw

EstrogensEstrogen HRT

Increases bone mass in post-menopausal womenAlso significantly increases risk of breast cancer, endometrial cancer, stroke, and DVT.Not recommended for treatment of osteoporosis

SERMsActivate estrogen receptors in bone and inhibit osteoclastic activityHave anti-estrogenic effects in breast and endometriumReduces risk of vertebral body fractures

Medical ManagementCalcitonin

Intranasal formulationInhibits osteoclast activityEfficacy

Not as efficacious as other agents in increasing BMDReduces risk of vertebral body fractures

Analgesic property makes it useful in treating painful vertebral compression fractures

PTH (Teriparatide)Anabolic agent Intermittent doses stimulate osteoblastic activityEfficacy

Increases bone mass by 10% over 2 yearsReduces risk of all osteoporotic fractures by over 50%

ContraindicationsPaget disease, previous skeletal radiation, osteosarcoma

Surgical ManagementOsteoporotic vertebral compression fractures

BedrestPain ManagementBracing

Vertebroplasty and KyphoplastyDecrease painImprove mobility and function

IndicationsChronically painful VCFs in patients who have failed 4-6 weeks conservative therapy

ContraindicationsFractures with disruption of posterior vertebral wallNeurological deficitComplete collapse of vertebral body

Vertebroplasty

TechniqueDescribed in 1987Percutaneous transpedicular needle insertion into VBPMMA injected to fill VBInjection terminated if extra-VB extravasation occurs

Outcomes70-90% experience pain improvement in non-randomized studies

ComplicationsExtravertebral extravasation occurs in 30-65%Clinically significant complications occur in 10%

Increased pain, radiculopathy, spinal cord injury, pulmonary embolism, rib fracture, infection

KyphoplastyTechnique

Percutaneous insertion of inflatable bone tamp into VBTamp elevates the depressed VB and creates cavityCavity is filled with PMMA

AdvantageImproves VB height and sagittal alignment

Outcomes90% experience pain improvement in non-randomized studies

ComplicationsExtravertebral extravasation occurs in less than 10%Clinically significant complications occur in less than 2%

Study DesignMulti-center double-blinded randomized clinical trial assigning 131 patients with 1-3 osteoporotic compression fractures to undergo either vertebroplasty or placebo procedure between 2004 and 2008

Assessed outcomes at 1 month

OutcomesBoth groups experienced improvement in pain and disability

No difference in pain or pain-related disability between the two groups

Study DesignMulti-center double-blinded randomized clinical trial assigning 78 patients with 1-2 osteoporotic fractures to undergo either vertebroplasty or placebo procedure between 2004 and 2008

Assessed outcomes at 1 week, 1 month, 3 months, and 6 months

OutcomesBoth groups experienced improvement in pain, physical function, quality of life

No benefit of vertebroplasty over placebo

Osteoporosis and Spinal Fusion

MethodsIdentified 2293 patients with adult spinal deformity undergoing thoracolumbar fusion > 8 levels

Multivariate analysis of risk factors for revision surgery at 1 and 5 years

Results44% of patients had osteoporosis

10.5% revision rate at 1 year and 18.5% revision rate at 5 years

Osteoporosis significantly associated with revision surgery in univariate analysis at 1, 2, 3, 4, and 5 years

Osteoporosis was significantly associated with revision surgery in multivariate analysis at 5 years

Osteoporosis and Spinal FixationStrategies

Screw Placement

Screw Augmentation with Hooks

Screw Augmentation with Cement

Multiple Points of Fixation

Expandable Screws

Screw PlacementIncrease Screw Length

Greater pullout strength

Increase Screw DiameterGreater pullout strength

Bicortical screws30% greater pullout strength

CementPMMA bone cement

Can be injected into the pedicle around the screw

Increases screw pullout strength by three-fold

Risks Extraosseous extravasation

Multiple Fixation PointsFixation

Include additional levels in construct

Decreases stress on each individual screw

Reduces risk of pullout failure at each segment

Expandable ScrewsDistal half split lengthwiseFins can be opened as screwadvancesIncreases diameter of tip by 2 mmSuperior in pullout strength tostandard pedicle screws

ConclusionsOsteoporosis matters

Ensure patient is appropriately treated medically

Vertebroplasty is controversial

Many techniques available to reduce risk of construct failure

Thank You

OHSU Musculoskeletal Update

Scoliosis

Matthew F. Halsey, M.D.Doernbecher Children’s Hospital

OHSU

6 Sep 2019 OHSU Musculoskeletal Update

Scoliosis

Definition:An abnormal curvature

of the spine in all three planes resulting in deformity, pain and functional impairment

6 Sep 2019


Definition

• Coronal plane– Evaluated on P/A

radiographs– Measured by Cobb

angle– Must measure >10°

6 Sep 2019

verywellhealth.com


Definition

• Sagittal plane– Evaluated on lateral

radiograph– Usually characterized by

flattening of thoracickyphosis andaccentuation of lumbarlordosis

6 Sep 2019

jcvjs.com


Definition

• Transverse plane– Evaluated on physical exam– Adam’s forward bending

test– Characterized by rib and/or

lumbar prominences• Measured with a scoliometer

– Posterior prominence islocated on the convex side ofthe curve


Incidence

• Idiopathic– 4.5%– Gender ratio is 1.25:1::female:male– For curves >20° ratio is 5.4:1– Treatment required 2.75/1000– 1/20 progress to possible bracing– 1/25 progress to possible surgery

– Rogala EJ, et al. JBJS 60A:173, 1978

6 Sep 2019

Etiology

• Idiopathic– Adolescent is most common– Incomplete understanding of

etiology– Genetic factors –

multifactorial with variable penetrance, unclear environmental impacts

– Tissue deficiencies– Vertebral growth abnormality– CNS abnormality


Not clinically indicated!!!


Etiology

• Other etiologies include– Neuromuscular– Neural axis– Congenital– Syndromic– Metabolic– Traumatic– Adult-onset

6 Sep 2019

sciencedirect.com

Natural History• Natural History

– Lonstein & Carlson, 1984• Smaller curves tend to stay small• Larger curves tend to progress• Progression is associated with

growth, especially at puberty– Sanders confirmed, 2008

• Based on hand film rather than pelvis

• More easily applied to boys, as well as girls

OHSU Musculoskeletal Update6 Sep 2019 OHSU Musculoskeletal Update

Natural History

• In childhood dependent on several factors including:– Etiology– Age (growth remaining)– Gender– Curve type

6 Sep 2019

Natural History of AIS curves in Adulthood

• Curves <30º– No differences compared to age-matched controls

• Curves >50°– Curve progression (2-3°/year)– Pain – increased frequency, similar duration/severity– Dyspnea– Cor pulmonale rarely – Mental health unaffected

6 Sep 2019 OHSU Musculoskeletal Update OHSU Musculoskeletal Update

Evaluation - History

• What prompted referral?• Pain profile• Neurologic symptoms• Family history• Medical history

• Goal is to identify overall level of skeletal maturity and possible red flags

6 Sep 2019

Red Flags in the History

• Night pain, especially if easily relieved by NSAIDs– Osteoid osteoma, osteoblastoma, aneurysmal

bone cyst, giant cell tumor• Neurologic deficit

– Spinal cord tumor, tethered cord• Either of these findings should prompt

MRI evaluation


Physical Examination

• Height, Weight, Proportions• Skin exam• Normal neuromuscular exam

– Strength– Sensation– Deep tendon reflexes– Clonus– Babinski– Abdominal reflex

6 Sep 2019

youtube.com



• Back– Shoulders– Flanks– Pelvis - limb length

discrepancy– Sagittal– Forward bend test– Flexibility – posture

• Use a robe and paper shorts for this exam



• Standing position

• Forward bending position

• Scoliometer

6 Sep 2019

Red Flags in Physical Examination

• Neurologic deficits or asymmetries – Suggests neural axis disorder (MRI)

• Café au lait spots– Suggests neurofibromatosis (MRI)

• Leg length discrepancy– Perhaps not a structural (true) scoliosis (leg

length x-ray)


Radiologic Examination

• Scoliosis Screen– Standing PA entire spine

– Standing lateral entire spine

– Cobb method

– Risser sign

– Left-hand film

6 Sep 2019


• EOS imaging– Lower radiation dose– May allow concurrent

hand imaging



• MRI– Suspicion of neural axis abnormality

• Left thoracic curve• Babinski/clonus• Asymmetric abdominal reflex

6 Sep 2019

Goals of Treatment• Potential Goals

– Maintain straight spine and normal figure– Avoid pain– Avoid activity limitations– Avoid surgery– Avoid pulmonary limitations– Have a normal life; not be disabled– Not waste time or treasure

OHSU Musculoskeletal Update6 Sep 2019

Goals of Treatment

• Whose goals do we address?– Patients– Families– Primary care providers– Therapists– Surgeons– Hospital administrators– Insurance payors– Government policy makers


Choices

• Typical treatments– Surgery– Observation– Bracing– Physiotherapeutic

scoliosis specific exercises (PSSE), e.g. the Schroth method

• Atypical treatments– Typical physical

therapy– Muscle stimulation– Chiropractic– Acupuncture


Surgery• Option of last resort• Powerful tool with significant risks• Main goals

– Prevent progression of curve– Correction of deformity– Secondary prevention of problems associated with

worsening of curve (pain, restrictive lung disease)• Typical indication: Cobb > 50º


Surgery


srs.org

Surgery

• Challenges– Surgical risks including:

• Neurologic injury• Infection• Mal-positioned hardware

– Long-term problems• Curve progression• Pain• Degenerative disk disease

– 10% reoperation rate for all reasons


Observation

• Benefits of observation– Low cost in terms of time and treasure– No risks associated with treatment– Less anxiety (usually)

• Challenges– Predicting natural history is imperfect– Curve size and maturity level (age) are inadequate to

predict outcome– Identify other curve parameters (EOS 3D analysis)


Bracing

• Alternative to casting• Well-established “industry”

– Orthotists in most communities– Standardized techniques and

approaches


Bracing

• Demonstrated efficacy in high-level prospective multi-center study (BrAIST)– Weinstein & Dolan, 2013, New England

Journal of Medicine– Bracing works!!!– So many more questions are raised though!


Bracing

• Challenges– Patient compliance – monitoring?– How many hours each day?– Plethora of choices

• Day v night; soft v hard; Boston v Rigo-Cheneau

– Quality control – correction in brace• Stiff curve v inadequate brace mold; does it matter?

– When to start?– When to stop?– How to reduce number needed to treat (NNT=3)


Physiotherapeutic Scoliosis Specific Exercises

• Initial development in 1920s

• Alternative to casting and fusion surgeries

• Promoted in European centers for decades

• Over the last decade has gained a foothold in North America



• Potential benefits– Prevent progression– Improve deformity (curve

correction)!?– Maintain figure and overall

appearance



• Challenges– Data are more limited

• Are results generalizable?• Are results persistent and/or sustainable?

– Infrastructure• Limited number of trained therapists• What patient and therapist commitment is

required?– Insurance does not always cover this therapy


Standard Physical Therapy

• Potential– Common method

• Well-promulgated• Easily taught and communicated• Easy maintenance

– Very helpful to limit pain that may be associated with AIS (Zapata et al, 2015)


Standard Physical Therapy

• Challenges– Little impact on natural history– Pain not always completely relieved


Lateral Electrical Surface Stimulation

• Developed by Axelgaard in 1976– Nighttime application of

electrodes on lateral convexity of spine

– Potential replacement of bracing

– Supportive articles through the 1980s


Lateral Electrical Surface Stimulation

• Challenges– A subsequent study found results equal to

natural history (Nachemson, 1995). SRS-funded, prospective study

• Bracing success 74% (95% CI=52-84%)• LESS success 33% (12-60%)• Natural history success 34% (16-49%)

• Abandoned treatment modalityOHSU Musculoskeletal Update6 Sep 2019

Chiropractic Manipulation• Potential

– Limit progression of scoliosis without surgery

– Decrease pain associated with scoliosis

• Challenges– Lack of data (Romano & Negrini,

2008)– Emphasis on early diagnosis and

treatment (? NNT elevated)– Lack of anatomic basis of treatment


Acupuncture

• Few studies available to analyze– Weiss et al, 2008

• Brief exploratory study• No follow-up data to this point


Synopsis

• Scientific understanding of scoliosis remains elusive

• Natural history is not without consequence and remains difficult to predict

• Treatments are imperfect and flawed• Goals for patients/parents, providers, and

payors are frequently disparate and incongruent


Challenges

• Identify the etiology

• Improve our prediction models

• Evaluate rigorously our treatment methods

• Increase value

OHSU Musculoskeletal Update6 Sep 2019 OHSU Musculoskeletal Update

Thanks!

6 Sep 2019

NAME THAT GROAN! NAME THAT GROAN!Hans Carlson, MDAssociate Professor Physical Medicine & RehabilitationOHSU

NAME THAT GROAN!Using our clinical skills to

make the diagnosis

The prepared mind…

Where does it hurt?

What’s there that can hurt?

Musculoskeletal Injuries

TendonsMusclesLigamentsJointsBursaNervesReferred Pain

Know the patterns!

History - “Red Flags”

TraumaFeverWeight LossNight/Rest PainHistory of CancerRecurrent Pain or Failure to ImproveBowel or Bladder DysfunctionSensory or Motor DeficitsLeg > Back Pain

NAME THAT GROAN!

Name that Groan!

• Rules• Cases will be presented…

• Slowly• Contestants may write their diagnosis at any time.• Hold card up when done

• Briefly explain your thought process• One attempt per contestant/case• Correct answer will be given at the end

• The contestants with the earliest correct answer wins


• 50 year old male• Chronic LBP of 25 years duration• Remote left sciatica/foot drop• Increased pain with walking/standing

• No prior surgery/hospitalization• No bowel or bladder dysfunction


• No recent spine imaging for 9 years• History of degenerative changes

• Otherwise healthy


• Decreased spine ROM with mild low back pain, no leg pain

• Normal, symmetric LE reflexes• No clonus or Babinski• Decreased sensation left foot• Normal motor bilateral legs• Normal gait with decreased cadence

• Negative straight leg raise• Decreased ROM


• Increased symptoms over the past two years including…• Spontaneous painful priapism and rectal pain

• Relieved with arching back




Lumbar Spinal StenosisA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

MusculoskeletalPain

• 54 year old male• Chronic history of moderate intermittent

thoracolumbar spine pain• Started in high school, no trauma• Continued progression of symptoms

despite physical therapy, chiropractics• Symptoms now in buttock and posterior

thigh with sense of fatigue with activity• No lower extremity numbness, weakness• Complains that legs feel dead and he is

limping• Increased symptoms with general activity• Minimally decreased symptoms with

NSAID• No red flags


MusculoskeletalPain

PMHx• Unremarkable• Prior surgery

• ACL Repair• Tonsillectomy

• Prior imaging• Remote MRI with h/o degenerative changes


MusculoskeletalPain

• Decreased, mildly painful thoracic and lumbar spine ROM

• Normal LE motor, sensory, reflexes

• Unremarkable gait, skin• Cervical spine ROM normal• Moderate thoracolumbar paraspinal muscle tenderness

• Normal, pain-free bilateral hip ROM







• Electrodiagnostic Studies• Nerve Conductions Studies

• Normal sensory and motor in lower extremities

• EMG• Denervation in the thoracic paraspinal

muscles• Short duration motor units in the thoracic

paraspinal and right long head biceps femoris

• Remainder of the right UE and LE normal


Myopathy

Limb-girdle dystrophyFascioscapulahumeraldystrophyMyotonic dystrophyPompe’s disease


• 74 year old male• Chronic LBP and left sciatica• Multiple lumbar surgeries

• 3 years ago, left 4-5 decompression• Prior L3-4 decompression/fusion

• No help with recent surgery• Pain in the low back region

• Radiating into the left leg with activity

• Left calf cramping with walking


• No recent spine imaging since last surgery 3 years ago

• No further spine surgery planned• Spinal cord stimulator offered• Hypertension,hypercholesterolemia


• Decreased spine ROM with mild low back pain, no leg pain

• Decreased, symmetric LE reflexes

• No clonus or Babinski• Normal sensation bilateral feet• Normal motor bilateral feet• Normal gait with decreased cadence

• Negative straight leg raise

IntermittentClaudicationA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 65 year old female• Right THA 5 years ago with good relief of right hip pain

• Left THA 4 years ago with good relief of left hip pain but …

• Immediately felt leg length discrepancy (L>R) with walking leading to …

• New right anterior-lateral hip pain • Increased with weight-bearing, walking• Radiation to knee• No LE paresthesia


• Re-evaluation with Orthopedist• Unremarkable exam and imaging

• Treatment with PT, chiropractor, shoe lift, NSAIDs without help.

• History of mild scoliosis, no back pain

• Hypertension, fibromyalgia, hypercholesterolemia


• Normal spine ROM with mild low back pain, no leg pain

• Decreased, symmetric LE reflexes• Normal bilateral hip ROM

• No pain• Normal sensation bilateral feet• Normal motor bilateral legs• Antalgic gait with decreased cadence• Pain with RLE weight bearing

• Negative straight leg raise, reverse straight leg raise





Iliopsoas BursitisA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 73 y.o. female• Chronic LBP• Acute exacerbation of LBP and groin pain x 4 months without trauma

• Unable to perform ADL’s due to pain

• History: “arthritis”, bilateral mastectomy, hypertension and hypercholesterolemia


• PMHx• “Arthritis”• Remote bilateral mastectomy• Hypertension, hypercholesterolemia

• Prior work-up - PCP• Hip x-rays negative• Lumbar spine MRI

• Neurosurgery consult • Normal M/S/R, negative SLR• Antalgic gait - R LBP, L groin pain• No surgery recommended



PelvicInsufficiency FracturesA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred


• 26 y.o. female• 8 months of LBP and leg pain • Secondary to MVA• Intermittent paresthesia• No LE weakness• No bowel/bladder dysfunction


• Normal motor/sensory/reflexes• Decreased lumbar ROM• Mildly positive straight leg raise• Moderately uncomfortable


• Initial management• L-spine x-rays unremarkable• PT (traditional)• NSAID’s, muscle relaxants, oxycodone

• Trigger point injections


• Imaging work-up• MRI

• L4-5, L5-S1 disc protrusion• No significant nerve compression


• CT scanMusculoskeletalPainA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

• MRI pelvis


• Discogram• Positive for pain at L4-5,L5-S1• Recommendation

• 2 Level fusion



• Second Opinion• Decreased physical activity secondary to pain

• Neurologically intact• Decreased lumbar spine and hamstring range of motion



BenignNon-specificMechanical Low Back PainA. Bone/Cartilage/JointB. Tendon/MuscleC. Ligament/BursaD. NerveE. Other/Referred

radiographic findings associated with aging - ohsu

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