Neuroprevent. Electromiografía. Monitoreo intraoperatorio y Rehabilitación

04/09/2022

02/09/2022

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449 994 00 06 NEUROPREVENT Electromiografía Aguascalientes.

24/08/2022

15/08/2022

Exercise is Medicine:

Die chronische Auswirkungen von körperlichem Training auf wichtige periphere Organsysteme, die an der Regulierung der Energiehomöostase beteiligt sind, und damit verbundene Auswirkungen auf den Ganzkörper-Stoffwechsel und die systemische Gesundheit. 🏋 🏋 🚴‍♂🚴‍♂🚴

👉 Bewegungstraining verbessert die maximale Sauerstoffaufnahme (VO2max), senkt die Ruheherzfrequenz und den Blutdruck und erhöht die Gesamtmuskelmasse.

👉 Das mikrovaskuläre Netzwerk (Kapillaren, Arteriolen und Venolen) wird erweitert und die mikrovaskuläre Dilatationsreaktion wird verbessert.

👉 Die Funktion der Betazellen wird verbessert, die Blutzuckeraufnahme durch Muskeln, Fettgewebe und Leber erhöht, und die Insulinempfindlichkeit des peripheren Gewebes wird verbessert.

👉 Die Fähigkeit zur Mobilisierung von NEFA (nicht veresterte freie Fettsäuren) aus dem Fettgewebe wird gesteigert, während sich die Fähigkeit der Leber zur Glukoseproduktion erhöht und die De-novo-Lipogenese verringert.

👉 Die Fähigkeit zur Oxidation von Fett in Leber und Muskeln wird in Verbindung mit einer höheren oxidativen Kapazität, Biogenese und Dynamik der Mitochondrien verbessert. Dies führt zu einer Verringerung der viszeralen Fettgewebedepots und der ektopischen („ nicht am physiologischen Ort befindlichen“) Fettspeicherung.

👉 Insgesamt verbessern diese strukturellen, funktionellen und metabolischen Anpassungen die aerobe Kapazität, die Ganzkörper-Insulinsensitivität, die Glukosekontrolle und die oxidative Kapazität und verringern eine Hypertriglyceridämie und chronische Entzündungen. Diese Veränderungen verringern das Risiko der Entwicklung von Insulinresistenz, Typ-2-Diabetes, Nicht-alkoholischer Fettleber (NAFL) und Herz-Kreislauf-Erkrankungen, des metabolischen Syndroms, der Adipositas und letztlich der frühen Sterblichkeit.

CV, kardiovaskulär; IMTG, intramuskuläre Triglyceride; TG, Triglyceride.

Quelle: https://pubmed.ncbi.nlm.nih.gov/32529412/

14/08/2022

Just published in “Journal of Shoulder & Elbow Surgery” 🔥 🔥 🔥
Thoracic Outlet Syndrome: A review. 🙆 🙆

👉 Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet (s. figure) and presents with arm pain and swelling, arm fatigue, paresthesias, weakness and discoloration of the hand.

👉 TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical exam findings (disputed TOS).

👉 TOS is not a diagnosis of exclusion and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical exam maneuvers, and imaging.

👉 Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib which can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections.

👉 The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By eight weeks postoperatively, patients can begin resistance strength training.

https://pubmed.ncbi.nlm.nih.gov/35963513/

03/08/2022

Der SLR und seine Erweiterung 🤓 🤓 🤓

👉 Der Straight leg raise Test (SLR, hier eine Abbildung aus dem renommierten New Englisch Journal of Medicine), gilt in der Orthopädie traditionell als ein klassischer Test zum Einschluss bzw. Ausschluss eines kompressiven Geschehens (klassischerweise eines Bandscheibenvorfalls) in der Lendenwirbelsäule. Tritt dabei ein ausstrahlender Schmerz bis unterhalb des Kniegelenks bei einer Flexion des Beines zwischen 30°-70° auf (die Angaben sind hier sehr variabel), so ging man von einem positiven Testergebnis aus. https://pubmed.ncbi.nlm.nih.gov/25806916/, https://pubmed.ncbi.nlm.nih.gov/10788860/,

👉 Allerdings sollte man wissen, dass der SLR im Hinblick auf das Vorliegen eines Bandscheibenvorfalls (Bildgebung oder Befund bei OP) zwar recht gut geeignet ist, einen solchen auszuschließen (hohe Sensitivität, ca. 90%) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007431.pub2/full; seine Spezifität ist in dieser Hinsicht allerdings gering. https://pubmed.ncbi.nlm.nih.gov/29253501/, https://books.google.de/books/about/Netter_s_Orthopaedic_Clinical_Examinatio.html?id=RJ0MEAAAQBAJ&redir_esc=y.

👉 Einschränkend muss erwähnt werden, dass der SLR in einem modernen Verständnis nicht nur eine Dehnung der Nervenwurzel über raumforderndes Bandscheibenmaterial (s. Abb.), sondern generell eine erhöhte Mechanosensitivität anzeigt. https://pubmed.ncbi.nlm.nih.gov/29385943/, https://pubmed.ncbi.nlm.nih.gov/32766466/. Beispielsweise könnte eine Neuritis, eine Inflammation ohne axonale Schädigung oder eine Radikulitis ohne Nervenkompression ebenfalls einen positiven SLR bedingen, da auch hier eine erhöhte Mechanosensitivität zu erwarten ist. https://pubmed.ncbi.nlm.nih.gov/11585565/, https://pubmed.ncbi.nlm.nih.gov/16154692/, https://pubmed.ncbi.nlm.nih.gov/8235812/

👉Zudem gilt es zu bedenken, dass viele asymptomatische Menschen Bandscheibenvorfälle auf Bildern aufweisen, sodass der Referenzstandard „Bildgebung“ in dieser Hinsicht fragwürdig erscheint (sog. Verification bias). https://pubmed.ncbi.nlm.nih.gov/25430861/, https://pubmed.ncbi.nlm.nih.gov/34548049/.

👉 Dennoch lässt sich die Validität des SLRs für Bandscheibenvorfälle bzw. Nervenwurzelkompression durch eine teilweise auch schon früher genutzte strukturelle Differenzierung deutlich verbessern: Pesonen et al. schlagen in mehreren Arbeiten folgende Differenzierung als Erweiterung des SLRs (ESLR) vor:

„In der jeweiligen Hüftflexionsstellung (sofern unter 90°), in der die Probleme des Patienten auftreten bzw. sich verstärken, wird eine strukturelle Differenzierung durchgeführt. Als positiv wird der SLR dann gewertet, wenn
📍 1. Symptome beim SLR auftreten und
📍 2. durch die passende strukturelle Differenzierung (distal →bei proximalen Symptomen, proximal →bei Distalen) eine Symptomverstärkung auftritt. (s. Abbildung in den Kommentaren)

📍Gibt der Patient also distale Symptome an, dann wird mit einer Innenrotation der Hüfte strukturell, d.h. neural vs. nicht neural, differenziert

📍 Beschreibt er dagegen proximale Symptome, dann wird eine Dorsalflexion im oberen Sprunggelenk als entsprechende Differenzierung eingesetzt.
https://pubmed.ncbi.nlm.nih.gov/33761924/, https://pubmed.ncbi.nlm.nih.gov/34548049/

👉 Verglichen mit dem traditionellen SLR konnten die Autoren ein deutlich höheres Likelihood-Ratio (sprich höhere diagnostische Genauigkeit, Hintergründe s. https://flexikon.doccheck.com/de/Likelihood-Quotient) für eine Nervenwurzelkompression im MRT nachweisen (2.4 (p = 0.34) vs. 5.6 (p < 0.05). Ein positiver ESLR erhöhte die Chance für das Vorliegen eines Bandscheibenvorfalls bzw. einer Nervenwurzelkompression um den Faktor 8. https://pubmed.ncbi.nlm.nih.gov/34548049/

02/08/2022

Rotator cuff biomechanics…. 🤓 🤓

👉 Supraspinates originates from the supraspinatus fossa of the scapula and ends on the greater tuberosity of the humerus, with a footprint much smaller than that believed in the past. https://pubmed.ncbi.nlm.nih.gov/18451386/

In fact, its footprint occupies a very restricted area of the greater tuberosity, while the infraspinatus and subscapularis are interested in the remaining area. On the basis of this information, it is possible to understand why the supraspinatus tendon during external rotation is much less important than it was believed to be in the past, with much more relevant flexion/abduction functions. https://pubmed.ncbi.nlm.nih.gov/9356931/

👉 The subscapularis muscle originates from the anterior aspect of the scapula and ends mostly in the lesser tuberosity of the humerus, while a small portion ends in the greater tuberosity. /https://pubmed.ncbi.nlm.nih.gov/18472282/

Besides other cuff tendons, the classical interpretation of the subscapularis as internal rotator needs to be revised/re-evaluated/re-examined. Internal rotation remains its main function, of course, while its secondary roles change depending on the position of the humeral head with respect to the scapula. Consequently, this tendon is an abductor, a flexor, an extensor, and a depressor. https://pubmed.ncbi.nlm.nih.gov/18451386

Because of the shared insertion of the supraspinatus and subscapularis, it is possible that in certain positions of the arm, the subscapularis may work as external rotator. https://pubmed.ncbi.nlm.nih.gov/10758292/, https://pubmed.ncbi.nlm.nih.gov/8175814/

Kuechle et al. (https://pubmed.ncbi.nlm.nih.gov/9356931/)have shown that the subscapularis is a more important flexor than the supra- and infraspinatus.

👉 Infraspinatus and teres minor are often considered together, especially as far as biomechanics is concerned. https://pubmed.ncbi.nlm.nih.gov/7994959/, https://pubmed.ncbi.nlm.nih.gov/21986041/

The footprint of the infraspinatus is much wider than it was believed in the past and that this tendon is always torn considerably in the presence of postero-superior cuff tears. With the arm at rest, the supra-and infraspinatus act as external rotator and flexor/abductor (https://pubmed.ncbi.nlm.nih.gov/7931787/); the functions are also the same with the arm in other positions.

The infraspinatus acts more as an abductor when the arm rotates internally, while during external rotation the subscapularis assumes this function. https://pubmed.ncbi.nlm.nih.gov/8175814/

Furthermore, the infraspinatus and teres minor are of crucial importance as depressors of the humeral head. https://pubmed.ncbi.nlm.nih.gov/7994959, https://pubmed.ncbi.nlm.nih.gov/7661251/, https://pubmed.ncbi.nlm.nih.gov/21908156/

Figure: https://onlinelibrary.wiley.com/doi/full/10.1002/ece3.4392

02/08/2022

Los signos de advertencia de las úlceras de decúbito, o úlceras por presión, son los siguientes:

-Cambios inusuales en el color o en la textura de la piel.
-Hinchazón.
-Supuración.
-Un área de la piel que se siente más fría o más caliente al tacto que otras áreas.
-Áreas sensibles.

Es importante acudir al especialista para saber tratar este tipo de heridas.

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27/07/2022

Pathways Leading to Pain in Peripheral Neuropathy

👉 After peripheral-nerve injury, a cascade of events up-regulates expression of membrane channels in the nociceptive neurons of the dorsal-root ganglion.

👉 Sprouting sympathetic axons form interwoven baskets around cell bodies, causing exaggerated pain.

👉 At the site of peripheral-nerve damage (inset), sodium channels spread along the axon, resulting in ectopic neural discharges.

👉 Projections from nociceptive neurons in the dorsal-root
ganglion to spinal interneurons enhance excitation by release of substance P, calcitonin gene–related protein (CGRP), and glutamate.

👉The second-order neuron in the spinal cord, which is normally activated by glutamate through the α-amino-3-hydroxy-5-methyl-4-isoxazole prioponic acid (AMPA) receptors (orange triangle), is induced to fire spontaneously (central sensitization) through activation of the N-methyl-d-aspartate (NMDA) receptor (green triangle).

👉 Excitation of the second-order neuron leads to an increase in intracellular calcium and activation of protein kinases (PK) that phosphorylate intracellular proteins such as NMDA receptors.

👉Dynorphin, an opioid neuropeptide whose levels are elevated in chronic pain syndromes, can also contribute to ectopic excitation of the second-order neuron through activation of NMDA receptors.

👉There is loss of inhibition of second-order neurons by reduction of input from γ-aminobutyric acid (GABA) through down-regulation of GABAA receptors (pink oval).

👉Sprouts of central terminals of nonnociceptive neurons in the dorsal-root ganglion (Aβ neurons) express nociceptive substances in the dorsal horn, contributing to hyperalgesia and tactile allodynia.

https://www.nejm.org/doi/full/10.1056/nejmcp022282

14/07/2022

Chronic pain and infection

👇👇👇

Maybe you have observed in clinical practice that pain intensity increases in persistent pain patients during or shortly after infection?

Chronic pain is an under recognized result of infection and might take many forms including nociceptive, neuropathic and nociplastic pain. The inextricable link between chronic pain and infection is illustrated in a recent study evaluating nearly 2 million patients with covid- 19, which found chronic pain to be the most common lingering complaint at least 30 days after diagnosis, affecting 5.1% of the 23% of patients with so- called long haul symptoms. https://collections.nlm.nih.gov/catalog/nlm:nlmuid-9918334383006676-pdf

Cohen et al. (2022, BMJ, https://bmjmedicine.bmj.com/content/1/1/e000108) reviewed the various mechanisms by which chronic pain can occur after infection (figure).

Inflammation after infection might cause an abnormal immune response that triggers acute and chronic neuropathic, nociceptive, or nociplastic pain. Several mechanisms are discussed:

1. M;imicry of axolemmal surface molecules (gangliosides) by microbial antigens leading to an antibody mediated attack on the nerve axolemma. Examples of such immune related painful conditions are multiple sclerosis, reactive arthritis, inflammatory bowel disease, and Lyme disease.

Similarly, infection could trigger autoimmune related pain via epitope spreading and bystander activation.

2. In epitope spreading (also known as antigen spreading), endogenous epitopes develop secondary to the release of self- antigens during inflammation. https://pubmed.ncbi.nlm.nih.gov/25445494/

3. Bystander activation is characterized by autoreactive B and T cells that are activated in an antigen independent manner. https://pubmed.ncbi.nlm.nih.gov/31326230/

4. Antimicrobial toxicity. Antiviral drug treatments augment oxidative stress with subsequent neuropathy and tissue damage.

5. Central Sensitization central sensitization from physical or psychological triggers. Central sensitisation is defined as an increased responsiveness of nociceptors in the central nervous system to either normal or sub-threshold afferent input. https://www.iasp-pain.org/resources/terminology/?navItemNumber=576

13/07/2022

In osteoarthritis there is an imbalance of factors regarding tissue degradation vs. tissue repair: It`s not wear-and-tear!

🤓👇👇

👉Many proinflammatory cytokines and growth factors have been identified in the OA joint (Figure, https://jamanetwork.com/journals/jama/article-abstract/2776205).Cytokines present at relatively high levels in OA synovial fluid include interleukin (IL) 6, monocyte chemoattract antprotein1,vascular endothelial growth

👉 The pro-inflammatory factors are responsible for the progressive destruction and remodeling of the joint through the stimulation of matrix-degrading enzymes, including the matrix metalloproteinases. https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.34453, https://linkinghub.elsevier.com/retrieve/pii/S1063458420300509

👉 The growth factors that normally would stimulate matrix production and repair of joint tissues are overwhelmed by pro-inflammatory mediators. Certain growth factors including TGFβ and BMP-2 promote osteophyte formation and contribute to subchondral sclerosis.

👉 The pro-inflammatory mediators and anabolic factors are produced locally by the cells within the affected tissues including the articular chondrocytes, synovial fibroblasts and immune cells in the synovium, inflammatory cells in periarticular fat, as well as cells in bone, including osteoblasts, osteocytes, osteoclasts and bone marrow mesenchymal stem cells
https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.34453, https://linkinghub.elsevier.com/retrieve/pii/S106345841501300X

👉 The cytokines are potential targets for disease modification in OA; however, currently it is not clear which cytokines are primary drivers of joint destruction, and which are involved secondarily.

Abbreviations
(IL, interleukin; LIF, leukemia inhibitory factor; MCP, monocyte chemoattractant protein, MIF, macrophage migration inhibitory factor; MIG, monokine Induced By Interferon-Gamma; bFGF, basic fibroblast growth factor; TGF, transforming growth factor; IGF, insulin-like growth factor, BMP, bone morphogenetic protein; CDMP; cartilage-derived morphogenetic protein.)

29/06/2022

This Review summarizes problems with the hands, wrists, and fingers that are commonly encountered in primary care, including carpal tunnel syndrome and arthritis, among others, and offers a range of treatment options for each.

28/03/2022

Amyotrophic lateral sclerosis is the most common motor neuron disease in adults. Unfortunately, delayed diagnosis and uncertain prognosis are usual, with implications for outcomes; timely interventions can slow disease progression.

This new Series in The Lancet Neurology aims to provide clinicians with a review of the latest advances in research ➡️ https://hubs.ly/Q016Vr_P0

24/03/2022

Seguimiento del paciente post-COVID: complicaciones pulmonares y extrapulmonares agudas

VISUALES Y APUNTES ➕ https://bit.ly/Complicaciones-POST-COVID

A lo largo de las últimas semanas hemos ido abordando diferentes aspectos de la COVID-19: sus efectos a largo plazo o sus complicaciones neurológicas agudas y post agudas. Esta revisión la hemos basado en el nuevo manual 'Fisiopatología de la COVID-19 en diferentes órganos y sistemas', un de estudio imprescindible para los profesionales interesados en aprender más sobre esta enfermedad. Hoy ofrecemos el último capítulo de la serie a través de dos visuales sobre las complicaciones agudas de la COVID-19: pulmonares y extrapulmonares