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Medical Insider Blog

Stimrouter for shoulder pain in stroke patients

  • Posted Jun 21, 2016
  • hchadmin

You may not know this, but individuals who suffer from stroke commonly see the muscles surrounding their shoulder become weaker and weaker and their shoulder gradually dislocates from the socket.

When this happens, it is extremely painful, and the patient -- because of the stroke -- often lacks the ability to express the pain because they've been rendered mute by the stroke itself.

Additionally it is not uncommon for the stroke itself to damage the pain-sensing system which results in a magnification of an already extremely painful syndrome!

The Stimrouter is a small, thin wire that is implanted with a needle in the shoulder next to the axillary nerve. It is then tunneled to the surface just underneath the skin where, on the outside of the arm, a tiny patch is placed to transmit electrical signals down to the nerve for two reasons: 1) to activate the deltoid muscle, which then relocates the humorous bone into the shoulder joint stopping the dislocation, and 2) to actually block the signal of pain that is transmitted to the brain from the shoulder itself.

The appropriate candidate, first and formemost, is any stroke patient who has shoulder pain. Additionally, the Stimrouter has also been approved for stimulation of any nerve in the trunk or extremities for any nerve-related pain. Click here for a patient testimonial. 

While the shoulder pain isn't necessarily associated with nerve damage in the shoulder, it is associated with the the nerve damage in the brain itself and the consequence is an extremely painful syndrome called shoulder hand syndrome. 

Regarding sciatic nerve pain, the Stimrouter is not the best tool in the bag for these issues, but there are many other types of implantable devices for sciatic pain that work extremely well.  Many of those are standard spinal cord stimulator devices, but also dorsal root ganglion stimulator devices and many others.  
When patients ask how they can relieve the shoulder pain after a stroke, we have been having great difficulty for many years treating this problem.  Usually we brace the shoulder or put the shoulder into a sling, but this very poorly treats the underlying problem. And that is why the Stimrouter is such a revolutionary concept and product.

Shoulder pain from other causes such as labral tears and rotator cuff tears and arthritis are probably still best served by an orthopedic surgeon.
However, as technology advances, if we can get better and better at blocking pain, we may be able to treat shoulder pain itself without surgery in the future.

W. Porter McRoberts, MD
Interventional Spine and Pain Medicine  

 

Minimally Invasive Hernia Repair

  • Posted Apr 25, 2016
  • Michael Perez, MD

One of the most common reasons individuals seek surgical medical attention is for hernia repair. Over 600,000 hernias are repaired annually in the United States alone, the majority on an outpatient basis. 

Hernias commonly occur at natural openings in the body such as the umbilicus, inguinal canal or esophageal hiatus. They can also occur at sites of previous surgical incisions. When a loop of intestine or abdominal tissue pushes into the hernia sac, severe pain and other potentially serious complications can result.

There is no adequate nonsurgical medical treatment for a hernia. Under certain circumstances the hernia may be watched and followed closely by a physician. These situations are unique to those individuals who are at high risk for operation. Minimally invasive hernia surgery has been perfected in the past 2 decades. The goals are: to reduce pain, improve outcomes and reduce the time of recovery. In laparoscopic minimally invasive hernia surgery, a telescope attached to a camera is inserted through a small incision. This technique is the same whether or not robotic assistance is employed. Other small incisions are made in the abdomen.

The hernia defect is reinforced with a mesh and secured in position with stitches or staples, depending on the preference of the surgeon. The principles of surgical repair involve the use of prosthetic mesh to repair defects in order to minimize tension on the repair. A tension free repair has a lesser chance of hernia recurrence. In addition the risk of infection is markedly decreased compared to traditional open hernia repair. In fact, for inguinal hernia repairs, we can even perform the dissection in the extraperitoneal space, avoiding any intra-abdominal adhesions.

For all types of minimally invasive hernia repairs, patients are able to return to normal activity much faster. My experience with minimally invasive inguinal hernia repairs has shown that patient can even return to full athletic activity within 1-2 wks. A patient is a candidate for laparoscopic hernia repair if they are medically able to undergo the appropriate anesthesia. Also, the defect must be in an area that allows the surgeon to place the laparoscopic or robotic trocars in positions where repair is possible. In some very large hernias, the abdominal wall is distorted to such a degree that it is impossible to safely place laparoscopic instruments. Even in these cases the techniques learned with minimally invasive surgery can be applied to decrease the trauma of open repairs.

Patients with hernias should be referred to appropriately trained surgeons to assess the feasibility of minimally invasive hernia repair. Minimally invasive surgery involves laparoscopic techniques and robotic assistance may be appropriate as well.

Click here to learn more about Dr. Michael Perez.


Stretching: The Truth

  • Posted Nov 04, 2015
  • M. Alicia Edwards, MS, ATC

Stretching has been greatly studied in the past 15 years, and the results are in: static stretching is no longer a prerequisite to exercise and sport. Dynamic stretching has taken its place when preparing muscles and joints for physical activity. There are many questions that arise when it comes to exercise prep and optimizing performance:


               Are you still an avid pre-exercise static stretcher?         
         What is dynamic stretching? 
   Do you warm up?     Should you cool down?


Let's discuss each of these further.


Low Load Long Duration (Static) Stretching


Static stretching is defined as "to stretch muscles at rest." This seems counterproductive when we think about the times this type of stretching is most often performed – before exercise or sport. According to research, this type of stretching has been shown to actually decrease athletic performance. This fact is well known around the strength training community, and studies have only recently been testing the effect of this type of stretching with endurance athletes. Prolonged static stretching of a muscle and tendon decreases its 'stretch response,' which is a response where the muscle and tendon stores energy when it is stretched quickly.   When this reflex decreases, the muscles are weaker, subsequently decreasing performance.  So, you may be wondering, "Is static stretching even necessary?" The answer is YES, as long as it is done at the end of the exercise. Lengthening muscles and tendons is an important part of every physical activity routine and is appropriate for all ages.


Dynamic (Functional) Stretching


Dynamic and functional stretching help lubricate the joints and prepare the body for the bulk of the activity or workout. This is done by stimulating the same 'stretch response' we previously discussed. This type of stretching stores energy within the muscles and tendons and will translate to increased reflex response and athletic performance. For lower body, athletes' functional movements may include things like bodyweight squats, high knees, jumping jacks and lunges. For upper body athletes like overhead throwers or swimmers, these moments may include arm swings, arm circles and push-ups. 


Warm-up


For most people who currently participate in an active lifestyle or play a competitive sport, the concept of completing a warm-up prior to activity is a no-brainer. A proper warm-up is a proven way to help decrease the risk of injury, as well as increase athletic and physical activity function.  A warm-up is a mild to moderate physical activity that increases blood flow to the upper body and lower body musculature. It literally 'warms up' the muscles and joints, prepares the cardiovascular system for increased work and increases the body temperature. Hemoglobin in the blood releases oxygen easier at a higher temperature. Translation: more oxygen and blood to the muscles equals better performance. 


Cool Down


Cooling down after strenuous activity allows the body to gradually return to homeostasis. Homeostasis is 'your body's happy place.' It is when your body's internal functions are regulated at a normal, comfortable state. Letting the body cool down can be a safer way to complete exercise. How many people (including yourself) have you known to become faint or dizzy following exercise? Part of the reason this happens is because exercise is ended abruptly. This allows blood to pool in the large muscles groups of the legs. Slowly decreasing activity will let the body slowly readjust and redistribute the blood, decreasing the risk of becoming faint or lightheaded.


What does all this mean?


So, the take away is this: no matter what activity you are performing, a proper warm-up is always the first step, followed by dynamic stretching, cool down, and finally, static stretching.  The simple rearrangement of these components may very well be the key to better performance!

Stay tuned for next month's topic:  "Adhesions are the Reasons?" We'll discuss chronic tightness from myofascial restrictions and adhesions, how to find out if you have an adhesion and what you can do about it.


M. Alicia Edwards, MS, ATC, is a certified athletic trainer who practices with Holy Cross Orthopedic Institute Fort Lauderdale's Sports Medicine Program. For a sports medicine physician referral, call 954-900-6653.


Understanding Urinary Incontinence

  • Posted Oct 19, 2015
  • Anele R. Manfredini, MD

Urinary Incontinence (UI) is a condition involving an involuntary loss of urine that affects millions of women. The risk of public embarrassment may keep patients from enjoying many activities. When urine loss occurs during sexual activity, it can cause tremendous emotional distress.

Women experience UI twice as often as men. Pregnancy, childbirth, menopause and the structure of the female urinary tract account for this difference. However, both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis and physical problems associated with aging. Most cases of UI affect older women, but it can be seen at all ages.

Reversible Causes of Urinary Incontinence

There are reversible causes of UI that should be excluded before extensive work-up:
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction

Types of Urinary Incontinence

Stress Incontinence: involuntary loss of urine during an increase of intra-abdominal pressure produced from activities such as coughing, laughing or exercising.

Overactive Bladder / Urge Incontinence: the involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full.

Overflow Incontinence: urine loss associated with overdistension of the bladder, typically caused by an underactive bladder (detrusor) muscle and/or outlet obstruction.

A diagnosis of UI can be made on the basis of a history, a good physical examination and laboratory tests.

Treatment Options for Urinary Incontinence

Stresss Incontinence: Treatment includes the rehabilitation of pelvic floor muscles through the use of pelvic muscle exercises (Kegel exercises), weighted vaginal cones and pelvic floor electrical stimulation. Other options include occlusive devices such as pessaries, alpha-adrenergic drugs and local estrogen replacement therapy (ERT).

Overactive Bladder: Treatments include behavioral therapy, pharmacologic agents, pelvic floor electrical stimulation, extracorporeal magnetic innervation, local ERT and neuromodulation.

Mixed: Treatment is based on the predominant symptom.

Overflow Incontinence: Treatments include medications, catheters to empty the bladder if necessary; and if no improvement, then surgery.

Physical Therapy / Rehabilitation

Physical therapists evaluate and treat joint dysfunction, muscle tightness, and weakness or imbalance in muscle groups. Women's health physical therapists, trained in the area of pelvic health, can identify possible reasons for pelvic floor dysfunction and develop a treatment plan, with your physician, specific to you. They may use hands-on techniques to address muscle tightness, or give you targeted exercises to improve muslce strength and correct problems. Other treatment strategies include biofeedback, postural training and strengthening of the core muscles.

Benefits of Physical Therapy

• Gives you control over your life and your bladder
•  Saves money and embarrassment by allowing less use of pads and undergarments
• Reduces use of medications for incontinence
•  Possibly prevents the need for surgery

Reference: Am Fam Physician. 2000 Dec 1;62(11):2433-2444

Dr. Anele Manfredini is a family medicine physician who specializes in women's health and practices at our Holy Cross Dorothy Mangurian Comprehensive Women's Center in Fort Lauderdale, FL. Our Women's Center also offers Women's Health Rehabilitation Services that offer treatments for pelvic floor dysfunctions and women's health issues. For referral information for Dr. Manfredini and/or Women's Health Rehabilitation Services, call 954-900-6653.


Abnormal Uterine Bleeding: Advances in Treatment

  • Posted Aug 12, 2015
  • Ghea Adeboyejo, MD

Chronic abnormal uterine bleeding is a problem that plagues 20% to 35% of women at some time in their lives, and generates 2.7 million office visits each year in the U.S. This chronic heavy or chronic prolonged vaginal bleeding exerts a heavy price in terms of quality of life, lost time from work and healthcare resources. Initial management usually begins with pharmaceutical treatment. While some patients are adequately treated with medical therapy, others may require or desire a longer acting, lower maintenance option. In the past, treatment options were limited and many women required a hysterectomy to control abnormal bleeding. While some cases of abnormal bleeding are still best treated with hysterectomy, newer minimally invasive procedures may offer women relief from chronic benign bleeding without long recovery times or the risks of surgery and general anesthesia.

Endometrial Ablation

Endometrial ablation is a minimally invasive option for the treatment of heavy or prolonged vaginal bleeding. The first generation non-resective endometrial ablation device was FDA-approved in 1997. Ablation of the endometrium is performed by inserting a device into the uterine cavity to uniformly destroy the uterine lining. The gynecologist can accomplish this with extremes of temperature—either heating or cooling.

There are currently five non-resective ablation devices available in the U.S. All of these devices reduce bleeding in 80% or more of women who undergo treatment. Once it is confirmed by biopsy that uterine bleeding is not due to endometrial malignancy, the gynecologist may select the most appropriate device for that patient. Uterine size and the size of any sub-mucosal fibroids are factors that affect device selection. The ability to perform endometrial ablation in an office setting offers the benefit of reduced patient costs, greater patient acceptability and ease of scheduling. All non-resective ablation procedures can be performed in the office setting under local anesthesia; however, cryoablation appears to be associated with the least pain during the procedure.

Cryoablation

Cryoablation offers two distinct advantages over the heating modalities—decreased operative pain and the fact that it is performed under direct ultrasound guidance. A Heroption device cools the endometrial tissue to sub-zero temperature. This extreme cooling destroys the basal layer of the endometrium and causes numbness. Less operative pain allows us to perform cryoablations in the comfort of an office setting using only oral and local analgesics. In addition, the use of perioperative ultrasound helps to ensure complete ablation and avoid many complications.

Other methods of endometrial ablation use high heat, thus stimulating pain fibers and are therefore usually performed in the operative suite under general anesthesia. In addition, thermal ablations are not routinely performed with ultrasound assistance.

Benefits of Cryoablation

In-office endometrial cryoablation is a safe and effective treatment for benign, heavy or frequent uterine bleeding. Its advantages include avoidance of potential complications associated with general anesthesia or hysterectomy, less pain, and extremely short recovery time.

Recovery Time After Endometrial Ablation

Most patients are able to return to work in one to two days after endometrial ablation. In addition, most studies have shown an 85%-90% satisfaction with treatment after ablation. In one study, 30% of women reported no further periods, 39% reported scanty, infrequent periods, and 29% reported a return to normal light periods at one year follow up.

Dr. Adeboyejo is an OB/GYN with the Holy Cross Medical Group in Fort Lauderdale, FL. For referral information, call 954-900-6653.


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About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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