Neuro-Rehabilitación Temprana

Extending the straight leg raise test 🤓

👉 The straight leg raise test (SLR, here a figure from the renowned New English Journal of Medicine) is traditionally considered a classic test in orthopedics for the inclusion or exclusion of a compressive event (classically a herniated disc) in the lumbar spine. If a radiating pain occurs below the knee joint with a flexion of the leg between 30°-70° (the information here is very variable), a positive test result was assumed.( https://pubmed.ncbi.nlm.nih.gov/25806916/, https://pubmed.ncbi.nlm.nih.gov/10788860/, https://pubmed.ncbi.nlm.nih.gov/38771839/)

👉 However, it should be known that the SLR is quite well suited to rule out such a herniated disc (imaging or findings during surgery) with regard to the presence of a herniated disc (imaging or findings during surgery) (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007431.pub2/full, but its specificity is low in this respect. https://pubmed.ncbi.nlm.nih.gov/29253501/, https://books.google.de/books/about/Netter_s_Orthopaedic_Clinical_Examinatio.html?id=RJ0MEAAAQBAJ&redir_esc=y)

👉 It must be mentioned that in a modern understanding, the SLR not only indicates a stretching of the nerve root via space-occupying intervertebral disc material (see figure), but also an increased mechanosensitivity in general.( https://pubmed.ncbi.nlm.nih.gov/29385943/, https://pubmed.ncbi.nlm.nih.gov/32766466/). For example, neuritis, inflammation without axonal damage or radiculitis without nerve compression could also cause a positive SLR, as increased mechanosensitivity is also to be expected here. (https://pubmed.ncbi.nlm.nih.gov/11585565/, https://pubmed.ncbi.nlm.nih.gov/16154692/, https://pubmed.ncbi.nlm.nih.gov/8235812/)

👉In addition, it should be borne in mind that many asymptomatic people have herniated discs on images, so that the reference standard "imaging" appears questionable in this respect (so-called verification bias). (https://pubmed.ncbi.nlm.nih.gov/25430861/, https://pubmed.ncbi.nlm.nih.gov/34548049/)

👉 Nevertheless, the validity of the SLR for herniated discs or nerve root compression can be significantly improved by structural differentiation, some of which has already been used in the past: Pesonen et al. propose the following differentiation as an extension of the SLR (ESLR) in several studies. (s. pictures in comments)

In the respective hip flexion position (if below 90°), in which the patient's problems occur or intensify, structural differentiation is carried out. The SLR is considered positive if:

📍 1. Symptoms of SLR occur and
📍 2. through the appropriate structural differentiation (distal →in proximal symptoms, proximal →in distal) an intensification of symptoms occurs. (see illustration in the comments)

📍So if the patient reports distal symptoms, then an internal rotation of the hip differentiates structurally, i.e. neural vs. non-neural.

📍 If, on the other hand, the patient describes proximal symptoms, then dorsiflexion in the upper ankle joint is used as a corresponding differentiation. (https://pubmed.ncbi.nlm.nih.gov/33761924/, https://pubmed.ncbi.nlm.nih.gov/34548049/)

👉Compared to traditional SLR, the authors were able to determine a significantly higher likelihood ratio (i.e. higher diagnostic accuracy, background s. https://flexikon.doccheck.com/de/Likelihood-Quotient) for nerve root compression on MRI (2.4 (p = 0.34) vs. 5.6 (p < 0.05). A positive ESLR increased the chance of a herniated disc or nerve root compression by a factor of 8. (https://pubmed.ncbi.nlm.nih.gov/34548049/)

Los estímulos ambientales físicos y cognitivos son capaces de lograr un "rejuvenecimiento molecular del cerebro”

» https://www.t13.cl/595316-fb

"Cualquier alteración o déficit en su funcionamiento va a verse relacionada de forma directa con la calidad de la marcha y, por tanto, con la perdida de autonomía y riesgo de caída"

Fisioterapeuta recuerda que el deterioro cognitivo conlleva déficit motor que aumentan el riesgo de caída La fisioterapeuta de la Asociación Española de Fisioterapeutas en Neurología (AEF-NEURO), Isabel Alen...

¿Escuchar música sirve para el insomnio?

🔹Probablemente mejora la calidad del sueño

🔹Podría mejorar la duración del sueño

🔹Se desconoce si afecta las interrupciones del sueño

🤝 En colaboración con

If you’re Starting Strength training and you’re older then why not use machines: accessible, possibly less intimidating, AND effective!

Resistance training is evidenced to positively impact the functional performance of older adults, which serves to maintain independence and quality of life, preventing or delaying institutionalization or hospitalization. It has been proposed that training interventions should implement resistance and balance exercises associated with movements needed in everyday life, following the principle of “train the movement, not the muscle.” However, this strength training philosophy presents challenges, and the use of resistance machines might present an efficacious alternative… the current data supports that significant strength and functional performance outcomes are attainable using uncomplicated, machine-based resistance training.

Say goodbye to intimidation and hello to accessible, effective workouts that enhance independence and quality of life. 🌟 Ready to get stronger and stay active? Check out the full study for all the details! 📖👉 https://sportrxiv.org/index.php/server/preprint/view/428



🔗https://sportrxiv.org/index.php/server/preprint/view/428

Smartphone use on sleep and memory consolidation

The researchers show that nighttime smartphone use suppresses melatonin secretion significantly longer in adults than in adolescents who can recover if the smartphone is switched off 50 min before bedtime.

https://academic.oup.com/braincomms/article/6/3/fcae173/7675955
http://sciencemission.com/site/index.php?page=news&type=view&id=publications%2Feffects-of-evening&filter=22

Dermatomes and Myotomes of the Upper Limb according to Netter🙋‍♂️

📘 https://books.google.de/books/about/Netter_s_Neurology_E_Book.html?id=mnCaiQyfOFoC&redir_esc=y

The Pathophysiology of Radicular Pain 💡

👉 Radicular pain is a form of pain caused by irritation of the sensory root or the dorsal root ganglion (DRG) of a spinal nerve (https://link.springer.com/referenceworkentry/10.1007/978-3-540-29805-2_3710).

👉Radicular pain is not nociceptive pain, for the neural activity arises from the dorsal root, and not from stimulation of peripheral nerve endings. Therefore, it is not synonymous with somatic pain or somatic referred pain and needs to be distinguished from them. Nor is radicular pain synonymous with radiculopathy. Whereas radicular pain is caused by the generation of ectopic impulses, radiculopathy is caused by the blocking of conduction along sensory and motor axons, and is characterised by loss of nerve function (https://link.springer.com/referenceworkentry/10.1007/978-3-540-29805-2_3710).

👉 Mechanistically, radicular pain is characterized by spreading of the afferent nociceptive input combined with complex cellular and molecular processes that initiate and maintain the increased nociceptive signal input. Furthermore, both anatomical (https://pubmed.ncbi.nlm.nih.gov/10568867/, https://pubmed.ncbi.nlm.nih.gov/17850967/) and electrophysiological (https://pubmed.ncbi.nlm.nih.gov/20147564/) studies suggest that the spreading of radicular pain involves adjacent spinal segments. This supports the common clinical observation of involvement of multiple nerve roots, despite a single level of pathology.

👉 Although the spreading of the radicular afferent signal is a complex phenomenon, a certain sequence in the inflammatory cascade is apparent (s. figure, https://pubmed.ncbi.nlm.nih.gov/24553305/). Beginning with the disc degenerating nerve, proinflammatory cytokines are released at the site of lesion and at a distance through Wallerian degeneration (WD). During degeneration of the distal axon by WD, TNF-α is released by Schwann cells, endothelial cells, mast cells, and resident macrophages at the site of nerve injury. This causes ectopic firing at the dorsal root ganglion (DRG)), leading to an increased release of neurotrophins and ectopic firing at the dorsal horn, eventually leading to central sensitization (https://pubmed.ncbi.nlm.nih.gov/14624855/, https://pubmed.ncbi.nlm.nih.gov/15120588/, https://pubmed.ncbi.nlm.nih.gov/2388084/, https://pubmed.ncbi.nlm.nih.gov/10366647/).

👉 The cellular-molecular cascade may also start form the herniated disc material. The extrusion of material from the nucleus pulposus onto the spinal nerve leads to edema and ischemia. Experimental work has shown that exposure of nerve root (proximal to the DRG) to material from the nucleus pulposus material increased endoneurial fluid pressure and decreased blood flow into the DRG with secondary edema (https://pubmed.ncbi.nlm.nih.gov/9854750/). A key mediator released after disc herniation is the proinflammatory cytokine TNF-α. When TNF-α reaches the nerve root, production of the neurotrophic factor (NGF) in the surrounding inflamed tissue is initiated (https://pubmed.ncbi.nlm.nih.gov/9179382/, https://pubmed.ncbi.nlm.nih.gov/14615047/, https://pubmed.ncbi.nlm.nih.gov/12237190/).

👉 This, in turn, induces the production of another neurotrophin ,brain-derived neurotrophic factor (BDNF), in the DRG (https://pubmed.ncbi.nlm.nih.gov/12237190/, https://pubmed.ncbi.nlm.nih.gov/22280975/).Besides their neurotrophic qualities, such as the induction of nerve sprouting, both NGF and BDNF are also recognized as important factors in the development of central sensitization (https://pubmed.ncbi.nlm.nih.gov/16543102/) and may play important role in the pathophysiology of radicular pain. The release of cytokines may also directly interfere with both activity and expression of various ion-channels in the DRG (https://pubmed.ncbi.nlm.nih.gov/19339603/).

👉 In radicular pain, ectopic discharges can be generated at different locations of the nervous system. from electrophysiological analysis, it was calculated that approximately 75% of the overall ectopic firing was generated at the DRG and only 25% at the lesion or neuroma (https://pubmed.ncbi.nlm.nih.gov/10781925/). Cytokines and neurotrophins can initiate modulation and phosphorylation of ion channels, which forms the basis for generation of ectopic action potentials or ectopic firing (https://pubmed.ncbi.nlm.nih.gov/7999002/, https://pubmed.ncbi.nlm.nih.gov/21525373/). Because repetitive firing of the pain afferents forms the physiological reason for central sensitization (https://pubmed.ncbi.nlm.nih.gov/15120588/), this clearly contributes to the clinical syndrome of radicular pain (https://pubmed.ncbi.nlm.nih.gov/24553305/).

Las caídas son un problema para las personas mayores en los hogares.

Estas son las 3 intervenciones que podrían ayudar a prevenir las caídas:

✅ Eliminar los peligros en el hogar

✅ Usar gafas bien graduadas

❌ Se desconoce si los programas educativos pueden reducir el riesgo

🤝En colaboración con el Ministerio de Sanidad

👉🏻 Síguenos para más recursos para tomar mejores decisiones en salud

Cloward sign and referred pain by deep tissue stimulation of the cervical spine 💡

👉 In 1959, Ralph Bingham Cloward (1908–2000), published referral patterns of the cervical spine discs using cervical discography (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1629000/, s. Figure 1 a)

👉 He found that stimulating the anterolateral aspect of the cervical discs produced pain at the ipsilateral scapula. Stimulation in the midline of the anterior aspect of the disc produced pain between the shoulders in the middle of the back. Cloward described that pain from the C6-7 disc was felt in the inferior angle of the scapula. Pain from the C5-6 disc was felt in the center of the medial scapular border. Pain from C4-5 disc was experienced in the region of the spine and superior angle. Pain from the C3-4 disc was referred to the C7 spinous process and the posterior border of the trapezius muscle.

👉 Cloward also documented that when stimulating patients with posterolateral disc protrusions, the referral patterns were found to be more intense than when stimulating the anterior aspect of the disc and were found to spread from the vertebral border of the scapula out to the shoulder and upper arm as far as the elbow. idline posterior disc protrusions were found to refer pain to a confined area overlying the fifth cervical to the second thoracic spinous processes near the midline, with upper discs more cephalad and lower discs more caudad.

📷 Figure (https://link.springer.com/chapter/10.1007/978-3-319-31169-2_26): Cutaneous radiation of pain during irritation of individual structures. (a) Radiation of pain during irritation of intervertebral discs (Modified after Cloward, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1629000/); (b) radiation of pain during irritation of deep musculoligamentous structures in interspinous space (Modified after Feinstein, https://pubmed.ncbi.nlm.nih.gov/13211692/).

Just published 🔥 in JAMA

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

📘 https://pubmed.ncbi.nlm.nih.gov/38833257/

👉 Falls are common among older adults. In a 2018 survey, more than one-fourth of US older adults living in the community reported at least 1 fall in the past year. A serious fall in an older adult can result in injury (such as hip fracture) that causes decreased independence and decreased quality of life. The risk of falling increases with age for many reasons, including overall weakness and frailty; problems with balance, cognition, and vision; certain medications; acute illness; and other environmental hazards. Those who have fallen in the past are at high risk of falling again.

🤔 But how to prevent Falls in Older Adults?

👉 To answer this question, the US Preventive Services Task Force (USPSTF) reviewed many studies about interventions for older adults living in the community (not in a nursing home or other institutional care setting). These interventions include exercise therapy (such as working on gait, balance, and leg muscle strengthening), environmental assessments, medication reviews, and multifactorial interventions, which involve creating a customized plan based on individual risk factors. Among all of these interventions, exercise therapy was found to be most beneficial.

💡 The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults aged 65 years or older who are at in-creased risk of falls.

💡 For multifactorial interventions, there may be a small benefit, and primary care clinicians should consider multifactorial interventions for patients at higher risk of falling on a case-by case basis.

Hot off the press 🔥

Optimal Positions for Intervertebral Disc Rehydration💡

👉 Within the consistent daily rhythm of human life, intervertebral discs endure a variety of complex loads beyond the influences of gravity and muscle forces, leading to significant morphological changes (in terms of a reduction in volume, area, and height) as well as biomechanical alterations, including an increase in disc stiffness and a decrease in intradiscal pressure.

👉 Goode & Theodore [https://pubmed.ncbi.nlm.nih.gov/6683682/] observed that the morning height upon waking could be approximately 18 mm greater than the height at the end of the day. Through the use of ultrasound on seven volunteers, Ledsome et al. [https://pubmed.ncbi.nlm.nih.gov/8839471/] recorded an increase of 5.3 mm between the L1 and L4 vertebrae from evening to morning. Similarly, employing stereophotogrammetry on twelve younger individuals, Wing et al. [https://pubmed.ncbi.nlm.nih.gov/1502639/] noted a 20 mm increase in stature after 8 h of complete bed rest.

👉 In vivo studies on the effect of body posture on spinal diurnal changes have offered patients guidance on various movements to alleviate fatigue during work. Over the years, it has been established that the posture maintained during rest periods significantly impacts both overall stature and the recovery of disc height. For example, Magnusson et al. [https://pubmed.ncbi.nlm.nih.gov/7792550/] utilized stadiometry and a hinged table to demonstrate that a combination of 5 min of sitting with a 1 kg load applied to the shoulders, followed by 20 min of resting with passive hyperextension in a prone position (▶️ s. Fig. 6a), resulted in a significant disc height recovery (an average of 115%), surpassing the recovery observed from resting in a prone position without hyperextension (an average of 94%). They recommended 20 min of hyperextension in a prone position at a 20° angle for optimal height recovery [https://pubmed.ncbi.nlm.nih.gov/8961454/]. Furthermore, during the 5-min loading phase, they observed a notable height increase of 5.05 mm after just 15 s of hyperextension, significantly better than the 1.12 mm height gain from an unloaded sitting period [https://pubmed.ncbi.nlm.nih.gov/11415627/].

📘 Common reported other optimal position for disc rehydration after a period of heavy or sustaining lower back loading are described in a brand-new paper by Feki and colleagues. [https://link.springer.com/article/10.1007/s42235-024-00542-2 9].

▶️ 6 b. Press-ups: Munster et al. [https://pubmed.ncbi.nlm.nih.gov/29469602/], using forty-one healthy individuals, showed that 5 min of either sustained or dynamic prone press-ups could effectively unload the spine following 5 min of shoulder loading with 4.5 kg, resulting in a spine height increase of 4.46 mm (± 2.57 mm) and 4.85 mm (± 3.01 mm), respectively.
▶️ 6 c. Supine extension: Maintaining a supine position but with a cushion under the lumbar spine to ensure lumbar extension, Poortmans et al. [https://pubmed.ncbi.nlm.nih.gov/27637322/] observed an average spine height increase of 8.8 ± 2.5 mm.

▶️ 6d & 6e. Lumbar flexion at mid-range and end-range: Greke et al. [https://pubmed.ncbi.nlm.nih.gov/20833386/] investigated both mid-range and end-range lumbar flexion positions, where patients rested on their left side during unloading. They observed a significant increase in disc height, with a mean gain of 5.84 mm and 4.78 mm, respectively.

▶️ 6 f & 6g. Side-lying with/without manual distraction: The efficacy of the side-lying lumbar position in increasing disc height and hydration following a loading exercise was further supported by findings from Rodacki et al. [https://pubmed.ncbi.nlm.nih.gov/12690588/], Healey et al. [https://pubmed.ncbi.nlm.nih.gov/16338727/], and Rubinic et al. [https://pubmed.ncbi.nlm.nih.gov/31078315/].

Altogether, spinal flexion has been suggested as a beneficial exercise for patients aiming for disc recovery, as it facilitates the transport of large molecules into the disc through fluid flow [https://pubmed.ncbi.nlm.nih.gov/6685921/], enhances solute pe*******on into the posterior annulus thereby improving disc nutrition [https://pubmed.ncbi.nlm.nih.gov/3693067/], and increases foraminal dimensions [https://pubmed.ncbi.nlm.nih.gov/11317109/], which in turn augments disc height.

▶️ 6h. 50° gravity-assisted position: Research has shown that gravity inversion effectively counteracts the shrinkage of stature following loading and facilitates an increase in stature height. Boocock et al. [https://pubmed.ncbi.nlm.nih.gov/3229409/] observed a mean increase in total stature of 2.7 mm and noted that the rate of stature shrinkage following inversion unloading was twice that observed following rest in a standing position.

▶️ 6i. 110° supported sitting: Adopting a slouched sitting position, which involves sitting with an inclined backrests, leads to a reduction in intradiscal pressure. , Healey et al. https://pubmed.ncbi.nlm.nih.gov/16338727/ [] confirmed that 20 min of sitting with a backrest inclined at 110° facilitated stature recovery following a 20-min walking task.

▶️ 6 j. Inclined sitting with lumbar support: Pape and colleagues [https://pubmed.ncbi.nlm.nih.gov/28958435/] reported a mean spinal height increase during 10 min of slouched sitting without lumbar support of 2.94 ± 3.63 mm and of 4.74 ± 3.07 mm with lumbar support following a period of trunk loading.

🛑 Una reciente investigación ha encontrado que una mayor actividad física y ejercicio, no solamente pueden producir mejoras en la capacidad cognitiva, la función ejecutiva y la memoria de trabajo, sino también en el pensamiento creativo, lo que refuerza al ejercicio, como una estrategia eficaz, para mejorar la salud y el rendimiento cerebral general.

👨🏽‍🏫 Habrá que ver qué modalidades de ejercicio (p.ej., resistencia, fuerza, etc.), pueden ser más eficaces para mejorar la creatividad, o si presentan efectos similares.

🛑 EL Ejercicio incrementa la producción de neurotrófinas como BDNF, lo que mejora la neurogenesis y y modula la células inmunes en el sistema nervioso (microglia), lo que en conjunto previene la neurodegeneración y la aparición de enfermedades como al Alzheimer.

🛑El entrenamiento de fuerza mejora el brote axonal y la formación de nuevas uniones neuromuscular y preserva la fibras musculares, al reducir biomarcadores de denervación.

👨🏽‍🏫 Nunca es tarde para empezar a entrenar fuerza, siempre es demasiado temprano para dejar de hacerlo.

🛑 Mejorar la eficacia de la transmisión del impulso neural, a través de la inclusión de pocas series semanales de carga pesada y/o movimientos de alta velocidad de ejecución, priorizando la calidad del levantamiento, puede ser interesante para maximizar los resultados de desarrollo muscular crónicos.

👨🏽‍🏫 Además, una pérdida de la eficacia de trasmisión del impulso neural desde las aéreas corticales hacia la motoneurona inferior, da lugar al deterioro del reclutamiento y frecuencia de disparo de las UMs (unidades motoras), lo que se traduce finalmente en un estimulo pobre para el desencadenamiento de hipertrofia.

👉🏽 El incremento de la fatiga intrasesión por ejemplo, puede ser un potencial factor que impacte negativamente las adaptaciones a largo plazo. Por tanto, también es necesario realizar una gestión de la fatiga adecuada.

Pathophysiology of lumbar disc degeneration, disc herniation, and discogenic pain in a nutshell 💡

👉 Interaction of chemical and mechanicals factors as illustrated by Netter

📸Illustration: https://link.springer.com/chapter/10.1007/978-3-031-50357-3_24

❇️Pretty fascinating science on taste.

“Since taste receptor cells (TRCs) undergo rapid turnover, maintaining neurosensory integrity (i.e., sweet taste receptors signaling to “sweet” neurons) is essential.

➡️The labeled-line model of taste transmission connects taste reception and signal integration in the brain.

https://nej.md/4brYn6f