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Nieto-Blasco J, Castiella-Muruzábal S, Tuda-Flores JA, Fernández-Cuadros ME, Oliveros-Escudero B, Alaejos-Fuentes JA. [Winged scapula, a condition for the surgical area?]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:584-588. [PMID: 23099036 DOI: 10.1016/j.redar.2012.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 08/25/2012] [Accepted: 09/08/2012] [Indexed: 06/01/2023]
Abstract
The winged scapula secondary to long thoracic nerve injury is an uncommon condition. It is most frequently reported in the literature associated with surgical activities, either due to poor positioning during anesthesia or by an iatrogenic traumatic event during surgical procedures. We expose 3 cases and a brief etiological and literature review, to present the multiple origins of this injury, which are not always related to this area of activity, as these are not the only causes of this injury.
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Fajardo Pérez M, Alfaro de la Torre P, López Álvarez S, Diéguez García P. [Comments to the article "thoracic paravertebral block plus pectoral nerve block for mastectomy in a patient with advanced amyotrophic lateral sclerosis"]. ACTA ACUST UNITED AC 2013; 61:354-5. [PMID: 24144349 DOI: 10.1016/j.redar.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 08/11/2013] [Accepted: 09/04/2013] [Indexed: 11/19/2022]
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Sopena-Zubiria LA, Fernández-Meré LA, Valdés Arias C, Muñoz González F, Sánchez Asheras J, Ibáñez Ernández C. [Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:12-17. [PMID: 22429631 DOI: 10.1016/j.redar.2011.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 10/26/2011] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. MATERIAL AND METHODS An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. RESULTS In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. CONCLUSIONS Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.
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Imai M, Obokata M, Ono Y, Kobayashi N, Kuribara J, Ui G, Tange S, Kamiyoshihara M. [Case report; a case of refractory vasospastic angina with twice CPA event related to dysfunction of autonomic nervous system, which was successfully treated with thoracic sympathectomy]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2011; 100:3634-3636. [PMID: 22338896 DOI: 10.2169/naika.100.3634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Paluzzi A, Woon K, Bodkin P, Robertson IJ. 'Scapula alata' as a consequence of park bench position for a retro-mastoid craniectomy. Br J Neurosurg 2007; 21:522-4. [PMID: 17852104 DOI: 10.1080/02688690701504063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We report on a patient who developed winged scapula on the contralateral side to the approach for a cerebellopontine tumour excision, an unreported complication following this procedure. We think this was due to damage of the long thoracic nerve in the dependant side, while in the park bench position.
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Sailler L, Madaule S, Astudillo L, Carel C, Pugnet G, Miliotto O, Arlet P. Neuropathie thoracique douloureuse isolée: première description au cours d'une maladie de Gougerot. Rev Med Interne 2007; 28:191-3. [PMID: 17188404 DOI: 10.1016/j.revmed.2006.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Accepted: 11/10/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Thoracic neuropathy is rare, and is usually associated with diabetes mellitus. We report a first case of isolated multi-metameric thoracic neuropathy revealing Sjögren's disease. EXEGESIS A 64-year old man consulted for symptoms suggesting a progressive and extensive (from T7 to T10) bilateral thoracic neuropathy. Diabetes mellitus and other causes of neuropathy were excluded. Spinal MRI, electromyography and CSF analysis were normal. Though the patient had no sicca syndrome symptoms, the diagnosis of Sjögren's syndrome was made on hypergammaglobulinemia, elevated ACAN (1/5000) with anti-SSA specificity and a grade III minor salivary gland biopsy. He improved spectacularly on corticosteroids (prednisone, 1 mg/kg/d). Sicca syndrome became clinically evident in April 2006. CONCLUSION Pure sensitive thoracic neuropathy can reveal Sjögren's syndrome.
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Lee SH, Sung JK. Inflammatory pseudotumor of the spinal nerve complicated by paraneoplastic pemphigus. Case illustration. J Neurosurg Spine 2006; 4:514. [PMID: 16776366 DOI: 10.3171/spi.2006.4.6.514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lo YL, Prakash KM, Leoh TH, Tan YE, Dan YF, Ratnagopal P. Pectoral Nerve Conduction Studies: Technique in Healthy Subjects and Evaluation of Brachial Plexopathy. Arch Phys Med Rehabil 2005; 86:1702-5. [PMID: 16084829 DOI: 10.1016/j.apmr.2005.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To define the optimal nerve conduction study (NCS) technique of the pectoral nerves and evaluate its clinical utility. DESIGN Prospective electrophysiologic study with healthy controls. SETTING Electrophysiologic laboratory in a large general hospital. PARTICIPANTS Thirty healthy controls and 10 patients with cervical root or brachial plexus pathologies. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Correlation of pectoral NCS with electromyography and magnetic resonance imaging. RESULTS For pectoral NCS, the mean values +/- standard deviation of onset latency, amplitude, and interside amplitude ratio (ratio of smaller over larger amplitude) were 2.01+/-0.22 ms, 11.75+/-2.21 mV, and .95+/-.04 mV, respectively. Subject age correlated significantly with both onset latency (r=.46, P<.001) and amplitude (r=-.34, P<.008). All 5 patients with brachial plexopathy had amplitude ratios below the normal limit of controls (.87). However, this was not seen for all 5 patients with cervical spondylotic radiculopathy. CONCLUSIONS The pectoral NCS technique is feasible in healthy subjects. It is useful when differentiating brachial plexopathy from cervical root lesions.
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Chopra R, Morris CG, Friedman WA, Mendenhall WM. Radiotherapy and Radiosurgery for Benign Neurofibromas. Am J Clin Oncol 2005; 28:317-20. [PMID: 15923807 DOI: 10.1097/01.coc.0000156923.52181.3d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate the efficacy of radiotherapy (RT) and stereotactic radiosurgery (SRS) for neurofibromas. We studied 4 patients treated with RT (3 patients) or SRS (1 patient) and followed from 1.7 to 14.8 years. The tumor remained locally controlled in all patients. No significant complications related to treatment were observed. RT and SRS are likely to locally control neurofibromas in patients who require treatment and are not good candidates for complete resection.
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Ebata A, Kokubun N, Miyamoto T, Hirata K. [The bilateral long thoracic nerve palsy presenting with "scapula alata", as a result of weight training. A case report]. Rinsho Shinkeigaku 2005; 45:308-11. [PMID: 15912800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
A 28-year-old male barber with no similar disease in his family admitted to our hospital because of difficulty of raising his arms in March 2003. When he was 18 years old, he broke his left clavicle. He started weight training from January 2003, then he gradually felt difficulty to raise his arms. Physical examination on admission showed weakness and atrophy of both serratus anterior muscles and there was no weakness in the other muscles. Serum CK level was 806 IU/l and CT scan of the upper thoracic levels revealed atrophy of the serratus anterior muscles on the both sides. Needle electromyography showed neurogenic change in the right serratus anterior muscle. Thus the diagnosis of bilateral long thoracic nerve palsy was made. Bilateral scapular winging (scapula alata) is commonly caused by systemic disease, especially muscular dystrophy or spinal muscular atrophy. Bilateral long thoracic nerve palsy by weight training should be known as one of the cause for the "scapula alata".
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Abstract
Diabetic thoracic polyradiculopathy usually causes severe, chronic abdominal pain in patients with type 2 diabetes of variable duration. Other diabetic complications, weight loss and paretic abdominal wall protrusion are common. Sensory, motor and autonomic functions are affected. The diagnosis can be made from the characteristic history, physical examination findings, paraspinal electromyography, and other procedures. The differential diagnosis includes postherpetic neuralgia, abdominal wall pain, malignancy, and other spinal disorders. The pathology appears to be immune-mediated neurovasculitis resulting in ischemic injury. Traditional therapy is symptomatic, but recent pathological findings and clinical experience suggest that immunotherapy may be effective.
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Lopchinsky RA. Locating the axillary vein and preserving the medial pectoral nerve. Am J Surg 2004; 188:193-4. [PMID: 15249251 DOI: 10.1016/j.amjsurg.2003.12.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2003] [Revised: 12/22/2003] [Indexed: 11/23/2022]
Abstract
The exposure for an axillary dissection has become more limited as surgical treatment for breast cancer has evolved from a radical mastectomy to a limited axillary dissection. Exposure of the axillary vein is made more difficult by the smaller incisions, by preservation of intercostobrachial nerves, and by the induration resulting from a previous sentinel node biopsy. To assist in the identification of the axillary vein, I describe the course of a visible but small vein adjacent to the medial pectoral nerve. The vein can be easily identified at the lateral edge of the pectoralis major. It, frequently together with the medial pectoral nerve, traverses in a craniomedial direction and leads to either the lateral thoracic vein (near its junction with the axillary vein) or directly to the axillary vein. Dissection of this vessel identifies the axillary vein, preserves the medial pectoral nerve and allows a more complete and safe level II dissection.
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Ebied AM, Kemp GJ, Frostick SP. Measuring myoelectric fatigue of the serratus anterior in healthy subjects and patients with long thoracic nerve palsy. J Orthop Res 2004; 22:872-7. [PMID: 15183448 DOI: 10.1016/j.orthres.2003.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2003] [Accepted: 12/03/2003] [Indexed: 02/04/2023]
Abstract
Proper function of serratus anterior plays a vital role in the movement and stability of the scapula, and thus of the glenohumeral joint and the upper limb. The unique anatomy of this muscle makes direct measurements of its fatigue properties impossible. Here we describe for the first time indirect measurements of the myoelectric manifestations of fatigue in the serratus anterior. Eight healthy volunteers (29-35 years) were tested, four of them on two different occasions, using two exercise protocols (60 s isometric maximum upward force in 120 degrees arm flexion, and 60 s maximum forward force at 90 degrees arm flexion) with simultaneous recording by surface and wire electrodes applied according to established methods. Signals were analysed to obtain the rate of fall of median EMG frequency and the rate of rise of amplitude. Both exercise protocols gave similar results. Frequency-slope measurements (mean rate of fall 0.6+/-0.1% initial value per second (% s(-1)) with both surface and wire electrodes) were more precise than those of amplitude (mean rate of rise 2.6+/-0.3% s(-1) with surface electrodes, only 1.3+/-0.2% s(-1) with wire electrodes). Surface electrodes gave much lower variation than fine wires, the coefficient of variation of slopes for surface electrodes being approximately 20-40% both between studies in a single subject and between subjects. In 5 patients (aged 22-59 years) recovering from long thoracic nerve palsy studied using surface electrodes the frequency slopes was normal (0.6+/-0.1% s(-1)), while the amplitude slope was reduced (0.9+/-0.4% s(-1), P = 0.01). This shows abnormal fatigue properties of the reinnervated muscle and a dissociation between the frequency and amplitude manifestations of fatigue.
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Chappuis F, Justafré JC, Duchunstang L, Loutan L, Taylor WRJ. Dengue fever and long thoracic nerve palsy in a traveler returning from Thailand. J Travel Med 2004; 11:112-4. [PMID: 15109477 DOI: 10.2310/7060.2004.16983] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Van Harreveld A, Smith HM. On a "sympathetic" component in the afferent innervation of trunk dermatomes. J Neurophysiol 2004; 15:313-8. [PMID: 14955702 DOI: 10.1152/jn.1952.15.4.313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Newton CR, Victorino GP. Image of the month. Thoracic neurilemoma. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 2003; 138:341-2. [PMID: 12611584 DOI: 10.1001/archsurg.138.3.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kurokawa I, Kumano K, Murakawa K. Clinical correlates of prolonged pain in Japanese patients with acute herpes zoster. J Int Med Res 2002; 30:56-65. [PMID: 11921500 DOI: 10.1177/147323000203000109] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To determine which risk factors are relevant to the occurrence of post-herpetic neuralgia in Japanese patients with acute herpes zoster, correlations between the prolongation of pain and various disease factors were examined in 263 adult patients presenting within 10 days of the onset of rash at 17 institutions in the Hyogo region of Japan. All patients in whom pain persisted for more than 3 months were over 60 years of age. The pain also tended to be more prolonged in those with clustered vesicles, disturbed sleep and hypanaesthesia. Other factors such as underlying disease states, critically involved regions, scar tissue, generalized rash and allodynia were not relevant to the duration of pain. Although decreased pain persistence was observed in patients in whom acyclovir therapy was initiated within 72 h of the onset of symptoms in comparison with those in whom it was initiated after this time, the difference between the two groups of patients was not statistically significant. Our results suggest that advanced age, the presence of clustered vesicles, and disturbed sleep and hypanaesthesia influence the prolongation of herpes zoster pain.
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Elesber AA, Kent PD, Jennings CA. Compressive neuropathy of the brachial plexus and long thoracic nerve: a rare complication of heparin anticoagulation. Chest 2001; 120:309-11. [PMID: 11451857 DOI: 10.1378/chest.120.1.309] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
We present a case of a 69-year-old woman who developed brachial plexopathy and long thoracic nerve palsy secondary to compression from a hematoma while receiving heparin therapy for the treatment of a stroke. The patient was treated conservatively with discontinuation of heparin and had complete resolution of her compressive neuropathy. This is the first report of a patient with long thoracic nerve palsy with a brachial plexopathy complicating anticoagulation. We review the literature on hematoma-induced compressive neuropathies and treatment options. Our review concludes by emphasizing the importance of clinical judgment in determining the best therapeutic modality.
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Abstract
The diagnosis and management of pelvic pain presents a challenge to the medical practitioner. The approach should be systematic and organized to provide the best possible care. The aim of this article is to increase awareness among urologists so that they may be more able to understand and support their patients.
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Abstract
The shoulder is the most mobile joint in the body. Because it serves as a way station for the nerves supplying the upper limb, it creates a potential for nerve lesions that may be caused or significantly influenced by the complex dynamics of the shoulder girdle. This article presents the most commonly encountered lesions as well as an algorithm for their diagnosis and treatment.
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Singh H, Magruder M, Bushnik T, Lin VW. Expiratory muscle activation by functional magnetic stimulation of thoracic and lumbar spinal nerves. Crit Care Med 1999; 27:2201-5. [PMID: 10548207 DOI: 10.1097/00003246-199910000-00022] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was conducted to stimulate respiratory muscles by functional magnetic stimulation (FMS) of the spinal nerves (T1-L5) to obtain maximum expiratory function. DESIGN A prospective before and after trial. SETTING Functional Magnetic Stimulation Laboratory, Spinal Cord Injury Service, VA Palo Alto Health Care System, Palo Alto, CA. PARTICIPANTS Twelve normal able-bodied subjects. INTERVENTION A commercially available magnetic stimulator with a round magnetic coil (MC) was used. Respiratory muscle activation was achieved by placing the MC at each spinous process ranging from T1 to L5 vertebral levels. MAIN OUTCOME MEASURE The planned major outcome was to determine the optimal MC placement for producing maximal expiratory pressure (MEP) and expiratory reserve volume (ERV) by FMS. These measurements were compared with the subjects' voluntary maximal efforts. A profile with varying stimulation intensities was also obtained in select individuals for determining the highest expiratory pressure. RESULTS Stimulation at the T9 spinal level resulted in the highest mean MEP and ERV. Stimulation between T8 and L5 produced similar MEP and ERV as obtained from the T9 MC placement. The mean maximum MEP and ERV produced by FMS were 76.8 +/- 6.4 cm H2O (7.52 +/- 0.62 kPa) and 1.28 +/- 0.15 L, which were 67% and 79% of the subjects' voluntary maximal efforts, respectively. A stimulation intensity of 80% resulted in the highest expiratory pressure. CONCLUSION FMS of lower thoracic and lumbar regions produced significant expiratory pressures and volumes. FMS of the expiratory muscles may prove to be a valuable technique for restoring cough in patients with spinal cord injury or other neurologic diseases, and in critical care or perioperative settings.
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Okuda Y, Kitajima T, Asai T. Stellate ganglion block, cervical sympathetic block and cervicothoracic sympathetic block. Eur J Anaesthesiol 1999; 16:272-3. [PMID: 10234501 DOI: 10.1046/j.1365-2346.1999.00468.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther 1999; 29:31-8. [PMID: 10100119 DOI: 10.2519/jospt.1999.29.1.31] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Marin R. Scapula winger's brace: a case series on the management of long thoracic nerve palsy. Arch Phys Med Rehabil 1998; 79:1226-30. [PMID: 9779675 DOI: 10.1016/s0003-9993(98)90266-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the clinical utility of a new scapula winger's brace. DESIGN A case series. SETTING A tertiary military clinic serving a young population. PARTICIPANTS Fourteen patients referred to the clinic for thoracic nerve palsy of a least 3 months' duration. OUTCOME MEASURES Manual muscle tests with and without the brace and patients' compliance/satisfaction with brace as measured by personal interview during follow-up. RESULTS Muscle strength increased by one grade with brace application; patients who maintained compliance (n = 6) recovered their brace-free shoulder flexion strength and/or had reduced pain at the last follow-up (1 to 7 months after brace). All patients reported a subjective feeling of increased shoulder flexion strength and decreased pain with brace application. CONCLUSION The scapula winger's brace is a useful tool for physiatrists in the management of scapular winging secondary to long thoracic nerve palsy. Additional studies are needed to confirm the conclusion that the device's benefits derive from proprioceptive feedback that prevents muscle overuse or overstretch and from its transfer of contralateral shoulder protraction force to the affected scapula.
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