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NEW YORK — Maybe you’ve never heard of transverse myelitis, but those diagnosed will assure you it’s devastating. Basically, your body doesn’t have the muscles required to move your hands or fingers. Now, after years of medical dead-ends, a new procedure may solve the riddle outright.

For 15-year-old Nicole, simple things like fixing her hair or painting her nails used to give her the hardest time.

“There were definitely things that were difficult like sports and gym class and stuff,” said Nicole, transverse myelitis patient.

At just five, Nicole was diagnosed with transverse myelitis — a rare nervous system disease. She lost control of all but five muscles in her right hand. Most people have 30 muscles.

“I think the closest analogy is perhaps Polio,” Scott W. Wolfe, M.D., Orthopedic Hand Surgeon at Hospital for Special Surgery in New York said.

Dr. Wolfe spent three months on an answer. The unique solution: matching working, available tendons in her arm to non-working muscles in her palm.

“That gives us the opportunity to take working muscle units from one position in the forearm, and reconnect them in a different place and have those same do a different task.” Dr. Wolfe said.

Surgeons both stabilized Nicole’s thumb and then transferred those tendons at the same time. A muscle that used to straighten Nicole’s wrist is now used to bend her fingers.

“I am definitely really surprised on how it’s working out so quickly,” Nicole said.

Nicole absorbed three month’s worth of physical therapy in just three weeks and is hungry for more. Good news for the 14-hundred people diagnosed with her condition yearly.

“Everything’s just so much easier, I can text quicker. I can even do simple things like hold something in one hand and open a door with the other, Nicole added,”

Now, Nicole can primp, pour and yes, text. It’s simple, yet revolutionary progress.

It will take Nicole two full years of therapy before she gains full strength in her right hand. Oddly, there are no specific causes of transverse myelitis — nor is there any familial pre-disposition. Most often, the condition blossoms after damage to nerve fibers following a viral infection.

New Tendons Restore Hands — Research Summary

BACKGROUND: Transverse myelitis is a rare nervous system disorder caused by an inflammation of the spinal cord. The disease may result in injury across the spinal cord. The segment of the spinal cord where damage occurs determines which parts of the body are affected. The disorder occurs in both children and adults. Usually, people with transverse myelitis experience only one acute episode; however, complications can linger. (SOURCE: www.mayoclinic.com)

SYMPTOMS: Symptoms of transverse myelitis usually develop over a few hours and worsen over the course of a few days. What begins as sudden lower back pain and abnormal feelings in the toes can quickly turn into more serious symptoms including paralysis and an inability to control bowels. Some patients are able to recover from the disorder with only minor injuries, but others may suffer permanent injuries that can affect their everyday living. (SOURCE: www.ninds.nih.gov)

CAUSES: Researchers aren’t sure what causes transverse myelitis but say it often develops after viral infections. It sometimes may occur as a complication of syphilis, measles, and some vaccinations used to fight chickenpox and rabies. An acute, rapidly-progressing form of the disorder may signal the first attack of multiple sclerosis. Bacterial skin infections have also been associated with the condition. (SOURCE: mayoclinic.com)

TREATMENT: As with many disorders of the spinal cord, there is currently no cure for transverse myelitis. Instead, patients may be prescribed anti-inflammatory drugs and medications to help manage symptoms. Most patients experience at least partial recovery. Some patients also participate in physical therapy, occupational therapy and or psychotherapy to help speed up recovery. In some cases, doctors may recommend plasma exchange therapy and intravenous steroids. (SOURCE: myelitis.org) MORE

Risk of knee injury higher than for male counterparts

S.S. Seward girls’ basketball player Sara Cannillo, who is recovering from surgery to repair the anterior cruciate ligament in her right knee, works with physical therapist Ray Youghhans at Access Physical Therapy & Wellness in Goshen on Monday, Feb. 14, 2011.TOM BUSHEY/Times Herald-Record
By Mira Wassef

Published: 2:00 AM – 02/27/11

It’s not like Sara Cannillo was climbing the side of a mountain or doing 360 degree spins off her bike during the X-Games.

Cannillo, a sophomore at S.S. Seward, was simply slowly jogging upcourt during a basketball game with nobody around her and, when she slowed down, her right knee buckled and she tore her ACL.

“I was really upset,” said the 5-foot-10 Cannillo, who also plays volleyball. “I was kind of mad because I really didn’t do anything. I was scared I wasn’t going to be able to play volleyball next year.”

ACL, which technically stands for anterior cruciate ligament, could easily stand for the anatomically chauvinistic ligament.

ACL tears, which are debilitating knee injuries when the center part of the knee connecting the femur and tibia tears, have plagued women’s athletics. In the past 10 to 15 years, doctors and researchers have found that females are 2 to 10 times more likely to suffer an ACL injury than their male counterparts.

“It’s become apparent that females have significantly higher risk than males, and that’s adjusted by how much time they spend playing sports,” said Dr. Robert Marx, attending orthopedic surgeon at the Hospital for Special Surgery in New York City and professor of orthopedics at Weill Cornell Medical College. “They are less common before puberty and more common in the junior and senior year of high school.”

Highland’s Stephanie Byrne was playing soccer in the state tournament in November when she cut the wrong way while playing defense and tore her left ACL. Byrne, a junior who also plays basketball and had to miss this season, also went down with no contact and heard a popping and cracking sound.

Byrne rehabbed for four weeks prior to surgery and now does it twice a week since the surgery in January.

“It hit me pretty hard,” Byrne said. “It was tough because basketball is my favorite sport and I didn’t get to play. I just want to go out there.”

Up until puberty, ACL ruptures reportedly occur at about the same rate in males and females. At the age of 12, there is a large rise in ACL injuries in females and they peak at age 16.

Reason difficult to pinpoint

Several studies have explored different reasons for the drastic difference between male and females when it comes to the debilitating knee injury, but have yet to pinpoint just one reason.

The most common theories are that ACL tears in women can be due to anatomical structure, genetics, estrogen levels or hormones, muscle development or physical fitness.

“The short answer is we don’t know why, but it’s definitely a combination of things,” Marx said. “A few reasons are that girls land in more knock-kneed positions from jumps. They have weak hips that allow the knee to crumble in that knock-knee position. They tend to be quadricep dominant and have weak hamstrings which also affect the knee.”

Cannillo and Byrne are just two examples of the estimated 80 percent of ACL injuries in females that are a result of non-contact. Those typically occur during change of direction, sudden deceleration, cutting movements, awkward landings or twisting, and when an athlete plants wrong.

Two-thirds of athletes usually hear a popping sound and experience swelling immediately. Soccer and basketball are the sports most common for ACL injuries in women, followed by volleyball and lacrosse.

Rehabilitating the knee

The rehabilitation process is long and arduous. After surgery, it typically takes six months to a year to fully recover, depending on the person. An average person takes nine months, Marx said.

Cannillo did rehab for two weeks pre-surgery and now does it three times a day since the surgery in January. Cannillo’s exercises include knee bends and quad muscle workouts.

“It’s definitely harder mentally,” Cannillo said of her rehab process. “It’s frustrating because the exercises are hard and you can’t do as much as you usually can.”

The first step of physical therapy is to return motion to the joint and surrounding muscles, and that is followed by strengthening the new ligament. The final phase is aimed to returning the athlete to doing things specific to their sport, Marx said. Basically, the athletes are relearning to do the menial things that once came easily, like walking and running.

Girls are also more likely than boys to reinjure the knee or injure the other knee, Marx said.

And that’s exactly what happened to Sabrina Byrne, Stephanie’s older sister.

Sabrina, 19, suffered two ACL injuries in 2009 when she was playing basketball at Highland. She was one of three Highland players who suffered an ACL injury that season.

Sabrina tore her left ACL in February of 2009 and the right knee in December while playing basketball.

“The first one I didn’t know what I was getting myself into,” she said. “I pushed to get back. I wish I didn’t because I wasn’t strong enough. I’m kind of hesitant to returning to play basketball because I don’t want it to happen again.”

mwassef@th-record.com

Preventing ACL injuries
A study performed by researchers at the Oslo Sports Trauma Research Center in Norway found that an ACL prevention strategy can cut ACL tears by 50 percent.

The best way to prevent an ACL injury is to implement and add warm-up drills like jumping and balancing. These drills will increase neuromuscular control and conditioning. In turn, muscular reactions will improve, thus decreasing the risk of an ACL injury. A warm-up program of at least 15 minutes two to three times per week is essential in order to prevent an ACL injury.

• Forward running to warm up the hip extensors and hamstrings

• One of the fundamental ways to avoid an ACL injury is to not wear shoes that have cleats in contact sports.

n When a person has already suffered an ACL injury, but wants to return to competitive sports, the best way to prevent another injury is to strengthen the quadriceps and hamstrings.

• Another way is to change mechanics like pivoting, cutting excessively because it puts extra stress on the knee.

• Overall, sports like football, soccer, basketball, and other contact sports the risk is always high.

• The best way is to wear a knee brace.

Stretching

Stretching the quadriceps and hamstrings before an event will also prevent ACL injury because it promotes flexibility, decreases firmness, and increases performance. The muscle stretching has to be done in repetitions.

Calf Stretch: 1-2 minutes of stretching the lower leg muscles. Ankle circles will stretch the gastrocnemius.

Quadriceps: 2-3 minutes of seated butterfly 3 reps of 20 seconds

Hamstrings: 1 minute of wall sits 2 reps of 30 seconds

Inner thigh stretch: 1 minute of knee to chest

Hip flexors: 2 reps of at least 20 seconds of lunges

drrmarx.com
The injury
When you injure your anterior cruciate ligament, you might hear a “popping” noise and you may feel your knee give out from under you. Other typical symptoms include:

• Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.

• Loss of full range of motion

• Tenderness along the joint line

• Discomfort while walking

The anterior cruciate ligament can be injured in several ways:

• Changing direction rapidly

• Stopping suddenly

• Slowing down while running

• Landing from a jump incorrectly

• Direct contact or collision, such as a football tackle

By Sanford R. Altman
Published: 2:00 AM – 02/27/11

Q. My father is in a nursing home for rehabilitation after his stroke made it difficult for him to get himself up or to walk. Although they originally told my mother that, given enough time and rehab, he would be able to return home to her, they now say that my father is no longer improving, so they are stopping physical therapy. If he came home, he would need much more help than my mother can ever give him. On top of that, they told us that when physical therapy ends, so does Medicare coverage, and it will cost us almost $400 per day. Can’t go home and can’t afford to stay there. Is that legal?

A. The answer to your question, unfortunately, depends upon which branch of the government you ask. The administration of Medicare is overseen by the Centers for Medicare and Medicaid Services (CMS). One of CMS’ rules is the “improvement standard” for continuing physical therapy, which the nursing home apparently utilized in this situation.

On the other side of the issue, federal court decisions have recently called the improvement standard improper. Many of us who practice elder law agree with the courts.
Related Stories

Two-part series

This is the first in a two-column series on Medicare coverage for physical therapy. Part two will appear next Sunday.

Why is this so important?

If you are Medicare eligible (generally over age 65), spend several days in the hospital and are then transferred to a nursing home for rehab, Medicare will cover you — to some extent. Medicare will fully cover 20 days and partially cover 80, the remainder being your co-pay, which is now about $140 per day.

There are two general categories of care at a nursing home, skilled nursing care and custodial care. Medicare covers you only if you receive skilled nursing care.

What is not covered? The most obvious example is people who are in a nursing home as a result of some form of dementia such as Alzheimer’s, but are otherwise physically healthy. This is referred to as “custodial care.”

There are gray areas. One of my clients had one type of catheter, which was considered skilled nursing care, but when they changed the catheter, it was not. At the other end of the spectrum, physical therapy is clearly covered as skilled nursing care.

The implications of this are far-reaching. When individuals are admitted to a nursing home for rehabilitation, physical therapy is part of their treatment. After successful physical therapy, they return home. While the CMS passes down standards to nursing homes, the nursing homes determine on an individual basis who stays on Medicare. In the case of physical therapy, the nursing home decides when a patient has stopped improving. At that point, the “improvement standard” kicks in and Medicare will no longer cover the patient, who must either pay with private funds and stay longer or go home, ready or not. Terminating physical therapy can also result in a deteriorating physical condition and prevent any possibility of returning home, sentencing the patient to life in the nursing home.

Why is this standard used?

From this scenario, one may well ask why we use the “improvement standard” at all. Shouldn’t rehabilitation continue at least to keep the patient from losing any progress he or she has already achieved?

The federal courts’ answer to this question is “yes.” The proper legal standard for continuing Medicare benefits is whether the services are needed to enable the individual to maintain his or her level of function. Treatment would continue to prevent deterioration even if there was no promise of improvement.

CMS has yet to weigh in, but new developments may force their hand. I’ll tackle those in next week’s column.

By John Pinoth [January 30th, 2011]

If you are injured at work, immediately report the accident to your employer and seek medical treatment from an employer authorized doctor. Read on for further information.

Why can’t I see my own doctor?

The law often says that employers must pay for all medical care related to the accident, so they control which doctors you may see. If you decide to go to your own doctor you’ll be responsible for the bills. In limited circumstances, an employer’s workers’ compensation insurance company will authorize a doctor of your choice. The earlier you make the request the more likely the Workers’ Compensation insurance carrier will authorize a doctor of your choice.

How will I be paid while I am out of work?

If you miss work, you are entitled to Temporary Disability Benefits. These are paid weekly until you return to work.

How much will I be paid?

You’ll receive around 70% of your gross weekly pay at the time of the injury, up to the state maximum, which is currently around $550.00 on average.

If the Workers Compensation Insurance Company denies my claim, can I apply for unemployment?

No, but you are entitled to weekly disability payments. If the Workers’ Compensation Insurance Company denies your claim for Temporary Disability Benefits, you cannot apply for unemployment because you are not actively seeking work and are unable to work. You should apply for State Temporary Disability Benefits. The State may request that you file a Workers’ Compensation Claim Petition to protect a lien for Temporary Disability Benefits paid to you.

How soon after the accident do I have to file a workers’ compensation claim?

You could have up to two years from the last date that workers’ compensation benefits (medical bills or temporary disability) were paid. If no medical bills or temporary disability benefits were paid, then you would have two years from the date of the accident.

Can I receive a monetary settlement if I am at work?

Yes, after you receive medical treatment and return to work, you are eligible to receive a settlement for your injury.

Can I collect workers compensation benefits if the accident was my fault?

Yes. As long as you were involved in performing your work while you were injured, it doesn’t matter if the accident was caused by you, a co-worker, or your employer.

Can I collect monies for my pain and suffering?

In some cases a claim, in addition to a workers compensation claim, can be filed against another party (known as a Third Party) seeking damages in addition to an award in the workers’ compensation court. You should consult with an attorney as soon as possible after the accident to determine whether your case would entitle you to bring a Third Party action. If you are successful in your Third Party action, you will be compensated for your pain and suffering.

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