Shoulder injury- post trauma- update; July, 29 , 2007

Mr Ernando , sent to me by dr Sutji, a neurologist, due to severe pain. She asked me to make rehabilitation program.

I asked him to stay in hospital, to seek which management could control the pain, and to make othose to make his right arm still useable.

It was important to manage the pain, due to bad posture he maintained .He walked in my office with his head tend slight bend to the right , position he used after injury to reduce the pain. If he could maintain the pain, he would able to control his posture, and could use his right hand. As the result, it helps to diminishes the atropy of the muscle. You could see, his right shoulder lower than his left side.

Mr Ernando work at mining corporate, he usually work down the earth. He and his friends us small train as the mobility devise. The inury happened when the train slipped, and his shoulder hit by hard stone.

Shoulder joint (= glenohumeral joint)

Shoulder joint , is a joint between glenoidales and humerus, so we could name it by glenohumeral . Glenohumeral joint is prone to dislocation due to its relatively poor bony fit and limited supporting musculature. The shallowness of the glenoid fossa and limited contact area between the fossa and the humeral head contribute to the joint instability .
In normal (undamaged capsule ) glenohumeral joint, a small negative intracapsular pressure helps stabilize the joint.

He brought roentgen taken after the injury, and the result was it was posterior dislocation.

Posterior dislocation was results from anterior direct trauma . (Biomechanics of musculoskeletal injury, William C Whiting; Ronald F zernicke; Human Kinetics, 1998)

Discussion:

When he came on May 8, 2007, I found deficit sensory 40 % - 60 %. Yes, injury at shoulder site, also could damage the brachial plexus. EMG taken before explained the deficit .

Hospitalized a week, given medicine for pain, drink by the clock; infra red radiation and electrical stimulation; exercise for correction his posture , and prevent further athropy.

Discharge from hospital with toradol 4 times daily, correct posture. Could used right for activity daily living. I asked him to use arm sling and shoulder sling simultaneously. Three times a day exercise to prevent atrophy, take the pain killer by the clock.

I wrote report to his doctor, a general practitioner as host doctor, and suggest if he could work not in the hole down the earth for few weeks. The doctor recommended to work behind the desk at head office,

Visited for control, May, 28 – 2007, deficit sensory 20 % .

A month later, I recommended him to work at the mining . He is an expert at explotion division. I asked him to use both hand to set the little bomb.

Although it is a good case for low laser, it was not suitable for him. He must back to work again , in the middle of the forest. , as soon as possible. If he stay at home, or stay in Jakarta to take laser , he just get the basic salary. The best income, if he do the exp lotion again.

As a doctor, especially a physical medicine and rehabilitation specialist ,we must take that as a consider. A team must build, with other doctor , therapist and social worker as needed.

Others drugs given as needed, like neurotropic agent , to help nerve repair.

We will follow by EMG , 3 month after the first one

Any comment ?

Low Level Laser for Hypokalemia- Update

Hypokalemia

Yulia, lovely young lady, hospitalized for 7^th times due to "paralysis". Yulia dearest, your working diagnosis was hypokalemia.

What is that?

Symptoms

The common symptoms for this kind problem are muscle weakness and cramping, and paralysis like yours, also paresthesias, palpitations, constipation, nausea or vomiting, abdominal cramping, polyuria, nocturia, or polydipsia.¹

What is kalium?

Kalium or Potassium is one of the body's major ions. Nearly 98% of the body's potassium is intracellular. The ratio of intracellular to extracellular potassium is important in determining the cellular membrane potential. Small changes in the extracellular potassium level can have profound effects on the function of the cardiovascular and neuromuscular systems.¹

Pretty Yulia, Potassium is about working of a cell.

How about the normal level

The reference range for serum potassium level is 3.5-5 mEq/L, with total body potassium stores of approximately 50 mEq/kg (ie, approximately 3500 mEq in a 70-kg person).

Hypokalemia is defined as a potassium level less than 3.5 mEq/L. ¹

Moderate hypokalemia is a serum level of 2.5-3 mEq/L. ¹

Severe hypokalemia is defined as a level less than 2.5 mEq/L.¹

Pathophysiology:

Hypokalemia may result from conditions as varied as renal or GI losses, inadequate diet, transcellular shift (movement of potassium from serum into cells), and medications.

Laser for Hypokalemi

Your father came to me , wonder if Low Level laser Therapy (LLLT) could work on this condition. I found Karu’s model. Karu’s model shows , light is absorbed by components of repiratory chain ( i.e. flavine dehydrogenase, cytochomes and cytochromes oxidase) which causean activation of the respiratory and the oxidation of the NAD pool , which leads to changes in the redox status of oth mitochondria and the cytoplasm. This in turn has an effect on membrane permeability/ transport , with changes in the Na ⁺ /H⁺ ratio and increase Na⁺/K⁺ ATPase activity.

How about your's dear?

The last time you were in hospital, your number just 1.5 mEq/L.(Severe hypokalemi). I gived you LLLT by transcutaneus, 45 minutes everyday, 10 times. It worked! At 4th administered, although your kalium still below 2.5 mEq/L, you felt strong enough, no muscle weakness. It was amazing.

Discussion :

Inadequate diet and GI problem could explained Yulia's . His father told me, her appetite not so good. She also prone for diarrhea.

So dear, yet LLLT help you , please take times to visit gastroenterologist.

Author: David Garth, MD, Consulting Staff, Department of Emergency Medicine, Mary Washington Hospital : eMedicine Specialties > Emergency Medicine > Endocrine And Metabolic ; Hypokalemia; Last Updated: September 20, 2005

KOREA !!!

Seoul, 2007

Indonesian's delegate with de Lisa !!

Going to Istanbul, 2009



Me and my poster Me and Queen's costum

Five Little Chickens

Five Little Chickens

Said the first little chicken, With a queer little squirm,
“Oh, I wish I could find, A fat little warm”

Said the next little chicken,With an odd little shrug
“Oh, I wish I could find, A fat little warm”

Said the third little chicken,With a sharp little sequel
“Oh, I wish I could find, Some nice yellow meal”

Said the fourth little chicken,With a small sigh of grief,
“Oh, I wish I could find, A green little leaf ”

Said the fifth little chicken,With a faint little moan
“Oh, I wish I could find, A wee gravel-stone”

“Now, see here” said the mother,From the green garden patch,
“If You want any breakfast, You must come and scratch”


----> Don't just day dreaming !!!

Low level laser for shoulder pain -after stroke - and shoulder injury

Causalgia, reflex sympathetic dystrophy, and the shoulder - hand - finger syndrome have been group into a characteristic medical condition that may cause severe, intractable pain and progressive functional impairment and disability

This condition is not rare for stroke problem

The circulation of upper extremity can be roughly divided into arterial and venous component : first, the arterial component. It is refers to cardiac pumping, proceeding to the distal portion of the extremity. The 2^nd are the venous return and lymphatic system. The muscles of the hand and arm force the fluid proximally by means of “pumps”

Mr Djoko, got stroke , nearly two years ago, hemiparetic with spasm at his right hand. This was the iniciating factor for his problem. He sent by neurologist due to pain on his right side. I found shoulder limitation , and swollen.

Low level laser given by transcutaneus approach 5 times ,everyday. I asked him to move his right extremity frequently.

Injury of shoulder

Mr Djoko visited my office again two weeks ago. This time, the pain suffered his left hand. almost a month ago, he slipped on stairs, grabbed the guard raill by his left hand. His tendon of biceps became overstrech.

Three times simultaneus transcutaneus low level laser not enough for this condition. It was very painfull for him, sometimes he feels pain on his chest

I used ILIB , combined with probe to delivery the laser. Probe go a long tendon biceps , also administered to ganglion stelata to block the nerve. Pain decreased , and diminished after the 7th treatment.













Discussion:

Pity mr Djoko. Yes, we could deliver laser as a nerve block, like using anesthetic agent.

An effective stellate block is judged if there is pain relief. Mr Djoko found, after stellate block using laser, the pain relief more rapid.

For both shoulder, the stiffness should be treated . active exercises of the shoulder and hand must be instituted as soon ans as energitically as the medical condition permits.

Mr Djoko found, along with pain decreasing , his hemiparetic side could moved more easily.

For his right arm, the problem iniciated only of his shoulder limitation , but for the left side, the manuver slipped on strairs sreching the biceps and the brachial plexus. So, it is more painfull, and more difficult to manage.
May be probe as anaesthetic was enough, but his fear must considerable. A man, both side hand injures , still works as goverment employee, it is fearfull.

There are some papers about laser for causalgia. I didn't find yet laser administered to the ganglion. I saw this kind aproach when I joined WALT Conggres in Tsukuba Japan, 2002.