Download Differential Diagnosis and Treatment of `Winging Scapula` by

Surinderjit Singh, M. D., M. S. * †
Mohammad A. Saeed, M. D., M.S. * †
Edgar S. Steinitz, M. D. * ‡ † - - - Editor & Chief
Tabassum Saeed, M. D., M. S. * †
* Founded 1981
Irfan Ansari, M. D. * § †
Srini Sundarum, M. D., M.P.H. * §
www.salu.net/electrodiagnose
Board Certified ABPM&R *, ABEM †, ABPM ‡ ABIM §
May, 2001
Volume 4, Issue 2
Differential Diagnosis and Treatment of ‘Winging Scapula’ by Mohammad A. Saeed, M. D., M. S.
- Electrodiagnostic Evaluation is Critical: For the severity, acuity and type of nerve lesion
- While rarely causes other than neurogenic cause scapular winging, invariably etiology
is from but a few distinct focal nerve lesions. These nerve palsies can be readily diagnosed and differentiated by Electrodiagnostic (EMG/NCV) study.
Evaluation- A careful clinical neurologic and musculoskeletal examination is important,
also assessing biomechanics of the shoulder and scapulothoracic function. Electrodiagnostic assessment can localize the specific nerve involved, and assess both severity and
acuity of involvement, which in turn helps to prognosticate and guide rehabilitation efforts. In some cases, correlation with X-Rays and MRI scanning is necessary.
Clinical Features of
Neuropathy
Pain
Winging at Rest
Winging with Activity
Accentuated by:
Deformity at Rest
Scapula Displacement
With Activity
Long Thoracic
Palsy
Spinal Accessory
Palsy
Dorsal Scapular
Palsy
- Minimal:
Periscapular
- Mild-Moderate:
Shouldergirdle
- Major complaint:
Medial Scapula
- Minimal:
Lower Scapular Border
- Mild:
Inferior Angle
- Forward elevation
- Resisted Protraction
- Arm abduction,
esp. when resisted
- Mild:
1Frontal
- Trapezius wasting with - Minimal except
shoulder drooping
rhomboid atrophy
- Inferior angle away
from midline
- Inferior angle
towards midline
Spinal Accessory Palsy
Scapular winging
- Minimal
- Difficulty abducting > 90
- Lowering arm from - Trapezius atrophy
above
- Shifted laterally
and dorsally
Long Thoracic Palsy
Treatment- depends on etiology. Conservative measures are generally appropriate, but
on occasions, surgical exploration and nerve decompression is necessary. The long tho- - Scapular winging esp.
forward flexion
racic nerve is frequently injured by direct trauma, prolonged pressure, or excessive
- Serratus Anterior Atrophy
stretch of the arm overhead. The spinal accessory nerve is vulnerable to surgical injury
such as lymph node biopsy and radical neck dissection. The dorsal scapular nerve can
rarely be entrapped within the scalene medius muscle.
Rehabilitation- includes physical therapy for muscle strengthening and compensation
by surrounding unaffected musculature, while also addressing musculoligamentous and
myofascial sequalae. A variety of braces have been developed to improve scapulothoracic stability, but are often not well tolerated. Rarely, orthopedic surgery for musculoDorsal Scapular Palsy
ligamentous stabilization of a severely winging scapula can help improve shoulder bioRomboid atrophy
mechanics and decrease secondary myofascial pain and dysfunction.
Bringing Electrodiagnostic and PM&R Expertise to Tacoma and Pierce County Since 1981
Electrodiagnosis & Rehabilitation Associates– Experience and Expertise brings Excellence
2
Psychopharmacology of Brain Injury Rehabilitation
by Irfan Ansari, M. D.
- Traumatic Brain Injury (TBI) results in neurobehavioral sequalae, and the many syndromes need
recognition and treatment to ensure maximal progress during rehabilitation. Human behavior is based upon complex CNS neurophysiological processes that have anatomic and neurochemical correlates which interacts with
the external milieu. Dysfunctional behavior results from a combination of discrete gray and white matter
ischemic injury, and diffuse, sometimes anoxic, axonal injury resulting in a heterogeneity of neurochemical deficiencies and dysregulation due to disrupted systems of neurotransmission. Agitation and delirium are the most
common sequalae, but also cognitive deficits with impairments of attention and memory, motor restlessness, aggression, disinhibition and emotional lability. Understanding the role of neurotransmitters is critical in developing insights into behavioral deficits, which guides selection of the most efficacious pharmacologic strategy.
- Catecholamines (Norepinephrine, epinephrine, and dopamine) have significant roles in learning, memory,
motivation, sleep-wake cycle regulation, and arousal and thus intervention that enhances brain levels holds significant promise for accelerating recovery from TBI and coma-emerging agitation.
- Serotinin is a neurotransmitter implicated in a variety of physiologic, affective, and cognitive functions ranging from pain modulation, sleep/arousal cycles, cardiac function, mood, anxiety, aggression, eating disorders,
addictive behavior, as well as memory and learning function and has preferential affinity for 5HT-2 and 5HT-3
receptor sites.
- Acetylcholine secreting cholinergic neurons play an important role in sleep onset and maintenance, and normal
cognition and behavior as well as improving memory, and it is well accepted that anticholinergic agents are often causative in development of delirium. Aricept, a potent cholingeric agonist, is being studied for its role in
improving post TBI memory function. Other neurotransmitters are also being studied including the excitatory
amino acid L-glutamate, G-protein coupled neuropeptides, and the inhibitory amino acid GABA.
- Sympathomimetic, Dopaminergic, Anxiolytic agents, and Anticonvulsants are the common available pharmacologic agents. Sympathomimetic include Dextroamphetamine and Methylphenidate which stimulate the release and inhibit the re-uptake of catecholamines. Methylphenidate is among the most frequently used agent to
treat posttraumatic agitation. Dopaminergic drugs such as Bromocriptine and Sinemet, have been utilized in the
treatment of aphasia, and Amantidine in TBI has shown efficacy in improving attention, arousal, motivation,
processing time, psychomotor speed and mobility. Valproic Acid is utilized in the management of aggression
mediated by its effect to  brain GABA levels, and Carbamazepine, not only to inhibit aggression, but commonly as a first line drug for seizure prophylaxis and as an antiepileptic due to relatively minimal cognitive side
effects compared to other agents. Episodic dyscontrol is best managed with anticonvulsants, but post-traumatic
agitation associated with inattention or distractibility is managed with stimulants such as Methylphenidate and
Amantidine. The new class of drug, Modafinil, is presently being studied. The role of Benzodiazepines is limited due to sedative and amnestic side effects, worsening confusion, and  carryover of newly learned information, and only for rapid resolution of violent agitation with concerns for patient and/or staff safety . For similar
reasons, anti-psychotic agents have a very limited role, although newer ‘atypical’ agents, Clozapine and Risperidone, hold promise and warrant further investigation. Clozapine is unique in its specific receptor activity on limbic, rather than striatal, dopaminergic receptors, thereby  incidence of extrapyramidal side effects. Choice of
medications depends upon presentation.
- Beta-blockers are on occasions used for motor restlessness associated with hyperarousal.
- Antidepressants- Trazadone, TCAs (Desipramine, Amitriptyline), and SSRIs are used for specific problems such as for anxiety and/or panic attacks, OCD, pathologic crying/laughter, and organic hyperphagia.
-It is critical to recognize that all pharmacological agents are used in conjunction with a thorough systematic behavioral evaluation and intervention. Two broad types of behavioral techniques include responseconsequence, and stimulus control learning. Both are dependent on associational learning such that in the more
severe cognitive impairment, focus is upon providing a highly structured and consistent environment. Always
consider that agitation could be a consequence of adverse drug side effects and concurrent medical conditions to
include pain, hypoxemia and/or infection which need to be ruled out, and if present, treatment instituted.
We are proud to announce Dr. Irfan Ansari’s appointment as the Rehabilitation Medical Director
for Franciscan Health System-West and St. Joseph Medical Center
Web site: www.salu.net/electrodiagnose