Introducing Parag Sheth

Introducing Parag Sheth – Mount Sinai’s Carpal Syndrome Tunnel Expert

This month, with our continued aim of ensuring our patients know and trust our physicians, Mount Sinai presents to you our long-standing Assistant Professor of rehabilitation medicine, Dr Parag Sheth. Dr Sheth holds a certification in Physical Medicine and Rehabilitation; his specialisation lies in Carpal Tunnel Syndrome (CTS).

Dr Sheth’s expertise is grounded in his rich and varied academic career. Beginning his studies receiving honors at Johns Hopkins University, Dr Sheth moved on to study at Stony Brook School of Medicine, and subsequently held the position of Chief Resident at St. Vincent’s Medical Center’s Rehabilitation Residency Program. Dr Sheth is now a fellow of The Mayo Clinic, where he specialised in Musculoskeletal Rehabilitation; and he has been with us at Mount Sinai for over 20 years. During his time practicing with us, Dr Sheth has always gone beyond the call-of-duty to ensure patient satisfaction.

CTS, Dr Sheth’s specialization, manifest itself as a tingling, numbness and sometimes pain in the hand and fingers. This is caused by a compression of the median nerve, which controls sensation and movement in the hand. It can sometimes be hard to identify as the symptoms are common and often go unchecked. Dr Sheth is renowned for his ability to exercise expert judgement on patient’s symptoms, but always communicates in way understandable to the patient; we believe this to be paramount to a patient’s happiness. Dr Sheth has often been praised for his ability to listen carefully, and explain the process of treatment and aftercare in a concise and easy to follow way; this has made him a patient favorite. 

His clinical focus also extends to: back pain, electrodiagnostic testing, epidural steroid injections, herniated disk, knee pain, low back pain, shoulder pain, neck pain, and spine stimulation.

Outside of his professional career with us, Dr Sheth also teaches a yearly cadaveric dissection and weekly musculoskeletal lectures where he has been awarded the Avital Fast Award and the Department Teacher of the Year award. His research has been published in Nature, Lancet, and The American Journal of Sports Medicine. 

Dr Sheth is “Board Certified” and accepts insurance plans. For more details on appointment availabilities and plan coverages, please contact our call center at: (212) 241-6321.

What Causes Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome (CTS) is the compression – and sometimes squashing – of the median nerve that passes through the wrist. Its symptoms can include numbness, tingling and pain in the thumbs, fingers and wrists, which can travel as far as to the arms and even to the shoulder. Modern medicine has a firm grip on what CTS is; what causes it is quite a different story.

Diagnosing CTS can be done through a relatively simple physical examination. One test is called the ‘flick signal’, for which the patient is asked, ‘what do you do when your symptoms are worse?’ If the patient responds with a hand movement that resembles the shaking of a thermometer, there is good reason to suspect CTS. There are plenty of other tests such as Phalen’s Test and Tinel’s Sign – yet, despite the relative wealth of ways to diagnose CTS, there actually isn’t any kind of test to identify the precise cause CTS, and – except for patients suffering from underlying diseases – the biological mechanisms that create this inflammatory disorder remain unknown. 

It is a common story that CTS is caused through repetitive and often high-stress tasks that involve the wrists and hands – typing, using a computer mouse, manual labour to even playing the piano. While the correlation between CTS and tasks of this nature is undoubted, there is minimal evidence to suggest any clear causality.

In fact, most studies today indicate that CTS’ causes go above and beyond mere so-called ‘workplace factors’ and that they are rather linked to ailments that cause swelling in the wrist (osteoarthritis and rheumatoid arthritis) and others that obstruct blood flow (hypothyroidism and diabetes). We also see CTS pop up in clusters within a family, which suggests that something genetic is at play. Lifestyle also appears to play a significant factor, as those who smoke, drink alcohol excessively, consume excessive salt and who are obese all show increased risk of developing CTS. Women are also three times more likely to develop CTS than men, particularly after childbirth and during menopause.

Despite the range of medical, physical, genetic and life-style related items that are linked to an increased risk in developing CTS, their relationship is that of a correlation and not one of cause and effect. A modicum of clarity might be achieved, however, by overlapping both ends of the spectrum – the ‘workplace effect’ with medical/genetic/lifestyle factors. When somebody is susceptible to CTS – whether it be through genetics, a medical condition or an unhealthy or stressful lifestyle – and they also subject their hands and wrist to frequent, repetitive task, the likelihood of suffering from CTS will be at its greatest.

If you believe you are at risk of developing CTS, we would like to encourage you to seek medical advice on how to prevent it; if you believe you might already be suffering from it, we suggest you speak to one of our specialists for a suitable treatment. The earlier CTS is treated, the more likely – and easier – a full recovery will become.

Neuroplasticity – The Brain's Repairing Mechanism

 Injuries to the head can result in long term damage to areas of the brain, varying depending on where on the head the injury was sustained. While a variety of therapeutic services can be employed to regain a certain level of functionality the brain also has a unique response to regional damage – neuroplasticity.

Neuroplasticity is the brain's ability to reorganize itself through lifetime creation of new neuron pathways. From birth developmental plasticity begins, as neuron branches and synapses form to process new sensory information. At the age of two or three, a child's brain has around 15,000 synapses per neuron. This is around twice as many as in the adult brain as neurons strengthen, weaken, and are eliminated with age. While this process slows down, the brain retains the ability to grow new neurons throughout life in response to new stimuli. One such circumstance under which the brain may begin to regenerate in this way is when a certain area of it is damaged.

Known as functional plasticity, in response to an area of the brain loosing functionality, often the surrounding healthy areas will take over those processes, restoring former abilities. Neurons which remain undamaged will grow new nerve endings to create new connections where the original links were broken due to injury. As well as restoring connections, undamaged neuron axons can create entirely new pathways, developing nerve endings that connect with other undamaged neurons, to carry out necessary functions. Especially in children, when damage is sustained in one hemisphere of the brain, the corresponding area in the other half of the brain may take on functions traditionally performed in the initial hemisphere.

One example of when natural adult neurogenesis (formation of new neuron endings) can occur is following a stroke. Strokes are caused either when a blood clot prevents sufficient oxygen flow to the brain or when a blood vessel bursts leading to internal bleeding in the head. If left untreated, a stroke can cause certain areas of the brain to cease to function. Strokes can cause long-lasting physical and psychological problems, however, the brain may attempt to compensate for permanent localized damage by re-routing function pathways.

Head injuries can cause debilitating damage that leave the patient with reduced functionality. Therapeutic rehabilitation, such as physiotherapy, occupational therapy, and speech therapy can go some way to recovering a patient's abilities, however, the body's natural propensity to repair itself, many also contribute to patient recovery following a localized head injury.

Recovering from a Traumatic Brain Injury

Injuries to the head or brain can have a range of effects, depending on the form the injury takes and the level of severity. Following a traumatic brain injury (TBI) many patients may display several of the same symptoms as the brain attempts to repair itself, including disorientation, mood swings, and difficulty performing simple tasks. Often after injury swelling, bleeding, or changes in the chemistry of the brain can affect normal functioning of the healthy brain tissue. As swelling decreases, blood flow is able to return to a normal level, and the patient may regain their ability to function in everyday activities.

The most rapid recovery of brain activity is likely to happen in the first six months of recovery, with the patient showing steady signs of improving in function. After this period patients may show signs of further recovery up until two years after the accident, though at a slower rate, and after two years improvement will decrease substantially. During the first six month period there are a range of actions that can be taken to improve chances of a fuller recovery.

The first important step to take during the recovery period is to get plenty of rest, so that the brain has a chance to recover and regain function. While the brain cannot regenerate cells that have died, areas of the brain may be able to take over the activities of the damaged areas by creating new nerve pathways. Avoiding stressful situations is also recommended as these can illicit and amplify mood swings and personality changes that can follow TBI. Avoiding activities where you could sustain further damage to the head is also necessary. The brain cannot recover 100% from a traumatic injury, and participating in risky activities increases the likelihood of repeat injury. The effects of repeat injury build on the original damage in a cumulative manner, lessening the chances of recovery.

Taking medicines should be carefully regulated as many can inhibit the repair of the brain. Although head injuries can cause the patient trouble in falling asleep avoid taking sleeping pills, sedatives, or tranquillisers. Many over-the-counter sleep medications contain antihistamines which can disrupt memory retention and the ability to learn new information in those who have sustained a TBI. If the patient is suffering from headaches, Tylenol should be administered over non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin which can occasionally cause the site of injury to bleed.

Occupational, speech, and physiotherapists may be employed to aid the rehabilitation process, depending on the nature of the injury, but taking these initial precautions can encourage the brain to begin a process of restoration. 

Exoskeleton Technology – Helping Paraplegics Walk Again

As technologies become more and more advanced new techniques for treating injury are constantly being developed. In 2011 the Mount Sinai Rehabilitation Center became one of only 30 hospitals in the world to test, and offer to a select few patients, a new tool that could changes the lives of paraplegic patients.

The robotics company Ekso Bionic has developed a battery-powered, robotic exoskeleton which enables patients who have lost function in their lower body to walk again. The suit, called Ekso, is a 50 pound framework made of aluminium and titanium that is controlled by a handheld remote. The patient's lower body is strapped into the suit which then uses 15 sensors to ascertain when the user is in a stable position. Pushing a button triggers the Ekso to then take a step forward. Initially only a therapeutic tool for use in rehabilitation centres, select patients are now being chosen to use the device at home.

One such patient is architect Robert Woo who became paralysed in 2007 due to an injury in the workplace. An accident, in which several tons of metal studs fell onto the trailer in which Woo was working, left him paralysed from the chest down and having to use a wheelchair to get around. The new technology has allowed him to travel around on his own two feet with the aid of forearm crutches. Following trials of the Ekso technology, Woo became on of the first people in the United States to be certified to purchase a similar technology, the ReWalk Personal 6.0 System, to use at home.

Alongside the new-found independence that the system has given him, it has also had unexpected effects on his body. Whereas prior to testing the walking technology Woo was incapable of any movement below the chest, he has found that with frequent use of the ReWalk system his upper leg muscles have begun to regain functionality. Although he still relies on the robotic support to walk the process has given him back enough muscle strength that he can now independently lift his legs while sitting.

The technology is still relatively and new each unit costs around $100,000 however, as developments continue the hope is that demand for the walking aid will increase. This in turn will increase production and thus bring the price down, making it easier for more patients to afford this life-changing device. 

Neurobics – Exercises to Keep the Brain Young

As we age our brain activity begins to slow down because the organ looses nerve connections and fails to form new ones. While this is a natural process there is a range of activities that can be done to somewhat reverse, or at least slow down, the mental ageing process.

Take Up a New Hobby

It has been noted that learning a new activity works to keep the brain young by keeping it active. Processing new information encourages the brain to form new connections between nerve cells and may even help to generate new cells. A new hobby can be anything from reading or taking a class to craft projects to physical exercise. New experiences trigger the release of dopamine, the neurotransmitter that stimulates motivation and perseverance in an activity and the hormone that encourages the production of new neurons.

Master the Crossword

While word and number games may just seem like a fun pass time they also have profound benefits on the neurological level. These brain exercises force various parts of the brain, such as the areas associated with language, numerical reasoning, and problem solving, to work. Over time this improves the performance of these areas and various studies have suggested that frequent work on crossword or sudoku puzzles may even delay the onset of illnesses such as dementia. This is because mental exercises force the brain to make connections and to recall information which, otherwise, can easily be forgotten as we age.

Keep Things Interesting

Just as important as taking up new activities is knowing when to stop doing an activity. If an exercise becomes habitual and routine your brain has normalized it and is no longer creating new neural connections. Much like if you do not do physical exercise the body will lose strength, without mental stimulation the brain becomes sluggish and slow. Shaking up your daily routine by adding in new elements keeps your brain sharp by constantly giving it new information to process. This can be as simple as taking a new route when you travel somewhere familiar. Instead of going into autopilot with well-established directional knowledge taking an unfamiliar route will actively engage the cortex and the hippocampus to process the new area.

It is inevitable that as the body ages the brain will lose some of the agility it had at peak age, in our mid -20s. However, keeping the brain exercised with novel activities can go a certain way to maintaining a healthy brain.

Caring for an Aphasia Patient

 Around 1,000,000 individuals in America suffer from some form of aphasia, struggling to communicate as easily as they did pre-injury. The role of an aphasia patient's carer is to aid the recovery process in the hope that the patient will regain a level of normality to their speech. Throughout the recovery period there are a series of actions that a carer can take to aid in relearning language, or to help a patient to feel more confident in communicating.

Keeping it Simple

One key thing to remember when communicating with an aphasia patient is that, while they may understand everything you say it may take them longer to process it. Keeping background noise and distractions to a minimum can help their comprehension. Avoid talking to them like you would a child and use adult language, however, keep sentences shorter and simple so it is easier for them to reply. Instructions should be broken down into simple steps and, initially, questions should be yes-or-no ones. This will allow an aphasia patient to slowly regain their ability to retain information.

Learn to Listen

Depending on the manifestation of a patient's aphasia it may take them a longer time to respond to a question. In these circumstances it is important not to rush them to respond and simply to be patient until they have finished talking. Avoid putting words into their mouths otherwise they will not have the opportunity to relearn speech for themselves. If forming full sentences is a struggle for a patient try working out other ways of communicating, such as using hand gestures, picture charts, or writing. The inability to vocalize thoughts does not mean that they do not understand what you have said so ask them if they have and simply cannot say their response.

Boost Their Confidence

An important aspect of the recovery process is the patient feels that they are living a normal life, so encourage them to to participate in every-day activities and decisions. Try to encourage them to carry out more daily tasks independently and avoid the urge to overprotect them. Although it may seem counter-intuitive to engage a patient in conversations with larger groups of people, it may be beneficial to their recovery. In a one-on-one setting there is a lot of pressure on the patient to respond to questions and engage in the conversation but in a small group they are able to join in when they feel ready and no one is waiting on them to reply. As their speech improves try taking the patient out into more public settings so that they can practice their communication skills in real life situations.

The most important thing to remember when aiding the recovery of an aphasia patient is that each case is different. Rehabilitation methods that may have worked for one patient may not work for another so work with them to find the best exercises for their situation.