Children with autism spectrum disorders (ASD) often exhibit motor clumsiness (Developmental Coordination Disorder, DCD), i.e. they struggle with everyday tasks that require motor coordination like dressing, self-care, and participating in... more
Children with autism spectrum disorders (ASD) often exhibit motor clumsiness (Developmental Coordination Disorder, DCD), i.e. they struggle with everyday tasks that require motor coordination like dressing, self-care, and participating in sport and leisure activities. Previous studies in these neurodevelopmental disorders have demonstrated functional abnormalities and alterations of white matter microstructural integrity in specific brain regions. These findings suggest that the global organization of brain networks is affected in DCD and ASD and support the hypothesis of a 'dys-connectivity syndrome' from a network perspective. No studies have compared the structural covariance networks between ASD and DCD in order to look for the signature of DCD independent of comorbid autism. Here, we aimed to address the question of whether abnormal connectivity in DCD overlaps that seen in autism or comorbid DCD-autism. Using graph theoretical analysis, we investigated differences in global and regional topological properties of structural brain networks in 53 children: 8 ASD children with DCD (DCD+ASD), 15 ASD children without DCD (ASD), 11 with DCD only, and 19 typically developing (TD) children. We constructed separate structural correlation networks based on cortical thickness derived from Freesurfer. The children were assessed on the Movement-ABC and the Beery Test of Visual Motor Integration. Behavioral results demonstrated that the DCD group and DCD+ASD group scored on average poorer than the TD and ASD groups on various motor measures. Furthermore, although the brain networks of all groups exhibited small-world properties, the topological architecture of the networks was significantly altered in children with ASD compared with DCD and TD. ASD children showed increased normalized path length and higher values of clustering coefficient. Also, paralimbic regions exhibited nodal clustering coefficient alterations in singular disorders. These changes were disorder-specific, and included alterations in clustering coefficient in the isthmus of the right cingulate gyrus and the pars orbitalis of the right inferior frontal gyrus in ASD children, and DCD-related increases in the lateral orbitofrontal cortex. Children meeting criteria for both DCD and ASD exhibited topological changes that were more widespread from those seen in children with only DCD, i.e. children with DCD+ASD showed alterations of clustering coefficient in (para)limbic regions, primary areas, and association areas. The DCD+ASD group showed changes in clustering coefficient in the left association cortex relative to the ASD group. Finally, the DCD+ASD group shared ASD-specific abnormalities in the pars orbitalis of right inferior frontal gyrus, which was hypothesized to reflect atypical emotional-cognitive processing. Our results provide evidence that DCD and ASD are neurodevelopmental disorders with a low degree of overlap in abnormalities in connectivity. The co-occurrence of DCD+ASD was also associated with a distinct topological pattern, highlighting the unique neural signature of comorbid neurodevelopmental disorders. Research highlights • Children with ASD and DCD were simultaneously investigated with state-of-the-art graph theoretical analyses. • The alterations of the DCD connectome were not seen in the ASD connectome. • Children with comorbid DCD+ASD demonstrated more widespread alterations in clustering coefficient than children with DCD.
STUDY DESIGN: An experimental study of muscle recruitment patterns during asymmetric lifting in healthy individuals.OBJECTIVE: To investigate muscle recruitment patterns during asymmetric lifting, representing a common daily living... more
STUDY DESIGN: An experimental study of muscle recruitment patterns during asymmetric lifting in healthy individuals.OBJECTIVE: To investigate muscle recruitment patterns during asymmetric lifting, representing a common daily living activity, to determine whether systematic differences exist between functioning of the local and global muscle systems.SUMMARY OF BACKGROUND DATA: The normal function of the local muscle system is to provide sufficient segmental stability to the spine. The global muscle system provides general trunk stabilization and enables the static and dynamic work necessary for daily living and sports activities. Current knowledge about these two muscle groups appears to be specifically derived from anatomic findings and experiments conducted under artificial circumstances. To the authors' knowledge, the recruitment patterns of both muscle groups have not been investigated in daily living activities.METHODS: Twenty-nine healthy individuals performed different variants of asymmetric lifting activities. Electromyographic data were collected from seven hip, abdominal, and back muscle pairs. In addition, trunk kinematics were measured by means of an ultrasonic movement analysis system.RESULTS: The left and right obliquus internus, rectus femoris, and multifidus showed symmetric co-contraction in all variants of activities. In contrast, significant left/right differences were observed in the external oblique, gluteus maximus, iliocostalis lumborum pars thoracis, and latissimus dorsi.CONCLUSIONS: The results of this study show a symmetric activation of the local muscles during the performance of low-load, asymmetric lifting tasks, which suggests that these muscles play a stabilizing role during these manoeuvres. The global muscles, however, hand show asymmetric patterns of activation during the same tasks, supporting their role as global stabilizers and prime movers.
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To investigate the factors related to the 1-month period prevalence of low back pain (LBP), neck pain (NP) and thoracic spine pain (TSP) in young adolescents, thereby considering potential correlates from the physical, sociodemographic,... more
To investigate the factors related to the 1-month period prevalence of low back pain (LBP), neck pain (NP) and thoracic spine pain (TSP) in young adolescents, thereby considering potential correlates from the physical, sociodemographic, lifestyle, psychosocial and comorbid pain domains. In this cross-sectional baseline study, 69 factors potentially associated with spinal pain were assessed among 842 healthy adolescents before pubertal peak growth. With consideration for possible sex differences in associations, multivariable analysis was used to simultaneously evaluate contributions of all variables collected in the five domains. A significantly higher odds of LBP was shown for having high levels of psychosomatic complaints (odds ratio: 4.4; 95 % confidence interval: 1.6-11.9), a high lumbar lordotic apex, retroversed pelvis, introverted personality, and high levels of negative over positive affect. Associations with a higher prevalence and odds of NP were found for psychosomatic complaints (7.8; 2.5-23.9), TSP in the last month (4.9; 2.2-10.8), backward trunk lean, high levels of negative over positive affect and depressed mood. Having experienced LBP (2.7; 1.3-5.7) or NP (5.5; 2.6-11.8) in the preceding month was associated with a higher odds of TSP, as were low self-esteem, excessive physical activity, sedentarism and not achieving the Fit-norm. Psychosomatic symptoms and pain comorbidities had the strongest association with 1-month period prevalence of spinal pain in young adolescents, followed by factors from the physical and psychosocial domains. The role that "physical factors" play in non-adult spinal pain may have been underestimated by previous studies.
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This report aims, in the light of the recent literature, to describe the clinical features of bilateral thoracic outlet syndrome in a case of Klippel-Feil syndrome, the results of electrophysiologic evaluation, and the outcome after... more
This report aims, in the light of the recent literature, to describe the clinical features of bilateral thoracic outlet syndrome in a case of Klippel-Feil syndrome, the results of electrophysiologic evaluation, and the outcome after surgical intervention. Cervical ribs in the context of Klippel-Feil syndrome as the cause of bilateral thoracic outlet syndrome is discussed. In Klippel-Feil syndrome, congenital fusion of cervical vertebrae occurs and may also be associated with various anomalies, including musculoskeletal anomalies. The typical neurologic defects in this syndrome are caused by compression of the cervical cord and/or the corresponding roots. A 25-year-old woman had experienced, for 3 years, sensory symptoms, mainly numbness and pain, in both arms and episodic color changes of the hands that were aggravated by certain activities. Radiologic examination revealed Klippel-Feil syndrome type I, accompanied by bilateral cervical ribs. Electrophysiologic evaluation demonstrated impairment of nerve conduction, as indicated by F wave changes, after the arms were raised. The patient underwent successful decompression of the neurovascular structures at the thoracic aperture. It is often difficult to diagnose thoracic outlet syndrome by conventional neurophysiology. Dynamic changes in F waves appear to be a useful finding. In the absence of symptoms of myeloradiculopathy, thoracic outlet syndrome could be the sole manifestation of Klippel-Feil syndrome.
Research Interests: Biomedical Engineering, Spine, Magnetic Resonance Imaging, Treatment Outcome, Humans, and 11 moreThoracic Outlet Syndrome, Female, Differential Diagnosis, Electromyography, Cervical Vertebrae, Clinical Sciences, Adult, Arnold Chiari Malformation, Electrodiagnosis, Klippel -Feil Syndrome, and Reoperation
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Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our... more
Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our purpose in this study to determine the intrinsic risk factors for the development of anterior knee pain in an athletic population over a 2-year period. Before the start of training, 282 male and female students enrolled in physical education classes were evaluated for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters. During this 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses revealed a significant difference between those subjects who developed patellofemoral pain and those who did not concerning quadriceps and gastrocnemius muscle flexibility, explosive strength, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. However, only a shortened quadriceps muscle, an altered vastus medialis obliquus muscle reflex response time, a decreased explosive strength, and a hypermobile patella had a significant correlation with the incidence of patellofemoral pain. We concluded that the latter four parameters play a dominant role in the genesis of anterior knee pain and we therefore deem them to be risk factors for this syndrome.
Research Interests: Mechanical Engineering, Biomedical Engineering, Pain, Skeletal muscle biology, Social Support, and 19 morePhysics Education, Adolescent, Prospective studies, Humans, Femur, Female, Male, American, Risk factors, Adult, Knee injuries, Motor Performance, Risk Factors, Knee Joint, Syndrome, Prospective Study, Biomechanical Phenomena, Patella, and Pliability
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Research Interests:
The pathogenesis of heterotopic ossification is still unclear and the preventive therapies are usually insufficient. The present study was designed to investigate the possible preventive effect of free radical scavengers on the... more
The pathogenesis of heterotopic ossification is still unclear and the preventive therapies are usually insufficient. The present study was designed to investigate the possible preventive effect of free radical scavengers on the development of experimentally induced heterotopic ossification in a rabbit model and to compare free radical scavengers with indomethacin to determine whether they act synergistically. A standard immobilization-manipulation model was used to induce heterotopic ossification in the hind legs of 40 1-year-old female New Zealand albino rabbits. The animals were divided into four groups and received daily either placebo, a free radical scavenger cocktail [allopurinol and N-acetylcysteine (A/A)], indomethacin or the combination of A/A and indomethacin in a randomized double-blind fashion. Every 4 days an X-ray was taken and the thickness and length of new bone formation was measured at the thigh. A marked statistically significant difference was found between the four groups. In the groups that received A/A, either alone or combined with indomethacin, an inhibition of bone growth, both in thickness and in length was demonstrated. In this experimental model free radical scavengers had a superior inhibitory effect on heterotopic ossification than indomethacin. Free radicals could play an important role in the pathogenesis of heterotopic ossification.
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Research Interests: Humans, Female, Male, Electromyography, Carpal Tunnel Syndrome, and 3 moreAged, Middle Aged, and Adult
Summary Intra-articular corticosteroid injections have long been used to treat osteoarthritis, whereas intra-articular hyaluronic acid injections for only a few years. In the literature, evidence-based reports on the efficacy of these... more
Summary Intra-articular corticosteroid injections have long been used to treat osteoarthritis, whereas intra-articular hyaluronic acid injections for only a few years. In the literature, evidence-based reports on the efficacy of these compounds are non-existent. In the ...
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Entrapment neuropathies frequently involve the foot. The diagnosis can be established by electrophysiological techniques for the exploration of muscles and nerves. Needle recording from the intrinsic foot muscles is a valuable asset in... more
Entrapment neuropathies frequently involve the foot. The diagnosis can be established by electrophysiological techniques for the exploration of muscles and nerves. Needle recording from the intrinsic foot muscles is a valuable asset in the detection of neurogenic syndromes. The motor and sensory nerve conduction velocities are determined using surface electrodes. The sensory nerve conduction study can be supplemented with somatosensory-evoked-potential studies. Based on these investigations, the location, severity and prognosis of the nerve lesion can be determined. In the presence of tunnel and compression syndromes involving the foot, studies of the tibial nerve (tarsal tunnel - Morton), peroneal nerve and sural nerve are of particular interest.
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This study was designed to reveal any correlation between radiological signs and clinical findings of cervical spine involvement in rheumatoid arthritis (RA). Fifty patients with definite rheumatoid arthritis were evaluated for cervical... more
This study was designed to reveal any correlation between radiological signs and clinical findings of cervical spine involvement in rheumatoid arthritis (RA). Fifty patients with definite rheumatoid arthritis were evaluated for cervical spine involvement by a clinical neurological examination, a somatosensory evoked potential (SEP) study and different radiological techniques including tomograms, computerized tomography (CT) and magnetic resonance imaging (MRI). Anterior atlantoaxial subluxation was a common finding, frequently associated with superior migration of the dens and subaxial subluxation. Two patients presented a posterior atlantoaxial subluxation due to complete erosion of the dens. Both had cervical cord compression and one of them had hypoglossal nerve paresis. The delineation of peridental pannus formation was clearly demonstrated by MRI. In the majority of cases cervical cord compression was caused by pannus formation or by vertical atlantoaxial subluxation. The correlation between the severity of the radiological findings and the clinical-neurological signs was poor. A 4-limb SEP study appeared to be a useful screening method for the detection of cervical medullary compression.
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More and more physiatrists are interested in learning how to use musculoskeletal ultrasonography in their clinical practice. The possibility of high resolution, dynamic, comparative and repeatable imaging makes it an important diagnostic... more
More and more physiatrists are interested in learning how to use musculoskeletal ultrasonography in their clinical practice. The possibility of high resolution, dynamic, comparative and repeatable imaging makes it an important diagnostic tool for soft tissue pathology. There is also growing interest to use sonography for guiding interventions such as aspirations and infiltrations. In daily practice these are often done blindly or palpation-guided. To improve the accuracy of interventions, fluoroscopy or computed tomography were traditionally used for guidance. Since sonography is non-ionizing, readily available and relatively low cost, it has become the first choice to guide many musculoskeletal interventions. Ultrasound allows real-time imaging of target and needle as well as surrounding vulnerable structures such as vessels and nerves. Many different techniques are proposed in the literature. Interventions under ultrasound guidance have been proven to be more accurate than unguide...
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Each day, the role of musculoskeletal ultrasound (US) in the management of sports injuries is being consolidated. Yet, there is no doubt that the probe of US is (should be) the stethoscope of musculoskeletal physicians dealing with sports... more
Each day, the role of musculoskeletal ultrasound (US) in the management of sports injuries is being consolidated. Yet, there is no doubt that the probe of US is (should be) the stethoscope of musculoskeletal physicians dealing with sports medicine. Not only for the diagnosis, but also for the close follow-up of the athletes and during likely onward interventions for their treatment, would US be of paramount importance. Accordingly, in this review paper on common sports injuries, we tried to shed light into the actual role of US in the clinical practice of sports medicine.
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Although the combination of a detailed physical examination and a subsequent electrodiagnostic study is used for the diagnosis of peripheral nerve disorders, prompt imaging may also be necessary in daily practice. In this regard, as... more
Although the combination of a detailed physical examination and a subsequent electrodiagnostic study is used for the diagnosis of peripheral nerve disorders, prompt imaging may also be necessary in daily practice. In this regard, as having higher spatial resolution, and being a faster, more cost-effective and dynamic study; ultrasound (US) has become a very convenient first-line imaging modality for the diagnosis, follow-up and treatment (i.e. guiding interventions or planning for surgery) of peripheral nerve pathologies. Yet, using the probe of US to "sono-auscultate" the peripheral nerves is indisputably paramount for unmasking the whole scenario of injury. Likewise, in this review, we will try to exemplify the role of US for the diagnosis and follow-up of peripheral nerve disorders in clinical practice.
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BackgroundShoulder pain is a common musculoskeletal symptom with a wide range of potential causes; however, the majority of conditions can be managed with conservative treatment. The aim of this study is to assess the efficacy and safety... more
BackgroundShoulder pain is a common musculoskeletal symptom with a wide range of potential causes; however, the majority of conditions can be managed with conservative treatment. The aim of this study is to assess the efficacy and safety of Traumeel injections versus corticosteroid injections and placebo in the treatment of rotator cuff syndrome and bursitis and expand the current evidence base for the conservative treatment of rotator cuff syndrome.Methods/DesignThis is a multi-center, randomized, double-blind, 16-week, three-arm, parallel-group, active- and placebo-controlled trial to assess the efficacy and safety of Traumeel 2 ml injection versus dexamethasone 8 mg injection versus placebo (saline solution). Patients will be randomly allocated to Traumeel, dexamethasone or placebo in a 2:2:1 randomization. After 1 week screening, patients will receive 3 injections at weekly intervals (days 1, 8 and 15) with additional follow-up assessments on day 22, a telephone consultation in ...
To identify risk factors and predict falling in stroke patients. To determine the strength of general vs mobility screening for this prediction. Prospective study. Patients in the first 6 months after stroke. The following assessments... more
To identify risk factors and predict falling in stroke patients. To determine the strength of general vs mobility screening for this prediction. Prospective study. Patients in the first 6 months after stroke. The following assessments were carried out: an interview concerning civil state and fall history, Mini-Mental State Examination, Geriatric Depression Scale, Falls Efficacy Scale (FES), Star Cancellation Task (SCT), Stroop test, Berg Balance Scale, Functional Ambulation Categories (FAC), Motricity Index, grip and quadriceps strength, Modified Ashworth Scale, Katz scale, and a 6-month fall follow-up. Sixty-five patients were included for analysis. Thirty -eight (58.5%) reported falling. Risk factors were: being single (odds ratio (OR) 4.7; 95% confidence interval (95% CI) 1.2-18.3), SCT-time (OR 1.2; 95% CI 1.0-1.3), grip strength on unaffected side (US) (OR 0.1; 95% CI 0.0-0.8), FAC 3 vs FAC 4-5 (OR 8.1; 95% CI 1.5-43.2), and walking aid vs none (OR 5.1; 95% CI 1.4-17.8). These ...
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Trunk bridging exercises are often used as therapeutic exercises for lumbopelvic stabilization. These exercises focus on the retraining of muscle coordination patterns in which optimal ratios between local segmental stabilizing and global... more
Trunk bridging exercises are often used as therapeutic exercises for lumbopelvic stabilization. These exercises focus on the retraining of muscle coordination patterns in which optimal ratios between local segmental stabilizing and global torque producing muscle activity are assumed to be essential. However, a description of such ratios is lacking. The purpose of this study was to investigate both relative (as a percentage of maximal voluntary isometric contraction) muscle activity levels and ratios of local to global muscle activity, during bridging stabilization exercises. Thirty healthy university students (15 men, 15 women) with a mean age of 19.6 year volunteered to perform 3 bridging exercises (single bridging, ball bridge and unilateral bridging). The surface electromyographic activity of different trunk muscles was evaluated on both sides. During all bridging exercises, the ratio of the internal oblique to the rectus abdominis was very high due to minimal relative activity o...
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Over the last few decades, application of ultrasound has been attempted to enhance transdermal transport of several drugs, a method referred to as "phonophoresis." The purposes of this study were to examine the influence of... more
Over the last few decades, application of ultrasound has been attempted to enhance transdermal transport of several drugs, a method referred to as "phonophoresis." The purposes of this study were to examine the influence of ultrasound on the transdermal delivery of ketoprofen in humans and to compare the concentrations found after continuous and pulsed application. Twenty-six patients with knee disorders requiring arthroscopy were randomly assigned to 1 of 3 groups. Just before surgery, phonophoresis of a ketoprofen gel (Fastum gel) was given to group A using continuous ultrasound (1 MHz, 1.5 W/cm2, for 5 minutes). Group B received the same treatment but with pulsed ultrasound (100 Hz, 20% duty cycle). Group C received 5 minutes of sham ultrasound with the ketoprofen gel. The ultrasound head was moved over a 10-cm2 area using small, continuous, circular movements. Biopsies of adipose tissue and synovial tissue were taken during surgery to evaluate the local penetration of ...
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Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our... more
Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our purpose in this study to determine the intrinsic risk factors for the development of anterior knee pain in an athletic population over a 2-year period. Before the start of training, 282 male and female students enrolled in physical education classes were evaluated for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters. During this 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses revealed a significant difference between those subjects who developed patellofemoral pain and those who did not concerning quadriceps and gastrocnemius muscle flexibil...
Research Interests: Mechanical Engineering, Biomedical Engineering, Pain, Skeletal muscle biology, Social Support, and 19 morePhysics Education, Adolescent, Prospective studies, Humans, Femur, Female, Male, American, Risk factors, Adult, Knee injuries, Motor Performance, Risk Factors, Knee Joint, Syndrome, Prospective Study, Biomechanical Phenomena, Patella, and Pliability
Research Interests:
Reports on post-traumatic cyst-like lesions in childhood are scarce in the orthopaedic literature. These lesions do not have major clinical importance, but proper identification and differential diagnosis are essential. They typically... more
Reports on post-traumatic cyst-like lesions in childhood are scarce in the orthopaedic literature. These lesions do not have major clinical importance, but proper identification and differential diagnosis are essential. They typically present as an incidental finding on ...
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An experimental study of muscle recruitment patterns during asymmetric lifting in healthy individuals. To investigate muscle recruitment patterns during asymmetric lifting, representing a common daily living activity, to determine whether... more
An experimental study of muscle recruitment patterns during asymmetric lifting in healthy individuals. To investigate muscle recruitment patterns during asymmetric lifting, representing a common daily living activity, to determine whether systematic differences exist between functioning of the local and global muscle systems. The normal function of the local muscle system is to provide sufficient segmental stability to the spine. The global muscle system provides general trunk stabilization and enables the static and dynamic work necessary for daily living and sports activities. Current knowledge about these two muscle groups appears to be specifically derived from anatomic findings and experiments conducted under artificial circumstances. To the authors' knowledge, the recruitment patterns of both muscle groups have not been investigated in daily living activities. Twenty-nine healthy individuals performed different variants of asymmetric lifting activities. Electromyographic data were collected from seven hip, abdominal, and back muscle pairs. In addition, trunk kinematics were measured by means of an ultrasonic movement analysis system. The left and right obliquus internus, rectus femoris, and multifidus showed symmetric co-contraction in all variants of activities. In contrast, significant left/right differences were observed in the external oblique, gluteus maximus, iliocostalis lumborum pars thoracis, and latissimus dorsi. The results of this study show a symmetric activation of the local muscles during the performance of low-load, asymmetric lifting tasks, which suggests that these muscles play a stabilizing role during these manoeuvres. The global muscles, however, hand show asymmetric patterns of activation during the same tasks, supporting their role as global stabilizers and prime movers.
Research Interests:
This report aims, in the light of the recent literature, to describe the clinical features of bilateral thoracic outlet syndrome in a case of Klippel-Feil syndrome, the results of electrophysiologic evaluation, and the outcome after... more
This report aims, in the light of the recent literature, to describe the clinical features of bilateral thoracic outlet syndrome in a case of Klippel-Feil syndrome, the results of electrophysiologic evaluation, and the outcome after surgical intervention. Cervical ribs in the context of Klippel-Feil syndrome as the cause of bilateral thoracic outlet syndrome is discussed. In Klippel-Feil syndrome, congenital fusion of cervical vertebrae occurs and may also be associated with various anomalies, including musculoskeletal anomalies. The typical neurologic defects in this syndrome are caused by compression of the cervical cord and/or the corresponding roots. A 25-year-old woman had experienced, for 3 years, sensory symptoms, mainly numbness and pain, in both arms and episodic color changes of the hands that were aggravated by certain activities. Radiologic examination revealed Klippel-Feil syndrome type I, accompanied by bilateral cervical ribs. Electrophysiologic evaluation demonstrated impairment of nerve conduction, as indicated by F wave changes, after the arms were raised. The patient underwent successful decompression of the neurovascular structures at the thoracic aperture. It is often difficult to diagnose thoracic outlet syndrome by conventional neurophysiology. Dynamic changes in F waves appear to be a useful finding. In the absence of symptoms of myeloradiculopathy, thoracic outlet syndrome could be the sole manifestation of Klippel-Feil syndrome.