PM&R

Rehabilitation Research: We Should Care and We Should Act

Neil A. Segal — 2010-07-01

In 1925, Dr. William J. Mayo was credited as saying “Rehabilitation is to be a master word in medicine.” As a field, rehabilitation medicine has a very exciting opportunity to serve society through a focus on human health, function, and participation. Physiatrists are poised to play a major role in improving the quality of life of patients and the health of society in an age of increasing numbers of older adults, an increasing prevalence of obesity, and competing needs to preserve health while reducing costs. The field has expanded to incorporate technology, sports and performing arts medicine, and image-guided interventions while still incorporating neurologic and musculoskeletal rehabilitation for children, workers, and older adults. Although diverse, rehabilitation medicine aims to optimize musculoskeletal and neurological human function.

Thermal and Electric Energy Fields by Noninvasive Monopolar Capacitive-Coupled Radiofrequency: Temperatures Achieved and Histological Outcomes in Tendons and Ligaments

Terry Whipple, Diana Villegas — 2010-05-13

Objective: To determine whether noninvasive monopolar capacitive-coupled radiofrequency (mcRF) can produce energy and thermal fields capable of breaking-down collagen molecules in deep connective structures without damaging untargeted tissues as evidenced by temperatures achieved and histological outcomes.Design: Basic science study on fresh untreated cadaveric specimens.Setting: Orthopaedic Research of Virginia (Institutional).Methods: Two upper and two lower extremities from cadaveric specimens were obtained for the study. Anatomical structures were surgically exposed. Fluoroptic thermometers were implanted into the mid-substance of the targeted structures as well as in the skin above the structures to be studied. mcRF pulses were delivered to the area of interest, and temperatures were recorded every second. Multiple samples of tissue from each treatment site and stage of treatment were harvested for analysis.Outcome Measures: Outcomes were evaluated by temperature changes in response to energy fields, multiobserver histological analysis under regular and polarized light, and direct observation of the tissues in the areas exposed to RF energy.Results: Temperatures recorded at the targeted structures reached above 50°C, as evidenced by the implanted thermometers. Histological analysis under regular and polarized light evidenced a progressive pattern of collagen denaturation that correlated well with temperatures recorded.Conclusion: This study established a direct relationship between noninvasive mcRF energy and temperatures recorded in deep structures (P < .001). Histological examination under regular and polarized light suggested that collagen changes are dose related. No evidence of damage to the nontargeted structures or to the tissue superficial to targeted structures was observed. As it has been demonstrated in survival animal studies, it is anticipated that the outcome of the changes induced in collagen fibers would trigger a desirable wound healing response. These findings can provide a meaningful context to the ongoing clinical use of mcRF.

Hypoesthesia in the Distal Residual Limb of Amputees

2010-07-01

Objective: To test the emerging hypothesis that there is polymodal fiber degeneration/loss in distal residual limbs (DRL) of amputees.Design: Prospective qualitative and quantitative psychophysical testing.Setting: A pain research center at an urban academic rehabilitation hospital.Participants: Forty-four amputees (32 with pain, 12 without pain) with a single (upper or lower) limb amputation. Subjects are a clinical “convenience” sample derived from our amputee or prosthetic clinics.Methods: Interventions were prospectively acquired psychophysical tests. The primary quantitative test was thermal Quantitative Sensory Testing (tQST) using a Peltier type thermal testing device, assessing sites on the DRL compared with anatomically similar regions on the contralateral “unaffected” extremity.Results: Perceptual responses for several qualitative psychophysical stimuli and perceptual thresholds for tQST cold sensation were significantly reduced in the DRL (t(43) = −2.613, P = .012). There were no significant tQST differences in thresholds for warm perception, cold pain, or hot pain (P > .05).Conclusion: These results show a point prevalence of differential hypoesthesia in distal residual limbs. There was a selective loss of cold, but not warm perception or threshold for hot or cold pain by tQST. There are several possible explanations for this polymodal and selective hypoesthesia; specifically, these data may be indicative of a differential “dying back” peripheral neuropathy of the DRL, which may be operational in such clinical features as postamputation pain.

Osteopathic Manipulative Treatment and Vertigo: A Pilot Study

Marcel Fraix — 2010-07-01

Objective: To assess the safety and feasibility of studying osteopathic manipulative treatment and its potential effectiveness for patients with vertigo.Design: A nonrandomized pilot study.Setting: Outpatient clinic affiliated with a teaching hospital and osteopathic medical school.Patients: The subjects were older than 18 years of age, with the diagnosis of vertigo for longer than 3 months.Intervention: The patients were treated with osteopathic manipulative treatment (OMT).Main Outcome Measurements: Treatment effectiveness was measured with the use of the Dizziness Handicap Inventory (DHI), a validated symptom inventory. Intensity and duration of adverse effects after OMT were used to measure study safety.Results: Of the 18 patients who were recruited all 18 (100%) met the inclusion criteria and were enrolled in the study. Sixteen patients (88.9%) completed the treatment course with OMT, and data with respect to the DHI were obtained from all 16 (100%). Significant improvement (P < .001) in total and subcomponent DHI scores was observed after completion of treatment. Of the 8 patients with moderate pretest scores, 7 (87.5%) had mild post-test scores after undergoing OMT, and of the 8 patients with severe pretest scores, 4 (50%) had mild post-test scores. Of the 18 enrolled patients, 3 (16.7%) experienced an exacerbation of their vertigo, and 5 (27.8%) experienced muscle soreness after OMT. These adverse effects were mild and transient, not lasting longer than 24 hours.Conclusions: This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Skateboarding Injuries in Vienna: Location, Frequency, and Severity

2010-07-01

Objective: To describe injury patterns of skateboard-associated injuries (SAIs) and to assess the frequency and severity of SAIs depending on an athlete's skateboarding experience.Design: Cross-sectional observation.Setting: Skating areas.Participants: A total of 100 Viennese skateboarders.Interventions: No intervention.Main Outcome Measures: The participants filled in a questionnaire that was used to assess selected sociodemographic data; duration and frequency of skateboarding; “stance”; and localization, rate, as well as the severity of SAIs during the past 24 months. Skating behavior and sociodemographic data were compared with frequency and severity of SAIs.Results: Response rate of questionnaires was 75% (n = 75) of the participants. Duration of skateboarding was 8 ± 5 years, and training time was 18 ± 11 hours/week. A total of 97% (73) of the respondents reported at least one injury: in 52% (39) of the respondents the most serious injury was mild to moderate (laceration, contusion, strain/sprain, and bruise), whereas in 45% (34) it was severe (ligament rupture, fracture). A total of 33% (13) of participants experiencing only mild-to-moderate injuries consulted a physician compared with 94% (32) with at least one serious injury. The most severely affected regions were lower leg/ankle/foot in 32% (24) of all respondents who experienced at least one severe injury and forearm/wrist/hand in 16% (12) who experienced at least one severe injury. Only 13% (10) used protective equipment. Multivariate logistic regression for the occurrence of at least one severe injury with all socioeconomic and sport-relevant data investigated revealed significant positive correlations with weekly training time (P = .037) and years of experience (P = .021). However, after correcting for multiple testing (Bonferroni adjustment for 8 tests), no significances remained.Conclusion: More experienced skateboarders seem to have a greater risk of incurring severe SAIs, but sociodemographic factors seem to have no influence on injury risk in this population. Only a minority of skateboarders used protective equipment.

Injectate Volumes Needed to Reach Specific Landmarks in Lumbar Transforaminal Epidural Injections

2010-07-01

Objectives: To identify the volumes of contrast material needed to reach specific landmarks during lumbar transforaminal epidural injections (L-TFEIs).Design: Prospective, nonrandomized, observational human study.Setting: Academic/private pain management practice.Patients: Sixty-nine patients undergoing L-TFEIs were investigated. Sixty patients were included in this study.Interventions: L-TFEIs were performed with the use of contrast-enhanced fluoroscopic visualization.Main Outcome Measurements: After the appropriate spinal needle position was confirmed, up to 5.0 mL of nonionic contrast material was slowly injected. Under biplanar fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: ipsilateral neural foramen, ipsilateral disks superior and inferior to the injected level, and across the midline of the spinous process.Results: After 1.1 mL of contrast was injected, 100% of L-TFEIs spread to the medial aspect of the superior pedicle (PED) of the corresponding level of injection. After 2.8 mL of contrast was injected, 95% of L-TFEIs spread to the superior aspect of the superior intervertebral disk (IVD) of the corresponding level of injection. After 3.6 mL of contrast was injected, 95% of L-TFEIs spread to the inferior aspect of the inferior IVD of the corresponding level of injection. After 3 mL of contrast was injected, 88% of L-TFEIs spread to cover both the superior and inferior IVDs of the corresponding level of injection. After 4 mL of contrast was injected, 93% of L-TFEIs spread to cover both the superior and inferior IVDs of the corresponding injection. After 4 ml of contrast was injected, 55% of L-TFEIs spread beyond the midline of the spinous process, but barely.Conclusion: This study demonstrates injectate volumes needed to reach specific anatomic landmarks in L-TFEIs. A volume of 4.0 mL of injectate reaches both the superior aspect of the superior IVD and the inferior aspect of the inferior IVD 93% of the time.

The Effects of a Brief Relaxation Program on Symptom Distress and Heart Rate Variability in Cancer Patients

2010-07-01

Objectives: To determine whether a 15-minute, one-time guided relaxation program for cancer patients could improve symptom distress as measured by the Edmonton Symptom Assessment System (ESAS). In addition, we were interested in characterizing the changes of the autonomic nervous system, as demonstrated by heart rate variability (HRV) high-frequency (HF) spectral analysis, before and after this relaxation program.Design: Nonrandomized pilot study.Setting: Comprehensive cancer center.Methods: Twenty cancer patients underwent a 15-minute relaxation program. The ESAS and a 5-minute HRV recording were completed before and after the relaxation program.Main Outcome Measures: The differences between the pre- and post-summed ESAS score and HRV values were compared by a paired t-test.Results: The summed ESAS scores were significantly lower after the relaxation program (P < .01), with an average 31% decrease in total score. However, no differences were found in HRV HF power. There was no correlation between the change in HRV HF and change in symptom distress, as measured by ESAS.Conclusions: A brief guided relaxation program can significantly improve symptoms as measured by ESAS. More research is required to understand the effects of relaxation on HF HRV power.

Comparison of Surface and Ultrasound Localization to Identify Forearm Flexor Muscles for Botulinum Toxin Injections

2010-07-01

Objective: To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin injection targets for forearm muscle spasticity.Design: Observational.Setting: Outpatient spasticity clinic in a tertiary care center.Subjects: Eighteen patients with upper-extremity flexor spasticity that interferes with function were included. Individuals with severe fixed contractures or traumatic injury of the involved forearm were excluded.Methods: Flexor pollicis longus, flexor carpi radialis, pronator teres, and flexor digitorum superficialis (FDS) were identified by 2 separate localization techniques: the method of Delagi et al for flexor carpi radialis, pronator teres, and flexor pollicis longus; and a surface landmark technique by Bickerton et al to identify the 4 muscle bellies of FDS. Proximodistal and lateral (radial) coordinates were recorded relative to a landmark line from the medial epicondyle to pisiform bone, and percentage of landmark line distance was calculated. After surface measurements were collected, the best point for injection was determined by using real-time US with a 12-MHz linear transducer. US measurements were recorded by using the same landmark line system.Results: Localization techniques were compared by using the Wilcoxon signed rank test. One-sample t-tests compared surface-mapped lateral coordinates to US-derived lateral coordinates with controls for multiple testing. Significant differences were observed between surface and US proximodistal and lateral coordinates for several flexor muscles.Conclusions: US should be considered as an adjunct for localization in patients with upper-limb spasticity. US can improve accuracy of toxin placement and help to avoid injection into vascular and nerve structures.

Venous Thromboembolic Events in the Rehabilitation Setting

Brian M. Kelly, Brian M. Yoder, Chi-Tsai Tang, Thomas W. Wakefield — 2010-07-01

Abstract: Venous thromboembolism (VTE) is a disease entity that encompasses both deep venous thrombosis and pulmonary embolism. During the past decade there have been significant advances in the understanding of prophylaxis and treatment of VTE. There is an extensive research base from which conclusions can be drawn, but the heterogeneity within the rehabilitation patient population makes the development of rigid VTE protocols challenging and overwhelming for the busy clinician. Given the prevalence of this condition and its associated morbidity and mortality, we review the evidence for the prevention, identification, and optimal treatment of VTE in the rehabilitation population. Our goal is to highlight studies that have the most clinical applicability for the care of VTE patients from a physiatrist's perspective. At times, information about acute care protocols is included in our discussion because these situations are encountered during the consultation process that identifies patients for rehabilitation needs.

Informed Consent and Phase 1 Research in Spinal Cord Injury

2010-07-01

Geron, a California-based for-profit biotechnology company, plans to launch a multicenter phase 1 study for human embryonic stem cell therapy (GRNOPC1) as soon as the Food and Drug Administration (FDA) releases its approval for the Investigational New Drug application []. The study will seek to enroll newly injured patients with “complete” thoracic (ASIA A) spinal cord injuries (SCIs; T3-T10) who will agree to have GRNOPC1 surgically injected into the lesion area 7 to 14 days after injury. Geron is not alone and will undoubtedly be joined by other research companies during the next decade who are similarly racing to develop and test treatment interventions for SCI. Thus, it is imperative that rehabilitation professionals become proficient with the ethics of phase 1 research studies.

Chronic Traumatic Encephalopathy

Thomas Watanabe, Elie Elovic, Ross Zafonte — 2010-07-01

A 51-year-old right-handed man presents to your office with family concerns of cognitive dysfunction. His wife reports that he experiences increased forgetfulness, irritability, and short-term memory issues with a slow decline during the past 2.5 years. He appears to have little insight into any of these concerns, yet he helps run an insurance company. His medical history is significant only for previous left shoulder and right knee surgeries. He takes no medications. He played Division I college football and 5 years of professional football as a middle linebacker during the 1980s. In the early part of his professional career, he had a brief 1-week exposure to anabolic steroids. There is a relatively short history of substance abuse, with heavy alcohol use for 1.5 years after his career ended.

Adult Onset Tethered Cord Syndrome Presenting With Unilateral Calf Atrophy

Kevin Kohan, Se Won Lee — 2010-07-01

Although tethered cord syndrome is a disease process that is well established in childhood, adult onset tethered cord syndrome (ATCS) is a less common disorder that is slowly gaining recognition. ATCS is caused by excessive tension of the spinal cord. The majority of reported cases of ATCS have been attributed to various forms of spinal dysraphism []. Spina bifida, which occurs in a minor subset of the population with cerebral palsy (CP), can lead to childhood tethered cord syndrome []. However, patients with occult spinal dysraphism may reach adulthood before they are diagnosed. The most common symptoms in adults, in order of prevalence, are pain, weakness, sensory deficits, and urinary or bowel dysfunctions []. To date there are only a few case reports of ATCS accompanied by muscle atrophy []. Here, we introduce a distinguishing presentation of ATCS with unilateral calf muscle atrophy in a patient with CP.

Progressive Resistance Training During Pregnancy: A Case Study

Melissa J. Benton, Pamela D. Swan, Maria Whyte — 2010-07-01

Regular exercise during pregnancy benefits maternal health by minimizing gains in fat mass []. Walking is often the preferred form of physical activity, especially during the 2nd and 3rd trimesters, when a reduction in regular physical activity programs may reach as much as 30% []. However, changes in body weight and abdominal girth make activities such as brisk walking uncomfortable and can generate a level of impact that is not well tolerated []. Resistance training is a feasible alternative that provides some of the cardiorespiratory benefits found with walking as well as gains in muscle mass and strength that may not be achieved with aerobic activities alone []. In fact, weight training is one of the most common exercise activities reported by healthy women during pregnancy [].

A Sound Solution to Tendonitis: Healing Tendon Tears With a Novel Low-Intensity, Low-Frequency Surface Acoustic Ultrasound Patch

Haim Moshe Adahan, Hanania Sharon, Itzhak Siev-Ner — 2010-07-01

The use of therapeutic modalities such as nitrous oxide; platelet-rich plasma therapy; stem cell transplantation; and low-intensity, low-frequency ultrasound (LILFU) to enhance tendon regenerative capacity in patients with tendinous insufficiency is in its early stages. Of those alternatives, only LILFU studies have provided level 1 evidence of efficacy in bone healing []. In vitro, low-intensity ultrasound, which exerts direct nonthermal effects on cell physiology, stimulates the expression of numerous genes involved in the healing process, including aggrecan, insulin-like growth factor, transforming growth factor, collagen, nitric oxide synthase, cytokines, and angiogenesis [].

Academy News

2010-07-01

The Academy presents its 71st Annual Assembly and Technical Exhibition on November 4-7, 2010, in Seattle. The AAPM&R 2010 Annual Assembly Preliminary Program was packaged with the June issue of PM&R. Preliminary Program content is also available online at www.aapmr.org/assembly.htm.

Journal Based CME

2010-07-01