American journal of physical medicine & rehabilitation
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Am J Phys Med Rehabil · Jun 1994
A clinician's guide to decision making capacity and ethically sound medical decisions.
Competence, or decision making capacity, refers to a patient's ability to understand a situation and to make a choice in light of that understanding. It requires the physician to disclose adequate information so that the patient is able to understand and choose. The standard for determining competence is that a person is deemed competent to make medical decisions if the person is capable of giving informed consent. ⋯ Of particular ethical interest, however, is rehabilitation medicine's efforts to exempt itself, in the early stages of rehabilitation, from the "moral force" of informed consent. Relying on its unique characteristics as a medical specialty, and on the fact that some of its patients have suffered sudden onset of severe impairment, rehabilitation medicine appears poised to espouse the "thank you theory" of medical practice. In addition, physiatrists may have a professional obligation to fully inform patients when potentially beneficial treatment is withheld from them, such as when they are denied access to or terminated from rehabilitation.
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Am J Phys Med Rehabil · Dec 1993
Case ReportsHistologically proven pressure sore-related osteomyelitis in the setting of negative technetium bone scans. Case report.
Pressure sores are common in patients with spinal cord injury, stroke or debilitating medical illness. Contiguous osteomyelitis is a well recognized complication of pressure ulcers, but remains a challenging diagnostic and management problem. Technetium bone scan is purported to be an extremely sensitive, although nonspecific diagnostic test for osteomyelitis. ⋯ We report three cases of pressure sore-related polymicrobial osteomyelitis where technetium bone scan was normal, yet bone biopsy demonstrated characteristic histopathologic changes of osteomyelitis. These cases raise questions regarding the sensitivity of bone scanning in the setting of pressure sores, and they demonstrate the need for further investigation into the correlation between nuclear medicine scan results and bone biopsy histopathology. Bone biopsy remains the gold standard for diagnosis of osteomyelitis, which can be present in bone underlying a pressure ulcer, even in the setting of a normal bone scan.
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Am J Phys Med Rehabil · Dec 1992
Clinical Trial Controlled Clinical TrialContinuous intrathecal baclofen in spinal cord spasticity. A prospective study.
Continuous intrathecal infusion of the well known antispastic medication baclofen was evaluated in ten consecutive patients. One year after pump implantation the average Ashworth scale for muscle tone decreased, compared with before treatment, 2.32 points (P < 0.0001), reflexes decreased 2.22 points (P < 0.0001) and the spasm score decreased 1.65 points (P < 0.0001). The average dose increased from 92.22 to 290.95 micrograms (P < 0.0001) between the 1st month of treatment and 1 yr of treatment. ⋯ The procedure is expensive and close follow-up is necessary for assessing efficacy and refilling the pump. Intrathecal baclofen infusion by subcutaneous pump is useful in treating the effects of spinal spasticity resistant to oral medications. However, there appears to be accommodation to intrathecal baclofen necessitating escalating doses to maintain clinical effects.
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Am J Phys Med Rehabil · Dec 1992
Case ReportsSpinal cord arteriovenous malformation in a person with congenital lymphatic abnormalities.
Spinal cord arteriovenous malformations have been described in association with a variety of congenital diseases affecting the vasculature, including Klippel-Trenaunay-Weber syndrome, Rendu-Osler-Weber syndrome and others, but rarely in association with lymphatic abnormalities. We report the case of a young man with congenital lymphedema and arteriovenous malformations of one lower extremity and a spinal cord arteriovenous malformation. Awareness of the possible presence of a central nervous system arteriovenous malformation in individuals with pre-existing arteriovenous and lymphatic abnormalities may be helpful in their diagnosis and management.
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Am J Phys Med Rehabil · Oct 1992
Standardized nerve conduction studies in the upper limb of the healthy elderly.
Nerve conduction studies are increasingly being performed on elderly individuals; however, no standardized data for the elderly population exists to provide an accurate interpretation of electrodiagnostic findings. The purpose of this study was to provide standardized data in the healthy elderly for the nerves of the upper limb that are routinely chosen for study by electromyographers. Nerve conduction studies were performed prospectively in one upper limb of 155 carefully screened healthy elderly individuals between the ages of 60 and 95 years. ⋯ However, age had a statistically significant but low strength effect on all ulnar nerve conduction velocities and distal latencies as well as the distal sensory amplitudes of all three nerves. Gender had a greater effect than age on these parameters as well as on median sensory distal latency. Other median motor and sensory conduction parameters along with radial sensory distal latency were not significantly related to age or gender based on two-way analysis of variance.