Physical medicine and rehabilitation clinics of North America
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Phys Med Rehabil Clin N Am · Aug 2002
ReviewTherapeutic spinal corticosteroid injections for the management of radiculopathies.
Current literature and a recent meta-analysis suggest a favorable role for corticosteroid injections in the nonoperative treatment of radiculopathy [70]. The superior results reported in recent literature may be attributable to precise fluoroscopically guided transforaminal placement of injectate close to the disc-nerve root interface and near the dorsal root ganglia, maximizing the therapeutic effect. The favorable results of corticosteroid injections in the treatment of radiculopathy caused by a focal disc herniation are consistent with the biochemical construct of radicular pain. ⋯ Such an emphasis is just beginning and inevitably will occur. Until then, decisions have to be predicated on the limited and flawed work conducted to date [71]. Nevertheless, the information gleaned from these published reports provides valuable insight not available just a decade ago.
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Phys Med Rehabil Clin N Am · Aug 2002
ReviewPhysical examination signs, clinical symptoms, and their relationship to electrodiagnostic findings and the presence of radiculopathy.
The validity of the history and physical examination varies with study method and the gold standard used. In general, symptoms are more sensitive than specific, and most patients with radiculopathy do present with some characteristic complaints. ⋯ Having a normal physical examination, however, does not rule out the possibility of having a radiculopathy that is revealed either electrodiagnostically or surgically. Although the history and physical examination may not be perfect tools for the diagnosis of radiculopathy or predicting electrodiagnostic outcome, they are an essential part of the clinical evaluation to assist in formulating a differential diagnosis and guiding the electrodiagnostic study.
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Throughout the course of military history, soldiers have continued to sustain amputation injuries during war times and during peacetime and training missions. What has changed over time is the etiology of, indication for, and management of the amputations. ⋯ More work still needs to be done, especially in the areas of greater prosthetic limb function and usage as well as phantom pain and sensation management. Collaborative efforts among physiatrists, surgeons, prosthetists, and therapists can only benefit the patient.
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Phys Med Rehabil Clin N Am · Nov 2001
ReviewPhysiologic and clinical monitoring of spastic hypertonia.
Spasticity has been defined as "a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome." Increased motor neuron excitability and enhanced stretch-evoked synaptic excitation of motor neurons are potential neurophysiologic mechanisms to explain this phenomenon. The relative contribution of these two distinct mechanisms likely varies depending on the location of the lesion in the central nervous system. The patient history is an important component of the clinical evaluation focusing on potential nociceptive inputs that can worsen spasticity (e.g., urinary tract infections, skin breakdown). ⋯ For generalized hypertonicity, intrathecal pump administration of medications or surgical interruption of reflex pathways has been helpful. Ultimately, the clinician must systematically approach the evaluation and treatment of spasticity. As decisions regarding moving from less to more invasive treatments are discussed, the potential risks and side effects of treatment options must be weighed versus the potential benefits that the patient might receive to maintain a rational approach to the management of spasticity.
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Phys Med Rehabil Clin N Am · Aug 2001
ReviewPromoting ethical and objective practice in the medicolegal arena of disability evaluation.
As providers of medical information and testimony, clinicians have ultimate responsibility for ethical conduct as it relates to this information. The authors offer the following recommendations for enhancing ethical relationships between expert clinicians and the courts. 1. Avoid or resist attorney efforts at enticement into joining the attorney-client team. ⋯ We suggest that a more useful cut-off would be .75, where experts are expected to generate findings that do not support the referring attorney's position at least 25% of the time. 9. Never arrive at opinions that are inconsistent with plaintiff records, examination data, test data, behavioral presentation, and so forth, especially when such opinions are favorable to the side of the retaining attorney firm. Instead, use the following recommendations. (ABSTRACT TRUNCATED)