Exposing medical students to expanding populations.

Physicians are required to advocate for and counsel patients based on the best science and the interests of the individual while avoiding discrimination, ensuring equal access to health and mental services. Nonetheless, the communication gap between physician and patients has long been observed. To this end, the Institute for the Public Understanding of Health and Medicine of the Rutgers University New Jersey Medical School has expanded its efforts. This report describes two new programs: a legacy lecture series for medical students and an international "experience", in Huancayo, Peru, for medical students and faculty. The MiniMed outreach program, now in its ninth year and first described in this journal in 2012, was designed to empower the powerless to communicate more effectively with clinicians, thus improving both the effectiveness of the physician-patient relationship and health care outcomes. The approach of the two new programs and their effects on patients, particularly the underserved, and medical students and faculty, are outlined in the following article.

Rehabilitation of patients with spinal cord disease.

Spinal cord injury and disease have multisystem consequences and many potential medical complications. This article addresses the various medical, psychosocial, and vocational issues associated with spinal cord injury and describes how the patient's lifestyle may be affected. The role of the physician and other rehabilitation professionals in the rehabilitation process is described. In addition, various medical concerns, complications, and available treatment modalities are discussed.

Pressure ulcers. What to do if preventive management fails.

Tissue breakdown is a direct response to external pressure, friction, or shear. The key to management of pressure ulcers is prevention. With good nursing care, as well as education of medical personnel, the patient, and family members, such lesions should rarely occur. The axioms of treatment are to remove all pressure, debride necrotic tissue, keep the ulcer clean, and prevent further injury. There is only empirical evidence attesting to the effectiveness of the various dressings and physical and topical agents used in treatment. Most pressure ulcers can be classified as grade I or II and healed by conservative measures; however, the process can be very time-consuming. Surgery is warranted for some grade III and all grade IV and V pressure ulcers and for potential complications, such as fistulas.

The effect of temperature on antidromic median sensory conduction.

It has been well documented that sensory nerve conduction studies are influenced by many factors. Twenty-two healthy subjects were electrophysiologically evaluated to measure the onset latency, peak latency and amplitude (baseline to negative peak) after cooling the non-dominant hand. The distal onset latency was prolonged by 0.06 msec/degrees C, peak latency by 0.1 msec/degrees C and the amplitude was increased by 1.8 microV/degrees C by cooling hand skin temperature from 34 to 26 degrees C. These results can be used to extrapolate the value at normal physiologic skin temperature for the subject whose temperature is lower than normal. The results were compared with previous reports.

Assessing the driving potential of cerebral vascular accident patients.

In this report, literature pertaining to training the post-cerebral vascular accident (CVA) driving candidate is reviewed; a driver training program is described, with special emphasis on evaluating the CVA candidate; the role of the occupational therapist as a disabled driver training instructor is outlined; information and suggestions for comprehensive evaluation and training of right- and left-CVA driving candidates are presented; and data comparing driver's training outcomes for right- and left-CVA candidates are provided. Retrospective data of left- and right-CVA driver performance are compared.

Head and neck cancer, a rehabilitation approach.

Survival from head and neck cancer is not uncommon. However, treatment is often radical and may compromise the patient's appearance, function, and quality of life. The most common modalities of treatment, employed either singly or in combination, are chemotherapy, radiation, and surgery. Each treatment modality involves unique complications and compromises, many of which are amenable to rehabilitation techniques. A role of the occupational therapist on a cancer rehabilitation team is described and an overview of the therapeutic procedures for the evaluation and treatment of common problems recognized in these patients is presented. The material is derived both from clinical experience of the rehabilitation team and from a literature review employed in developing the rehabilitation program.

Rehabilitation medicine within the Veterans Administration: report of a survey.

The health care delivery system of the Veterans Administration (VA) represents the largest single group of physicians practicing physical medicine and rehabilitation. The long-term needs of the aged, often disabled, and poor veterans of America's wars suggest that rehabilitation should be a high priority within the VA system. Yet, Max Cleland, former VA Administrator, and a VA Task Force on Rehabilitation have indicated that operational performance falls short of promises and that programs are fragmented and uncoordinated, with minimal research production. The results are reported of a 17-page questionnaire sent to the 273 full- and part-time physicians in Rehabilitation Medicine Services (RMS) in an attempt to determine the state of rehabilitation medicine in clinical practice, teaching, education, publishing and research.

A history of cancer rehabilitation.

More than 8 million people in the United States have a history of cancer and more than 1 million new cancers are diagnosed each year. The 5-year survival rates for most tumors continue to improve due to earlier detection and treatment strategies. With increased cancer survival rates, there is a greater need for physiatrists (physicians trained in physical medicine and rehabilitation) to coordinate rehabilitation services and prepare a comprehensive plan for treatment and follow-up. Rehabilitation for patients with cancer should be no different from rehabilitation for other diagnostic conditions. The ultimate goal should be the achievement of the highest functional status possible within the limits of the disease and the patient's choices. Physiatrists have training that enables them to assess functional disability, biomechanics, quality of life, and human development, as well as the knowledge to prescribe appropriate medications, modalities, and orthotic, prosthetic, and assistive devices. An examination of the history of cancer rehabilitation will steer us toward future success for our patients. It is important that past lessons direct us away from pitfalls, and that patients receive the rehabilitation services to which they are entitled.

AAEM Minimonograph #10: volume conduction.

A volume conductor is any medium with the capability of passively conducting a current between regions of potential difference. The monophasic positive intracellular action potential produces a monophasic negative extracellular waveform and a triphasic extracellular waveform in a poor and good volume conductor, respectively. The observed waveform characteristics are dependent upon both the recording electrode montage and the type of volume conductor surrounding the excitable tissue. The extracellular current flow associated with an action potential can be divided into two current sources flanking a central current sink. If a recording electrode is located over the negative current sink, a negative potential is observed. When the two current sources approach a recording electrode, a positive potential is recorded. If a positive deflection of the baseline is observed, one may conclude that the wave of depolarization under investigation did not originate under, but traveled toward, the recording location. Electric currents from external sources are free to propagate extraneurally as the body is a good volume conductor. Care must be taken to not activate nearby nerves and, subsequently, obtain a waveform contaminated with potentials from undesired sources. Additionally, electrical activity from neighboring muscles and nerves can summate in the volume conductor and yield responses capable of masking pathology. An understanding of the principles of volume conduction theory can help the electrodiagnostician avoid artifactual errors and erroneous conclusions.

Electrodiagnosis and recovery of function.

The study of electrodiagnosis with respect to recovery of function is in its infancy. There is a need for better understanding of the mechanisms of recovery and for better techniques to monitor recovery. This paper reviews the potential uses and limitations of current electrodiagnostic tests to predict and monitor neuromuscular recovery. It illustrates the use of these techniques in patients with spinal cord injury.

Cauda equina injury: late motor recovery.

A 21-year-old man was left with complete paraplegia and lower extremity sensory loss after a gunshot wound to the 4th lumbar vertebral body. Within three weeks of the injury he noted slight recovery of proximal left leg movements. With further motor recovery and rehabilitation, he was discharged ambulatory at nine months postinjury. The patient described late motor recovery developing 13 to 16 years after injury, particularly in right knee extensors and bilateral ankle plantar flexors, simultaneous with an aggressive home exercise program. Serial manual muscle tests revealed increased strength in hip flexors, knee flexors and extensors, and ankle plantar flexors. The patient progressed from ambulating with bilateral knee-ankle orthoses and forearm crutches to bilateral ankle-foot orthoses and a point cane. His original injury was a combination of neurapraxia, which recovered by resolution of conduction block in several weeks to months; axonotmesis, which recovered by axon regeneration over several years; and neurotmesis, which did not recover. The muscle strengthening achieved 14 years after cauda equina injury may represent strengthening of muscle fibers reiinervated after the initial nine-month rehabilitation program. Clinical implications for rehabilitation are discussed including the possible need for a therapeutic trial of muscle strengthening.