Persian Gulf War amputees: injuries and rehabilitative needs.

This study describes the injuries, complications, functional limitations, and rehabilitative needs of amputees managed at Walter Reed Army Medical Center during the Persian Gulf conflict (1991). Fourteen amputees were treated sustaining 21 amputations with 18 lower-limb and 3 upper-limb amputations. In six casualties there were multiple amputations. Battle injuries were the cause in 79%. Nerve injuries occurred in 79%, phantom pain in 64%, and functional limitations (ambulation and activities of daily living [ADLs]) were present in all casualties. Contractures were noted in 86%. Skin traction for open wounds was lacking in all but one case. With comprehensive rehabilitation, all casualties achieved independent ambulation, and 93% were independent in all ADLs at discharge, with one below-knee amputee successfully returning to duty. These findings highlight the need for education of military health care providers in skin traction techniques, and provision of multidisciplinary rehabilitative care for these casualties.

Amputee soldiers and their return to active duty.

This study was undertaken to determine the percentage of soldiers who remain on active duty after undergoing a Physical Evaluation Board (PEB) for an amputation. The computerized records of all amputee soldiers who were presented to one of four Army PEBs during an 8-year period (October 1980 to September 1988) were reviewed. Only 11 of 469 soldiers (2.3%, 95% CI 1.2-4.2%) remained on active duty after amputation. Of those who returned to duty, most (6 of 11) sustained partial hand amputations, three had partial foot amputations, and two were below-knee amputees. Among those returning to duty, there were no female soldiers. We conclude that continuation on active duty is a rare event after amputation. Further studies on active duty is a rare event after amputation. Further studies are necessary to define the characteristics associated with active duty service as an amputee and the impact of an amputation on performance of military duties.

Suction cup ground and reference electrodes in electrodiagnosis.

An alternative to the taped-disc surface electrodes typically used during monopolar and concentric needle electromyographic studies has been investigated. The use of suction cup surface electrodes in place of the taped metal disc surface electrodes increases patient and operator safety and enhances patient comfort and operator efficiency. A two-channel EMG, with a single active needle and two reference electrodes, was done on patients routinely referred for electromyographic studies. The motor units were stored and compared. Similarly, baseline noise was stored and compared. This study shows that no distortion of motor unit potentials in typically measured parameters, nor alteration in baseline "noise" occurs when using the suction cup electrode in place of the taped metal discs. The safer, more comfortable suction cup surface electrodes do not distort the motor unit potentials that electromyographers are accustomed to interpreting.

Isokinetic exercise system modification for short below-the-knee residual limbs.

The use of isokinetic exercise has been shown to be an effective way of strengthening debilitated muscles. In the below the knee amputee, significant quadriceps and hamstring muscle wasting has been documented. Although isokinetic strengthening of the debilitated knee extensors and flexors in the below the knee amputee would be beneficial, there are no fully described isokinetic equipment modifications in literature that would allow a short below the knee amputee to effectively use isokinetic equipment. This article describes such a modification.

Epidural corticosteroid injections for acute radiculopathy in a 95-year-old woman.

A previously independent 95-year-old woman had acute, disabling left lumbosacral radiculopathy diagnosed by clinical findings and imaging studies. Significant side effects of oral nonsteroidal and narcotic medications led to treatment with epidural steroids (triamcinolone acetonide). These injections provided pain relief, allowing a short course of inpatient rehabilitation that improved the patient's function and facilitated return to independent living. At 1-year follow-up, she continued to live independently and remained free of pain. We believe that epidural steroids coupled with a comprehensive rehabilitation program can lead to restoration of function in some elderly patients unable to tolerate the side effects of standard pain medications.

Speech dysfunction due to trazodone--fluoxetine combination in traumatic brain injury.

New serotonin reuptake inhibitors are available for the treatment of affective disorders and sleep dysfunction in traumatic brain injury (TBI) patients. Commonly reported serotonergic side-effects include nausea, headache, dizziness, nervousness and orthostatic hypotension. Trazodone, a non-selective serotonin reuptake inhibitor, is often used in conjunction with fluoxetine, a selective serotonin reuptake inhibitor, in order to combat the insomnia associated with fluoxetine. Successful use of this combination is generally limited by the cumulative serotonergic side-effects of the two medications. This paper describes the first reported case of speech dysfunction as a complication of combined trazodone and fluoxetine use. A 43-year-old male suffered bilateral wrist fractures and a moderate TBI during a fall. Within 1 week of adding fluoxetine to trazodone the patient developed new-onset dysarthria and speech blocking. Upon discontinuation of fluoxetine, speech returned to normal. Possible mechanisms include inhibition of hepatic metabolism, unmasking of caudate nucleus injury, increased noradrenergic activity or previously unreported serotonergic effects. This case illustrates the importance of monitoring drug combinations for unexpected side-effects in the TBI population.

Isolated lesion of the lateral cutaneous nerve of the forearm.

Because of its location in the antecubital fossa, the lateral cutaneous nerve of the forearm is at risk of injury when a person is carrying objects with the forearm flexed or during venipuncture. Injury to this nerve, however, is rarely reported. A case report of traumatic injury to the lateral cutaneous nerve, the use of appropriate nerve conduction studies for diagnosis, and a discussion of the available literature is presented.

Beta blockade in the treatment of autonomic dysreflexia: a case report and review.

Autonomic dysreflexia has long been considered a sympathetically mediated phenomenon. Recent articles have reported the use of alpha blockers as a means of treatment. We report the case of a 20-year-old C5 American Spinal Injury Association A spinal cord injured patient who almost daily experienced symptoms of headache, facial flushing, and hypertension consistent with autonomic dysreflexia. These symptoms caused him frequent discomfort and anxiety. Despite an extensive workup, we were unable to identify a source of his dysreflexic episodes. After starting metoprolol 50 mg every night, however, these episodes stopped and the patient showed no adverse effects from the medication.

Extensor digitorum brevis reflex in normals and patients with radiculopathies.

This prospective study evaluated the extensor digitorum brevis deep tendon reflex (EDBR) in a normal population and in patients with L-5 and S-1 radiculopathies. There were 88 subjects: 53 normals, 17 L-5, and 18 S-1 radiculopathy subjects. The clinical EDBR revealed a 91% specificity, with 18% sensitivity for L-5, and 11% for S-1. The electrodiagnostic EDBR yielded increased sensitivities of 35% for L-5 (P = 0.07) and 39% for S-1 (P = 0.04), with 87% specificity. H-reflexes showed 50% sensitivity for the S-1 group (P = 0.0006) and 91% specificity. EDBR latencies were significantly related to age and leg length (r2 = 0.46, P < 0.0001). Age alone explained 26% (P < 0.0001) of the EDBR variability and leg length 20% (P < 0.0001). EDBR clinical and electrodiagnostic reflexes have low sensitivities, high specificities, and do not discriminate L-5 from S-1 root involvement.

Radial motor nerve conduction studies.

The radial motor nerve fibers were studied in 30 subjects using a technique of surface stimulation in the axilla and the antecubital fossa. Surface recording over the extensor digitorum communis 8cm from the distal stimulation site was done. Mean distal latency was 2.6msec (SD = 0.44), amplitude 11.24mV (SD = 3.5), and conduction velocity 68m/sec (SD = 7.0). Side-to-side comparison using the t-test demonstrated no significant differences. Five subjects were tested 75 more times on two successive days and showed a variation in latency of 0.2msec or less in 74 of 75 trials. Amplitude was consistent during each day's trial, but it varied slightly from one day to the next. Three case reports show the usefulness of the procedure.

Potential drug interactions in a physical medicine and rehabilitation clinic.

Potentially preventable adverse drug-drug interactions increase morbidity and financial costs to hospitals and third party payers. This study's purpose is to document the prevalence of potential drug-drug interactions (PDDI) in patients referred to a Physical Medicine and Rehabilitation (PM&R) clinic, to identify risk factors associated with PDDI, and to evaluate physicians' ability to correctly identify these PDDI. Current medication lists were obtained by questionnaire and confirmed by chart review for 121 consecutive new patients. The physician-identified PDDI were compared with computer-identified PDDI. Twenty-seven patients (22%; 95% confidence interval, 15-31%) had PDDI. PDDI were associated with number of medications (P = 0.0011) and PM&R subspecialty clinic (P = 0.012). Twenty-nine of the 46 computer-identified interactions (63%) were not identified by the physicians, and the physicians falsely identified 28 other drug combinations as PDDI. Potential drug-drug interactions occur at high rates in PM&R outpatient populations, and physicians are inadequately prepared to identify these PDDI.

Helping hemiparetics to help themselves. Sensory feedback therapy.

Despite the presence of some voluntary movement, the loss of discrete control impairs functioning of the arm and hand in most hemiparetics. Seventy hemiparetic patients, aged 12 to 78 years, were treated and followed up for six months to three years. Electromyographic activity monitored from dysfunctional primary movers during attempted movement was displayed to the patients as a continuous oscilloscopic trace, reflecting generated muscle activity and allowing its quantification. Coupled with operant conditioning techniques, these displays were modified gradually by reinforcing the patient's effort with auditory feedback during successive approximations to a desired level. Such therapeutic use of electromyographic displays often resulted in a progressive improvement of voluntary movement. More than half the patients acquired and retained purposive movements that meaningfully improved their functional capabilities.

Lumbosacral radiculopathy screen. Optimizing the number of muscles studies.

The literature is unclear as to which muscles and how many are required for a sensitive lumbosacral radiculopathy (LSR) screen. A retrospective study of 247 electrodiagnostically confirmed LSRs in 201 patients over a 3-yr period was conducted to determine how many muscles were required to identify a LSR. All LSRs showed abnormal spontaneous activity (positive waves or fibrillation potentials) in two or more muscles innervated by the same nerve root level but different peripheral nerves. All cases were categorized by radiculopathy level, and the most frequently abnormal individual muscles were combined into different muscle screens. The frequency with which each muscle screen identified a radiculopathy was the frequency with which one or more muscles in the screen displayed abnormal spontaneous activity divided by the total number of radiculopathies. The paraspinal muscles (PM) alone identified 88% of LSRs. Without PM, two muscle screens identified only 14-68%, three muscle screens identified 37-89% and four muscle screens identified 45-92%. Including PM, three muscle screens identified 86-94% of LSRs, four muscle screens identified 91-97% and five muscle screens yielded 94-98% identification. Seven to ten muscle screens resulted in minimal improvements in identifying a LSR with 98-99% identification. We conclude that five muscle LSR screens, including PM, are sufficient to identify LSRs while minimizing patient discomfort and examiner time.

Topical capsaicin for chronic neck pain. A pilot study.

Substance P is thought to be the principle neurotransmitter of nociceptive impulses in type C sensory neurons. Prolonged repeated applications of capsaicin cream depletes the sensory C-fibers of substance P. In an open-labeled prospective pilot study, 23 patients with chronic neck pain (greater than 3 mo) completed the study. Patients applied topical capsaicin (0.025%) cream four times a day to painful areas in the neck and shoulder girdle for a 5-wk treatment period. One patient dropped out because of intolerable burning. Statistically significant improvement was obtained in two primary outcome variables, the visual analog pain scale (P = 0.00013) and the pain relief scale (P = 0.002). Paired t tests failed to show a significant improvement in the McGill Pain Questionnaire. This study demonstrated that topically applied capsaicin cream may decrease subjective neck pain. A double-blind, placebo-controlled trial is needed to confirm this treatment effect.

EMG feedback therapy: review of treatment of 114 patients.

Advances in the understanding of the relationship of proprioceptive (kinesthetic) feedback to motor physiology have prompted the study of therapeutic effects of audiovisual displays of EMG activity. Patients with various manifestations of disturbed neuromotor control were studied prospectively for three years. This group included 114 patients with hemiparesis, torticollis, dystonia, and spinal cord or peripheral nerve injury. Initially, all but one of these patients had some residual volitional motor activity, which was insufficient for adequate function, and all patients had had conventional therapy with little or no functional recovery. Prior to EMG feedback therapy, the duration of illness was from three months to 35 years. The shaping of a patient's motor responses usually occurred gradually, often over an 8 to 12 week period. This modification was accomplished by feeding processed audio-visual signals back to the patient. These signals were proportional to the degree of activity of the muscles responsible for the defective function. The concept of microvolt-second, as a unit of muscle activity, is introduced and defined. Patterned movements, which were previously defective were observed to improve to varying degrees. Following the initial course of treatment, reinforcement was required by some patients. The mechanisms of improvement after EMG feeback therapy are not well understood; however, some hypotheses are presented. The results of this study indicate that EMG feedback therapy may induce significant functional recovery in patients with disturbed neuromotor control.

Analysis of casualties referred to Army physical medicine services during the Persian Gulf conflict.

This study describes the casualties referred during the Persian Gulf War and underscores the valuable role of Army physical medicine and rehabilitation (PMR) services in evaluation and early rehabilitation of wartime casualties. Data regarding demographics, injury types, medical complications, complications of immobility and functional limitations were collected by military physiatrists at five Army Medical Centers with PMR services. Active duty soldiers injured in the Persian Gulf War who were referred totalled 222. Musculoskeletal injuries occurred in 57%, peripheral nerve injuries in 44%, penetrating wounds in 32%, fractures in 28%, brain injuries in 8%, amputations in 7%, burns in 6% and spinal cord injuries in 3%. The primary referral service was orthopedics (64%). Electrodiagnosis evaluations were performed for 41% of all referrals. Lower limb and upper limb contractures occurred in 10% and 9% of patients, respectively. Ambulatory impairments were seen in 48%. Nerve injuries were associated with penetrating wounds in 68%, with amputations in 67% and with fractures in 58%.