Total joint arthroplasty: principles and guidelines for postoperative physiatric management.

Postoperative physiatric treatment is an integral part of the replacement of hips, knees, ankles, shoulders, elbows, wrists, and digital joints. Neuromuscular substitution patterns and incoordination usually prevail after joint replacement because of the usual long-term expectation and experience of pain, limitation of motion, fatigue, weakness, and the unavoidable operative trauma. The goals of postoperative physiatric treatment, in line with those of joint replacement surgery, are relief of pain and reestablishment of comfortable, normal neuromuscular functions and their reasonable, safe application in appropriate activities of daily living and of locomotion. By close collaboration between the Department of Orthopedic Surgery and that of Physical Medicine and Rehabilitation, certain principles and detailed protocols of postoperative management have been developed over the last 10 years. These are described in some detail for each of the joint replacements. Optimal results can be achieved only through meticulous attention to physical and psychosocial details, with close cooperation and communication among the involved services and persons.

Bladder retraining. An organized program.

The management of neurogenic bladder dysfunction has been associated with a relatively high incidence of upper urinary tract infections and urosepsis. Today, the regular use of modern diagnostic tools in roentgenology and urodynamics is available. Moreover, contraindications to bladder retraining are better defined, and we have available better methods of evaluating urodynamics, superior reconstructive and corrective urologic surgery, judicious use of intermittent catheterization, and prompt detection and treatment of recurrent bacteriuria. We also know that, with an organized program of bladder retraining and follow-up, a substantial decrease in morbidity of patients with neurogenic bladder dysfunction has become possible.

Cervical fractures and spinal cord injury: outcome of surgical and nonsurgical management.

Data were collected retrospectively for 102 consecutive patients with a cervical spinal cord injury admitted to a spinal cord injury center between 1976 and 1986. Frankel's classification and level of spinal cord injury stayed the same or improved in all patients. The complications that occurred compared favorably with outcomes reported in the literature. Approximately 60% of patients achieved a catheter-free voiding status before dismissal from primary rehabilitation. Patients treated with early surgical stabilization of the cervical column were hospitalized a mean of 21 fewer days than their nonsurgical counterparts. In addition, patients treated with early surgical stabilization achieved their first therapeutic leave of absence from primary rehabilitation approximately 40 days sooner than patients stabilized nonsurgically. At final follow-up, however, no appreciable differences in achievement in activities of daily living and mobility were noted between patients treated with surgical stabilization of the cervical spinal column and those treated nonsurgically.

Hand function after metacarpophalangeal joint replacement in rheumatoid arthritis.

Hand function, determined by a standardized test, was compared before and after total metacarpophalangeal joint replacement with the Swanson Silastic rubber metacarpophalangeal prosthesis in patients with destructive rheumatoid arthritis. Two groups of rheumatoid patients were tested. Group 1 consisted of 10 patients who were examined 3 to 4 months after surgery. Group 2 included 11 patients who were evaluated 6 to 12 months postoperatively. Each group represented 43 prosthetic replacement procedures performed on 12 hands. Results indicate substantial postoperative improvement in tip prehension and grasp, while performance remained essentially unchanged for lateral prehension, pinch force, and power grip. A postoperative program of therapeutic exercises, functional hand activities and splinting is discussed.

Prostatosis, prostatitis or pelvic floor tension myalgia?

Patients with symptoms suggestive of prostatitis or prostatosis who do not have pathogenic bacteria in the prostatic secretions may, in fact, not have prostatic problems. The possibility of pelvic floor tension myalgia should be considered in these patients.

Bacteriuria during follow-up in patients with spinal cord injury: II Efficacy of antimicrobial suppressants.

Data from serial follow-up evaluations of 103 patients with traumatic or atraumatic myelopathy were recorded to determine rates significant bacteriuria in groups using different antimicrobial suppressive regimens or no pharmacologic agents. Rates of urinary tract infection were compared in patient taking methenamine salts with urinary acidifiers, co-trimoxazole, or no drug. At all follow-up period rates of infection were consistently lower in the groups taking methenamine and co-trimoxazole than in the group not taking a drug, the group taking co-trimoxazole having the lowest rates. These results suggest that the long-term use of antimicrobial suppressants can help reduce rates of urinary tract infection in bladder-retrained patients and in patients emptying by intermittent self-catheterization.

Bladder retraining of paraplegic women.

Forty-six women with neurogenic bladder dysfunctions attempted bladder retraining. Thirty-one (67%) were successful in reducing residual urine volume to less than 150ml an incontinence to nonsignificant amounts. Success was not dependent upon age, duration of previous indwelling catheterization, type of neurogenic bladder dysfunction, previous incontinence grades, bladder capacity, peak intraurethral pressure, or use of neuroactive drug, but was inversely correlated with the number of urinary tract infections occurring during bladder retraining (p less than 0.05).

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 1. Gathering momentum (the years before 1942).

Frank H. Krusen, MD, was arguably the most influential member of the small group of physicians who began in 1938 a long and difficult struggle to win acceptance of physical medicine and rehabilitation as a medical specialty. The struggle was aided immeasurably in 1943 when a millionaire philanthropist, M. Bernard Baruch, financed the establishment of the Baruch Committee on Physical Medicine. Dr. Krusen became the Director-Secretary of the Committee and began to keep a daily diary in which he recorded his activities and those of his colleagues in their quest for recognition of PM&R as a specialized field of medical practice. That recognition came in 1947 with the establishment of the American Board of Physical Medicine, but Dr. Krusen continued his diary through 1967. In 1988, 15 years after his death, Dr. Krusen's family donated a copy of the diary to the History of Medicine Library of the Mayo Clinic in Rochester, MN. The gift coincided with the American Academy of Physical Medicine and Rehabilitation's celebration of its 50th anniversary. This article, the first of four, introduces the reader to Dr. Krusen and describes his early years and his professional development in the years before 1943.

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 2. Forging ahead (1943-1947).

Presented here is a continuation of the story--as drawn from the diary entries of Frank. H. Krusen. MD--of the struggle to gain recognition for, and acceptance of, physical medicine as a medical specialty in its own right. It details the events, as described by physical medicine's strongest protagonist, between 1943 and 1947 that led finally to the establishment of the American Board of Physical Medicine. The millionaire philanthropist Bernard Baruch provided the financial resources that were required to establish academic and clinical programs in the field of physical medicine. Dr. Krusen was a key member of the Baruch Committee on Physical Medicine, which provided over sight for the newly created programs. His thoughts and sentiments concerning his role in the struggle, as he recorded them in his diary, are reported here.

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 4. Triumph over adversity (1954-1969).

This article, the last of four based on the diary of Dr. Frank H. Krusen, picks up the story of physiatry's conflict with other medical specialty groups within the American Medical Association. The conflict was focused on PM&R's use of the term "rehabilitation," but the underlying motive of groups opposing physical medicine was to limit the scope of physiatric practice. Dr. Krusen organized a well-documented and successful defense of the specialty and opened the door to the development of comprehensive care of persons with disabilities. Also related here are Dr. Krusen's legislative and public relations contributions to PM&R from 1963 until his retirement from Tufts-New England Medical Center in 1969. Dr. Krusen retired to Cape Cod and died there in 1973.

The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 3. Consolidating the position (1948-1953)

This article is a continuation of the story of the struggle to win recognition of physical medicine and rehabilitation as a medical specialty, as told in the pages of a daily diary kept by Frank H. Krusen, MD, from 1943 through 1967. The first two articles described Dr. Krusen's professional development before 1943, his efforts to establish a certifying Board for physiatrists, and the role of the Baruch Committee on Physical Medicine in Krusen's eventual successes. This article focuses on how Krusen and his physiatric colleagues campaigned to gain acceptance by organized medicine of the new specialty, to unite the fields of physical medicine and rehabilitation, and to identify and maintain the scope of physiatric practice despite challenges from other specialties.

Nonvalue of neomycin instillation after intermittent urinary catheterization.

This study evaluated weekly urine cultures of patients with neurogenic bladder disease who underwent intermittent urinary catheterization for bladder retraining. One group of 53 patients in 1974 received regular instillations of 0.1% neomycin after each catheterization. A similar group of 55 patients in 1975 did not receive neomycin and constituted a control group. Distribution of age, sex, diagnosis, and duration of bladder retraining was comparable in both groups. Quantitative bacterial colony counts of 10(4) to 10(5) or greater per ml of urine were considered significant. There was no difference in the incidence of bacteriuria between the neomycin-treated group and the control group (53 versus 49%, respectively), and most patients in each group had colony counts >10(5)/ml. Escherichia coli was seen less frequently in neomycin-treated patients (43.4 versus 62.5%), but a greater percentage of infections due to Pseudomonas aeruginosa, group D streptococci, and yeasts was noted in the neomycin-treated group than in the control group (41.5 versus 22.5%).

Bacteriuria during follow-up in patients with spinal cord injury: I. Rates of bacteriuria in various bladder-emptying methods.

Data from serial follow-up evaluations of 103 patients with traumatic and atraumatic myelopathy were recorded to determine rates of significant bacteriuria associated with various types of bladder emptying in an outpatient population. Urine culture specimens were obtained by sterile catheterization. Rates of urinary tract infection in bladder-retrained patients, patients using intermittent self-catheterization, and patients with indwelling catheters were compared at sequential follow-up visits. Infection rates were similar (20% to 30%) in persons with catheter-free voiding after successful bladder retraining and in those using sterile intermittent self-catheterization. In the latter group, however, there was a trend toward higher infection rates beyond 15 months after rehabilitation. As expected, persons with indwelling catheters had universally high infection rates. Generally lower infection rates were found in persons with incomplete myelopathies (18%) than in those with complete myelopathies (34%). Tetraplegic persons had 2.5 times the infection rate of paraplegic persons in the bladder-retrained group. Infection rates tended to be lower in persons with lower motor neuron bladder dysfunction than in those with upper motor neuron or mixed bladder dysfunction.

Mortality, survival and prevalence: traumatic spinal cord injury in Olmsted County, Minnesota, 1935-1981.

Mortality, prevalence, and survival from traumatic spinal cord injury were examined in Olmsted County, Minnesota, from 1935 through 1981. One hundred and fifty-four incident cases and 30 additional cases who were Olmsted County residents on at least one of four prevalence dates were identified. The average annual age-adjusted mortality for spinal cord injury, including deaths attributable to spinal cord injury occurring at any time after injury was 28.5 per million population. The rates in males were consistently greater than females, peaking to 61.0 in the period 1965-74. Thirty-eight percent of cases did not survive long enough to be hospitalized. Survival was 58% in the first week post-injury. However, for those who survived the first day and the first year, the 10-year survival was 77 and 87%, respectively. Early fatality in males was associated with single marital status (p = 0.0033) and concomitant head trauma (p = 0.0122), and in females with pedestrian or bicyclist status at injury (p less than 0.0001). Long-term survival was dependent on age (p less than 0.0001) and functional disability (p = 0.04). Point prevalence of spinal cord injured patients increased from 197 per million population in 1950 to 473 in 1980. This increase in prevalence was due at least in part to increasing incidence over time. An improvement in survival over the time period of the study could not be detected.

Determining residual urine volumes using a portable ultrasonographic device.

Residual urine volumes of 24 men with neurogenic bladder dysfunction were repetitively assessed 400 times with the BVI-2000 BladderScan portable ultrasonographic device prior to 100 episodes of intermittent catheterization. By comparing each examiner's first ultrasonographic measurement of urine volume with the catheterized urine volume, the mean error of the ultrasonographic measurements was -26mL (-11%) and the mean absolute error was 44mL (22%). The ultrasonographic measurements detected the presence of residual urine volumes of > or = 100mL with a sensitivity of 90% and a specificity of 81%. In the subset of catheterization episodes in which the catheterized urine volumes were < or = 200mL, the mean error of the ultrasonographic measurements was -15mL (-9%), the mean absolute error was 37 mL (28%), and the sensitivity and specificity were 77% and 81%, respectively. There was no clear advantage in using the average or maximum of two repeated ultrasonographic measurements over using each examiner's first ultrasonographic measurement alone. Increased examiner experience did not significantly decrease the errors encountered.

Traumatic spinal cord injury in Olmsted County, Minnesota, 1935-1981.

The incidence rate for acute traumatic spinal cord injury in Olmsted County, Minnesota, for 1935-1981, standardizing for age, sex, and calendar year, was 54.8 per million person-years--83.4 for males and 27.7 for females. Thirty-eight per cent of cases died prior to hospitalization. The annual incidence rate for those reaching hospital alive was 34.2 per million person-years. The proportion of cases dying during initial hospitalization was 11.5%. Considering all deaths within the first year after injury, the standardized mortality rate from spinal cord trauma was 25.5 per million person-years. Automobile-related injuries constituted half of all causes of spinal cord injury and death. An increase in both incidence and hospitalization rates of traumatic spinal cord injuries in the past 17 years was observed in young men, attributable to recreational and motorcycle-related events.