Traumatic brain injury/chronic pain syndrome: a case comparison study.

OBJECTIVE: To identify the pretreatment characteristics and progress in treatment and outcomes of chronic pain patients, with and without concomitant traumatic brain injury (TBI). DESIGN AND PATIENTS: Retrospective cohort study of 12 consecutive patients in a chronic pain treatment program who were discovered to have previously untreated brain injury and a cohort of 12 chronic pain patients from the same program matched for age and sex who did not have brain injury. SETTING: Interdisciplinary university-based outpatient rehabilitation medicine clinic. MAIN OUTCOME MEASURES: Length of time in treatment and vocational outcomes. RESULTS: A surprising number of patients referred for treatment of chronic pain were found to have history and symptoms indicative of previously untreated or undiagnosed mild traumatic brain injury (n = 21 of 65). Of these, 12 received therapy for both their brain injury and chronic pain. The 12 treated, dual diagnosed patients did not differ in terms of education, employment status, or marital status from the chronic pain patients. Those with TBI were more likely to have sustained an automobile injury and less likely to have a work-related injury. On admission, 25% of each group were working, and at discharge, that proportion reached 75% for each group. Those with TBI required significantly longer treatment (459 consecutive days) from intake to discharge compared with the control group (295 days). CONCLUSION: Patients who exhibit memory or concentration problems, who express confusion about their diagnosis, who were injured in an automobile accident, or who complain of pain in the head, neck, or arms should be questioned about the possibility of concurrent TBI. Most of these patients can achieve successful employment outcomes, however, the TBI group may require a longer treatment time.

Practitioner's guide to industrial back problems.

If return to work is part of the expected outcome, more and more data indicate that medical care alone does not hold the key to providing success. Our modern physical treatments may seem a humane alternative to no treatment, but they have not been proven to significantly alter the natural course of back problems. Even the results of strongly indicated surgical treatment differ little from doing nothing at all after a 4-year period. From the physical standpoint, activation has the best track record for recovery and can be simply provided in a manner that can be used lifelong. The real key to return to work goes beyond the physical treatment by addressing the predicament of what the patient will do until age 65. This humane approach to care has evolved from common frustrations of dealing with patients with back problems, observations in the third world, and information gained from scientific studies. Medical pain, and physical models alone are unsuccessful. To be humane and successful, we can no longer ignore the nonphysical factors that can, and do, influence patients' responses to physical treatment, especially when return to work is part of the expected outcome.

Disability issues with carpal tunnel syndrome. A case discussion.

This article reviews nerve entrapments and cumulative trauma disorders of the upper limbs including a problematic carpal tunnel syndrome (CTS) patient case, idiopathic arm pain, and ulnar neuropathy. Major points of the discourse focus on the problems of treatment, especially as they relate to impairment and disability management.

Sympathetic skin response in fifth lumbar and first sacral radiculopathies.

Skin temperature changes and sympathetic skin response (SSR) changes have previously been reported in lumbosacral radiculopathy patients (6). The SSR was studied in 14 normals and in 8 radiculopathy subjects with unilateral, EMG documented active radiculopathies to assess if the SSR becomes asymmetric when measured across appropriate dermatomes. The SSR was recorded in dermatomal patterns in both feet simultaneously with active electrodes on the plantar surface and reference electrodes on the dorsum. Four wave types were identified and normal values for latency of onset, latency of peak, and amplitude are presented with the normal left/right ratios presented. In all individual subjects the amplitudes of the SSR were extremely variable and asymmetric while latencies were less variable and more symmetric. There were no significant differences in symmetry between radiculopathy and normal subjects. When using this technique the SSR is not significantly altered in L5 and S1 radiculopathies.

Comparison of sensory mid-palm studies to other techniques in carpal tunnel syndrome.

This prospective study was done to assess a technique of comparing Median-Ulnar sensory latency differences across the wrist (Sensory Palm [M-U]) to diagnose carpal tunnel syndrome (CTS) and to compare the relative sensitivities of other previously reported techniques: Median-Radial sensory difference (Sensory Thumb [M-R]), Median-Ulnar mixed palm difference (Mix Palm [M-U]) and Median-Ulnar sensory digit difference (Sensory Digits [M-U]). 90 Hands met the electrodiagnostic (EDX) criteria for mild CTS. The Sensory Thumb (M-R) was abnormal in 90% of the hands followed in order by Mix Palm (M-U) 61%, Sensory Digits (M-U) 42% and Sensory Palm (M-U) 33%. All differences were statistically significant (p < .01). Sensory Palm (M-U) did not significantly add to the diagnosis of CTS. The Sensory Thumb (M-R) was relatively the most sensitive followed by Mix Palm (M-R) was relatively the most sensitive followed by Mix Palm (M-U), Sensory Digits (M-U) and Sensory Palm (M-U).

Spinal myoclonus complicating spasticity in spinal cord injury: a case study.

A case of spinal myoclonus that complicated spasticity management is presented. A 37-year-old man with a C6 American Spinal Injury Association class B spinal cord injury was referred for treatment of spasticity. He had failed previous treatments with baclofen and dantrolene but was partly relieved by diazepam, although with unacceptable side effects. Further evaluation, including simultaneous electroencephalogram, videotaping, and electromyography of the quadriceps, anterior tibialis, posterior tibialis, and medial hamstring suggested myoclonic jerks of spinal origin that initiated episodes of unsustained clonus. During the worst episodes, myoclonic jerks came once every 16 to 22 seconds and persisted for 4 to 5 hours. Each episode of clonus lasted approximately 4 to 6 seconds. Treatment with valproic acid greatly diminished the frequency of myoclonic jerks with minimal side effects. Functionally, the patient was much less fatigued and better able to maintain his full time employment.

Neurogenic atrophy of suboccipital muscles after a cervical injury: a case study.

This case report describes abnormalities in bilateral rectus capitis posterior minor muscles in one individual with persistent head and neck pain. These findings are muscle atrophy, fatty infiltration on magnetic resonance imaging, and electromyographic abnormalities compatible with denervated muscle. The objective of the study contained herein was to determine if fatty infiltration on magnetic resonance imaging of the rectus capitis posterior minor muscle is the result of disuse or denervation. Electromyography and magnetic resonance imaging data were collected from normal and atrophied muscles. Electromyography and magnetic resonance imaging abnormalities compatible with denervation atrophy were detected. Although we cannot rule out aging or other unknown causes, we suspect that denervation is caused by nerve damage from trauma to the C1 dorsal ramus as a consequence of entrapment within the rectus capitis posterior major muscle.

Dermatomyositis associated with fallopian tube carcinoma.

Dermatomyositis (DM) is an idiopathic inflammatory myopathy associated with characteristic cutaneous and extracutaneous manifestations, including malignancy. Primary fallopian tube carcinoma (FTC) is the least common site of origin for a malignant neoplasm of the female genital tract. This report describes the first documented case of DM and concurrent FTC in the United States. A 62-year-old woman presented with DM and was subsequently found to have FTC. During her clinical course, she had improvement in strength and function with treatment of the underlying FTC, which also correlated with lower creatinine phosphokinase levels. An association between DM and FTC may exist because of significant functional strength improvements after tumor removal and chemotherapy.

Telephone use to elicit voice or speech in brain injured subjects.

The initiation of speech is often delayed in the early stages of recovery from a serious brain injury. We have found a high percentage of patients with both speech and swallowing problems. This makes bedside assessment of swallowing safety difficult because one cannot listen for the sound of aspirated material on the vocal cords when a patient is at high risk for silent aspiration and is often unable to cooperate with a videofluoroscopic study. The use of the telephone has been described several times for aphasia treatment, but not to elicit speech or assess swallowing safety early after brain injury. This study, therefore, recruited subjects who had brain injuries and (1) were referred early for swallowing and other evaluations, (2) were out of coma and able to follow some commands, and (3) did not initiate voice or speak when asked to. Subjects were asked three questions under two different conditions: face to face and after ringing the telephone from another room. The results were recorded on videotape and analyzed by another investigator for quantifiable differences. Six of the seven subjects responded better with the telephone stimulus than without. This technique may elicit voice or speech early after brain injury in some patients and may be useful in bedside assessment of swallowing safety. It may also serve as an example of appropriate stimulation of brain injured subjects coming out of coma.

Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Quality Assurance Committee.

The sensitivity and specificity of nerve conduction studies (NCS's) and electromyography (EMG) for the diagnosis of carpal tunnel syndrome (CTS) were evaluated by a critical review of the literature. With a search of the medical literature in English through May 1991, 165 articles were identified and reviewed on the basis of six criteria of scientific methodology. The findings of 11 articles that met all six criteria and the results of 48 additional studies that met four or five criteria are presented. We concluded that median sensory and motor NCS's are valid and reproducible clinical laboratory studies that confirm a clinical diagnosis of CTS with a high degree of sensitivity and specificity. Clinical practice recommendations are made based on a comparison of the sensitivities of the several different median nerve conduction study (NCS) techniques.

Inclusion body myositis and transitional cell carcinoma of the bladder: significant resolution of symptoms after tumor excision.

Inclusion body myositis (IBM) is a separate class of the inflammatory myopathies with recently proposed clinical and pathological diagnostic criteria. An association between inflammatory myopathies and malignancy has been questioned in the literature. Recent reviews of the inflammatory myopathies suggest that only dermatomyositis is associated with malignancy. The largest study to date of patients with IBM found that 15% had a malignancy (6 of 40). We report the first documented case of IBM and concurrent transitional cell carcinoma of the bladder. We suggest that a causal relationship between IBM and malignancy may exist because of significantly improved functional strength gained after tumor removal.

American Association of Electrodiagnostic Medicine guidelines for outcome studies in electrodiagnostic medicine.

Based on a review of the literature and the clinical research experience of the authors and reviewers, the AAEM proposes 17 criteria which should be used to construct and evaluate diagnostic and/or therapeutic outcome studies for patients with symptoms and signs of neuromuscular diseases. Neuromuscular diseases are defined as diseases that cause pathology and/or dysfunction of the sensory, motor, and/or autonomic nerve offers and/or muscles.