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Between 1985 and 1990 the enactment of state mandatory seat belt laws has reduced the risk of death from auto accident by at least 40% and the risk of moderate to severe injury by 45%. Although head and facial trauma has also been significantly reduced, there has not been a decrease in injuries to other parts of the body. We evaluated seven restrained drivers who complained of persistent anterior and/or lateral chest wall pain after being in motor vehicle accidents. All had normal x-rays of the osseous thorax. Nuclear scan imaging subsequently revealed that all seven had a healing fracture of either the sternum or ribs. In each instance, direct trauma to the sternum and ribs anteriorly by the chest strap itself and/or laterally displaced bending forces transmitted to the postero lateral rib margins was sufficient to produce x-ray occult fractures.

The diagnosis of postpolio syndrome is based primarily on a thorough history supported by both clinical and laboratory examination. Similarly, the presence of an occult spinal stenosis may be suspected initially by a history of progressive lumbar or cervical radicular pain, as well as concomitant extremity weakness and/or myelopathic signs. Appropriate electrodiagnostic examinations, including somatosensory spinal-evoked potentials and electroneuromyography, as well as imaging studies, computer-assisted tomography scan, magnetic resonance imaging and/or myelography are all useful in confirming the clinical diagnosis of either cervical spinal stenosis or lumbar spinal stenosis in patients who also may have had a history of poliomyelitis. Four patients (three men and one woman) previously diagnosed as having postpolio syndrome were referred with predominate complaints of spinal and extremity pain as well as associated motor weakness. It was subsequently recognized that these patients, ranging in age from 45-65 yr, were actually presenting with symptomatic spinal stenosis. It was discovered that two patients had cervical spinal stenosis; the other two had lumbar spinal stenosis.

The specialist in physical medicine and rehabilitation, joining with medical and surgical colleagues, can contribute special skills to both the diagnosis and management of complications related to neoplastic diseases and their treatment. The multifaceted team approach-lending the skills of the physiatrist and the physical, occupational, and speech therapists as successfully employed in the rehabilitation of chronic neuro-musculoskeletal disability-can with equal facility be utilized in the management of the cancer patient. Although in these instances the rehabilitative goals of caring for patients with spinal metastatic disease may remain essentially the same, treatment time is often telescoped by progressive disease requiring frequent accommodation to the staging of functional levels of locomotion and self-care. The direct or remote effects of the cancer itself; the residual effects of radical surgery, and the toxic side effects of chemoprophylaxis and radiotherapy, combined with a sympathetic understanding of the dying process, individually or collectively are challenges the physiatrist has to master to become a productive member of the oncology treatment team. In this role the physiatrist can bring to bear his or her considerable diagnostic expertise in the neuro-musculoskeletal clinical and electroneuromyographic evaluation of spinal pain and weakness syndromes as well as their treatment. Realistic expectations, tempered by a knowledge of the natural history of the specific malignancy and the presence of associated comorbidities of pain, asthenia, and weakness, separately and together can influence the rehabilitation effort to restore patients to their fullest psychological, social, vocational, physical, avocational, and educational potential.1.

Electromyographic (EMG) examination demonstrating marked segmental compromise of the posterior primary ramus distal to the spinal root with relative sparing of the anterior ramus may be the earliest objective evidence of paraspinal muscle metastasis. Antecedent studies are often initially normal, failing to disclose the underlying cause of back pain. Although paraspinal muscle metastasis has been histopathologically demonstrated at postmortem, attempts to image the suspected malignancy with computed tomography have been unsuccessful because the tumor in muscle remains isodense. This study reports the use of magnetic resonance imaging (MRI) to substantiate the existence of EMG-suspected paraspinal muscle metastasis. An EMG pattern of segmental posterior primary ramus denervation is not pathognomonic of metastasis. A confirmatory MRI, however, does permit earlier treatment with palliative radiation therapy.

Therapeutic manipulation is one of the oldest and most enduring treatment approaches to spinal pain. Multiple clinical trials have been structured to assess its therapeutic efficacy. A review of these reports suggests that in the acute circumstance, manipulation may hasten recovery but is not of significant benefit in the management of chronic spinal pain.

Twelve patients treated with cervical traction for complaints of cervical radicular pain subsequently developed lumbar radicular discomfort. Intermittent cervical traction therapy had been initiated at 15 pounds and increased to 30 pounds. Lumbar spine roentgenographs in four patients demonstrated a transitional lumbar vertebrae and ten patients had evidence of spinal osteoarthritis with associated degenerative changes. Abnormal electroneuromyographs were found in four patients. In two additional patients with normal electromyographs, the spinal evoked potentials were asymmetrically slowed suggesting chronic lumbar root compromise. The onset of lumbar radiculopathy after intermittent cervical traction suggests that axial tension induced in the spinal cord's dural coverings can be transmitted to lumbar nerve roots. When these structures are tethered by anatomic variants and/or associated degenerative changes, spinal root excursion may be limited, and lumbar pain may be precipitated by traction.

There is a relative lack of information in the literature regarding the epidemiology, functional significance, and clinical resolution of the consequences of minor traumatic brain injury (MTBI). Most retrospective studies to date have been elicited by direct patient interview. Because it was supposed that a minor, but significant, traumatic brain injury would require continuing medical intervention beyond the emergency room contact, a survey was conducted of primary care physicians who were believed to be providing continuing medical care. Had their patients required reevaluations for symptoms of the post-MTBI syndrome? Two hundred fifty-six patients with traumatic brain injury initially seen in the emergency room of two community hospitals were reviewed. One hundred ninety-two (75%) had MTBIs (Glasgow coma scale more than 12 and a negative head CAT scan). One hundred twenty-two physicians were surveyed by mail; 67 (55%) responded. Twenty-one percent of their patients were experiencing symptoms of the post-MTBI syndrome from two to six months after their injuries. Studies relying on patient interviews have also estimated the post-MTBI syndrome at 20%. This correlation implies that "suggestion" does not bias patient interview style research in evaluating the post-MTBI syndrome.

A case is presented of a patient with the chief complaint of low back pain, who subsequently was found to have lumbar metastatic angiosarcoma. This report emphasizes the need for a thorough medical evaluation in all instances of radicular low back pain. The characteristics of metastatic intramedullary spinal cord tumor are outlined.

Lumbosacral and associated leg pain and paresthesias arousing patients from a sound sleep, or Vesper's curse, has been previously reported. An increase in right atrial filling pressure reflected in elevated paraspinal venous volumes within the reduced confines of a stenotic lumbar spine has been cited as the cause of this syndrome. Six cases of concomitant nocturnal calf cramps and fasciculations associated with the night pain and paresthesias are reported. In all cases a reduction in cardiopulmonary compliance was noted, with clinical and electromyographic evidence of paraspinal and lower extremity fasciculations increasing at night. Symptoms were relieved by assuming an erect or semi-reclining sleep position. In five of the six reported cases of lumbar spinal stenosis, spondylolisthesis was also present. The motor equivalent of Vesper's curse was evaluated by electromography, evoked potentials, CAT scan, and myelography. The multiple factors involved in the pathomechanics and pathophysiology of lumbar radiculopathy, and spinal stenosis and the role of the paravertebral plexus of veins are reviewed as they relate to the genesis of the restless legs syndrome.

Seven adult patients identified as having idiopathic transient osteoporosis of the hip (TOH) are reported. TOH is an uncommon entity, most often seen in women during the third trimester of pregnancy and in middle-aged men. It is characterized by groin pain, limited hip range of motion, nonspecific laboratory findings, localized radiographic evidence of osteopenia, and spontaneous recovery usually within two to nine months. Diagnosis remains dependent on clinical recognition and x-ray confirmation. Radioisotope scanning aids in the diagnosis; both bone and synovial biopsies are often less productive. Treatment consists of joint protection with limited weight bearing, range of motion exercise, progressive ambulation, and analgesics. An awareness of TOH facilities appropriate diagnosis and treatment and curtails unnecessary diagnostic procedures.

The Tethered Median Nerve Stress Test (TMNST) has proved to be a reliable clinical tool in the diagnosis of chronic, low-grade carpal tunnel syndrome (CTS). The TMNST consists of hyperextending the index finger at the distal interphalangeal joint with the wrist maintained in a supinated position. Proximal volar forearm pain radiation is experienced by patients with chronic CTS during this maneuver. This investigation shows that significant distal excursion of the median nerve occurs with hyperextension of the index finger and to a greater degree than with hyperextension of the adjacent digits. Pain experienced during the TMNST appears to be vascular in origin and its severity is directly related to the duration of testing. This finding emphasizes the important role of ischemia in chronic entrapment neuropathies.

During the last decade, five pregnant patients with symptoms and signs of a herniated lumbar disc were identified among a series of 48,760 consecutive deliveries at William Beaumont Hospital, an incidence of 1:10,000. In all cases, clinical evaluation and electromyography complemented conservative treatment during the final stage of pregnancy. Each patient was delivered by cesarean section. Large lumbar disc herniations in each case were subsequently identified by myelography. In all five cases, lumbar laminectomy was successful in facilitating the eventual resolution of the signs and symptoms of the radiculopathy. Although the mechanical and postural stresses of pregnancy have been cited as predisposing causes of a herniated lumbar disc, this study suggests otherwise. Lumbosacral vertebral disc ruptures of pregnancy, while relatively rare, should nevertheless be recognized early, distinguished from other causes of lumbosacral gestational plexopathy, and promptly treated.

Twenty-four women employed as computer operators were evaluated for complaints of occipital headaches, as well as neck and shoulder pain. Although the symptoms were highly variable with respect to duration, intensity and distribution, they were mutually consistent in that they started or intensified with the resumption of the work week. The patients varied in age from 25 to 58 with a median average of 48 years. Fifteen demonstrated radiographic evidence of cervical degenerative disc disease and in an additional four, electromyographic evidence of cervical root compromise was present. Multiple precipitating factors were identified in Monday's headache including the predisposing presence of unrecognized impairment of visual acuity in 4 and cervical radiculopathy in 16. Mechanically, prolonged postural cervical hyperextension frequently combined with repetitive head rotation appeared to trigger the discomfort complaints. Undue elevation of the CRT screen, prolonged copying of laterally displaced hard copy, the wearing of bifocals, as well as seating either excessively soft or with a tendency to pitch the operator forward were identified as additional aggravating factors.

Among the protean complications of diabetes mellitus are contractures of the joints and periarticular soft tissue. These complications have not been well described in the literature. This syndrome of "limited joint mobility," has been reported as occurring in young, insulin-dependent diabetics, with primary involvement of the small joints of the hands. In older diabetics, similar changes have been described with additional contractures developing in the large joints of the upper extremities. This report presents clinical findings occurring in five older diabetics with primary contractures of the shoulder. Theoretical considerations are also discussed regarding the neurophysiology of this entity as well as the current treatment options.

Eighteen women, all of whom had extensive but noninformative breast evaluations, including 10 mammograms and 4 biopies, were successfully treated by cervical traction for chronic breast pain. Each patient had distinct clinical or electromyographic evidence of cervical root compromise. Fifteen had roentgenographic evidence of cervical spondylosis, primarily at levels C6 and C7. Cervical angina, as a symptom constellation produced by cervical radiculopathy and mimicking coronary ischemic disease, is a well-defined entity. Less well recognized is persistent breast pain as a primary presenting symptom of cervical root compromise. In both instances, the early identification of the cervical radicular origin of the pain, with its quite different prognosis and associated therapeutic implications, can promptly help to allay the patient's physical and psychologic discomfort. The pathologic mechanism of pain production and the anatomic pattern of referral are described.

The escalation of airline travel compounded by federal deregulation, fostering crowded airports, delayed flights, and inconvenient gate scheduling, has forced the frequent flyer to run from one gate to another, carrying heavy under-the-seat bags. Eleven busy executive, nine men and two women, developed cervical radicular pain complaints associated with weakness and painful dysesthesias in the involved extremity. Four had right C6 root symptoms and seven had left C7 complaints. All had evidence, by x-ray, of cervical degenerative disc disease and three had abnormal electromyograms. Treatment, consisting of intermittent cervical traction after moist heat, as well as a modification of their travel habits including the use of a folding wheeled cart, in every instance resolved these complaints.

Fifty patients presenting with lumbosacral and inguinal pain were examined by routine clinical radiographic and electromyographic evaluations. All were without antecedent history of major pelvic trauma or spinal surgery but demonstrated evidence of pubic symphysis instability. Slip between the pubic rami in excess of 2 mm could be demonstrated in each with alternate leg weight bearing. Asymmetry of hip mobility on the symptomatic side with a reduction in abduction and external rotation was present in 20 patients. An approach to treatment of pain associated with pubic symphyseal and associated sacroiliac joint instability is described, combining both intraarticular steroids, lumbosacral supports and physical therapy modalities.

Lumbosacral or primary buttock pain and cutaneous anesthesia in the distribution of the posterior femoral cutaneous nerve were the initial symptoms in 5 patients later proven to have extensions of previously resected colorectal malignancy. The initial electromyographic impression of an inferior gluteal nerve mononeuropathy associated with recurrent neoplasia was confirmed by a positive colon biopsy in 1 case and widespread pelvic metastasis demonstrated at laparotomy in the 4 remaining cases. Four of the 5 patients also had increased levels of carcinoembryonic antigen. Roentgenographs and other laboratory data were otherwise normal in all 5 cases. Entrapment of the inferior gluteal nerve and the accompanying posterior femoral cutaneous nerves is facilitated by its medial, intrapelvic fixation at its origin from the sciatic nerve and the crowding effect of the piriformis muscle above, the dorsal rim of the sciatic notch behind and the inferior gluteal vessels and nodes below. The demonstration of hypestesia over the inferior lateral buttock and a concomitant history of colorectal malignancy should alter the examiner to the possible presence of an inferior gluteal nerve neuropathy.

Six patients with occult sternal metastasis presenting with chest pain, and four with sternal deformity associated with "arthritis" had undergone routine roentgenographic examinations, reported as "normal." Subsequent laminography of the sternum demonstrated lytic lesions confirmed by needle biopsy. Adenocarcinoma of the lung and breast were identified in two each of four patients; myeloma and kidney neoplasms were the primary source of malignancy in the remaining two patients. In widespread malignancy, metastasis to the skeletal chest wall is a well-recognized occurrence. Infrequently, it can be an isolated manifestation of an occult or recurrent malignancy, initially overlooked when routine roentgenograms are read as normal. Although sternal x-rays remain the most important means of diagnosis, in suspected cases of sternal metastasis laminography alone may initially reveal lytic lesions.

Routine physical examination of 600 patients referred with complaints of neck or shoulder pain included auscultation of both carotid and subclavian arteries. A treatment regimen including consideration of therapeutic cervical traction was precluded in 11 patients when unilateral carotid bruits were heard. Subsequent testing including radioisotopic carotid blood flow studies, and arteriography demonstrated 1 thoracic outlet syndrome, 1 arteriovenous malformation, 1 scarring secondary to radical neck dissection, 1 extrinsic pressure from an epidermoid carcinoma, 5 partial carotid occlusions secondary to intra-arterial plaque formation, and 2 normal carotid contrast studies. Successful surgery in all five of the stenotic patients and in the case of arteriovenous malformation aborted what might have otherwise been a less satisfactory outcome.

Electromyographic studies were performed on 16 patients with intractable low back pain and no antecedent history of malignancy or metastatic disease. In each case, electromyographic evidence of severe segmental denervation limited to the paraspinal muscles innervated by the posterior primary rami was found. Subsequent diagnostic studies in each patient revealed a primary neoplasm or tumor metastasis as the source of pain. Applying current knowledge of neuromuscular physiology, the electromyograph may prove to be a valuable aid to the early detection of remote metastasis to the spine and paraspinal muscle structures.

A prospective, controlled study was conducted to determine the prevalence of peripheral neuropathy (PN) in patients with anorexia nervosa (AN). Fifty-one patients (49 females, 2 males) between the ages of 12 and 47 (means = 22.5) who met the criteria for AN of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, were randomly selected from an inpatient eating disorders unit during 15 months. Fifty healthy volunteers (41 females, 9 males) between the ages of 17 and 50 (means = 26.5) served as controls. After a neurologic history, all patients were evaluated by physical examination and standardized electrodiagnostic testing. Chi-square contingency testing was used to assess data. Four study group patients (8%) had electrodiagnostic evidence of a sensorimotor PN compared with none in the control group. This is approaching statistical significance (p = 0.13). Three of four patients with AN for at least ten years were among those with PN. The prevalence of subjective symptoms among the study group (65%) as compared to the control group (4%) was of marked significance (p = 5.62 x 10(-10]. In addition, three anorexic patients were found to have an isolated peroneal nerve palsy. We conclude that PN is a notable complication of AN, particularly in long-standing cases. The PN is most likely a product of chronic malnutrition rather than a specific nutrient deficiency. Patients with AN also appear to be at increased risk for developing localized compression neuropathies secondary to subcutaneous tissue loss.

A psoas abscess is a recognized complication of Crohn disease. Less commonly, septic arthritis has been described with this entity. The occurrence of both these complications together in Crohn disease is quite rare. A 56-year-old patient with Crohn disease presented with weakness and pain in both lower extremities. Computerized body tomograms demonstrated a large psoas abscess with fistulous connections to the bowel as well as extending into the capsule of the left hip joint. X-ray examination revealed evidence of acute septic arthritis. Electromyographic studies demonstrated lumbosacral plexus involvement bilaterally. The patient subsequently underwent ileocolectomy with drainage of the left psoas abscess, followed by extensive inpatient rehabilitation. Some immediate strength improvement was noted bilaterally. At discharge, the patient remained paraparetic. In patients with known history of Crohn disease, a psoas abscess should be considered when there are symptoms of lower extremity pain, hip flexion contractures, and progressive weakness.

In 1986 the Board of Governors of the American Academy of Physical Medicine and Rehabilitation commissioned a survey of the Academy's membership to determine the practice patterns of physiatrists. Responses were received from 1,115 members (75%). Approximately 65% of respondents are under 43 years old; 64% are graduates of American medical schools. Fifty-six percent practice in communities with populations of 500,000 or more persons; only 9% practice in communities of less than 50,000 people. Nearly 53% practice in a single setting and the average work week is 50.6 hours, with most of those hours spent in some aspect of patient care. The most frequent diagnosis in all practice settings is pain syndrome; consultation is the primary activity. Survey results show that physiatry is still primarily a hospital-based specialty, although significant time is spent in office-based settings. Data gleaned from this first attempt at an extensive analysis of physiatric practice characteristics will be utilized in planning how to meet future needs of the specialty, its practitioners and their patients.

Tension of the median nerve produced by simultaneous extension of the supinated wrist and distal interphalangeal joint of the index finger was noted to result in proximal volar forearm pain radiation in patients with chronic carpal tunnel syndrome. This sign was less frequent in patients with a more acute syndrome. Adhesions between the median nerve and the overlying transverse carpal ligament and the development of a pseudoneuroma can individually or together occur in the chronic carpal tunnel syndrome limiting distal nerve excursion of the tethered nerve during simultaneous wrist and index finger extension.

External electromagnetic interference with cardiac pacemaker function is a recognized hazard of electronic instrumentation used for diagnosis or therapy. Although improved shielding and circuitry have made newer pacemakers less vulnerable to extraneous electronic artifact, their increasing use may expose more patients to the complications of electromagnetic interference. The effects of nerve conduction stimulation testing (NCST) on patients with cardiac pacemakers were evaluated both clinically and in the laboratory. Estimates of interference potentials likely to occur at a pacemaker input during NCST were made by making calculations from a theoretical model. For three different pacemakers, these estimates were compared to laboratory tests of sensitivity to interference. Some potential for pacemaker interference was shown to exist, although primarily with unipolar pacing leads. Twenty patients, five of whom were monitored electrocardiographically, underwent uneventful nerve conduction studies. Although pulse producing stimulators have the potential to affect demand type pacemakers, if current paths are confined within standard clinical parameters, untoward responses appear unlikely.

Electromyographic examination may demonstrate severe segmental compromise of the posterior primary ramus and relative sparing of the anterior ramus as the earliest objective evidences of spinal and paraspinal metastases. Antecedent studies, including roentgenographic, radioisotopic and neurologic investigations, are often initially normal, failing to reveal the underlying cause of the progressive back pain. The present report demonstrates metastatic spread both through the paravertebral venous plexus and by direct extension in contiguous muscle. In this special instance, segmental 4+ fibrillations in the paraspinal muscles are electrophysiologic manifestations of a local, active process of denervation rather than a remote effect of the malignant disease, as has been suggested by others.

As part of a larger investigation of factors associated with chronic obstructive pulmonary disease among Yugoslavian men, an attempt was made to measure the role played by alpha1-antitrypsin deficiency in the causation of those diseases. Almost 3,000 men from Tuzla, an industrial and mining center in central Bosnia, were screened for alpha1-antitrypsin deficiency. Twenty-six men heterozygous for the Pi MZ phenotype were found in this population. The men with the Pi MZ phenotype were compared with a random sample from the total population. The analysis of the data showed that there is an apparent physiologic impairment associated with Pi Z heterozygosity that produces a shift in the relationships between the different lung volumes without over-all hyperinflation, namely, an increase in residual volume at the expense of vital capacity. However, because of the low prevalence of the Pi Z gene, it does not appear to account for much of the high rate of chronic obstructive pulmonary disease found in this population.

Twenty patients admitted to hospital with congestive heart failure were evaluated for severe concomitant lumbosacral and leg pain. In each instance the discomfort was worse at night and progressively decreased with a resolution of the pulmonary edema. Neurologic and electromyographic examinations in all but four patients were normal with reflexes, strength and straight leg raising testing normal. An absent Achilles reflex was recognized in two, a diminished knee jerk reflex in one and in a third, weakness in the extensor hallucis longus. Lumbar spinal stenosis was identified in all of the patients with a concomitant degenerative spondylolisthesis present in nine instances and in an additional two a spondylolisthesis with interruption of the neural arch. It is theorized that diminished right heart compliance can induce a sufficient increase in venous volume and pressure within the paravertebral plexus of Batson to acutely exacerbate a chronic lumbar spinal stenosis. In support of this hypothesis, the multiple factors involved in the pathomechanics and physiology of lumbar radiculopathy, spinal stenosis and the role of the paravertebral plexus of veins are examined. Specifically, their response to altered volume and pressure gradients tending to induce venous "creep" as well to alterations in posture and diurnal cycles are reviewed.