Sacral insufficiency fractures: a report of two cases and a review of the literature

Sacral insufficiency fractures (SIF) are a type of stress fracture that occur primarily in postmenopausal women. They were first described in 1982 by Lourie and have since been frequently overlooked as a cause of low back, buttock, or groin pain. We present two cases of SIF to demonstrate the clinical presentation, diagnosis, and treatment of patients with SIF. Both patients were elderly women with complaints of pelvic and low back pain in the absence of significant trauma. Physical examination was significant for marked sacral tenderness. Diagnostic imaging supported the diagnosis of SIF. Both patients underwent early rehabilitation, including early ambulation, and had good functional outcomes. These patients serve to illustrate how conservative treatment yields excellent clinical results in the majority of patients, with most reporting improvement within 1-2 weeks after fracture and complete resolution of symptoms after 6-12 months of treatment.

Thoracic disk herniation presenting as abdominal and pelvic pain: a case report

We report the case of a young woman who presented with a 2-month history of severe abdominal and pelvic pain. The past history was significant for a fall from a bicycle 1 week before the onset of her pain. Physical examination was remarkable for periumbilical tenderness. Work-up including pelvic sonogram and diagnostic laparoscopy suggested endomyometritis. The pain was minimally relieved by nonsteroidal anti-inflammatory drugs and narcotic analgesics. Thoracic spine magnetic resonance imaging (MRI) revealed a large disk herniation at the T9-10 level compressing the spinal cord. The patient subsequently underwent T9-10 diskectomy and laminectomy with dramatic relief of her symptoms. Postoperative rehabilitation hastened her functional improvement. This is a rare case of symptomatic thoracic disk herniation after trauma presenting as abdominal and pelvic pain. Physicians should be aware of this unusual presentation of thoracic disk herniation to avoid invasive diagnostic procedures.

Paraneoplastic cerebellar degeneration as the first manifestation of cancer

Paraneoplastic cerebellar degeneration (PCD) is a type of paraneoplastic syndrome that primarily affects women with gynecological cancers. Patients typically experience pancerebellar symptoms, including gait ataxia, dysarthria, nystagmus, and truncal and appendicular ataxia. We present the case of a 50-year-old woman with PCD and presumed ovarian cancer who initially complained of ataxia and dysarthria. PCD was diagnosed on the basis of her symptoms, diagnostic imaging, and laboratory work. PCD symptoms may precede the diagnosis of malignancy by months or years. Early diagnosis and treatment of these syndromes, including rehabilitation, may result in improvements in quality of life for this population of patients.

Unilateral extremity swelling in female patients with cancer

Unilateral extremity swelling may be secondary to two major causes in female patients with cancer, deep venous thrombosis (DVT) and lymphedema. In women of all ages, DVT is high on the differential diagnosis list for unilateral extremity swelling. However, in women with an underlying malignancy, DVT and lymphedema must both be considered. Appropriate diagnosis and treatment are necessary to improve the quality of life and function of the female patient with cancer.

The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?

Sacral insufficiency fractures are an often unsuspected cause of low back pain in elderly women with osteoporosis who have sustained minimal or no trauma. Many of the references in the literature advocate bed rest initially; however, we support early mobilization, because most of these fractures are stable and require no surgical intervention. With good pain control, patients can begin progressive ambulation with assistive devices in a supervised environment and minimize the complications of immobility.

Paraneoplastic cerebellar degeneration as the first evidence of cancer: a case report

Paraneoplastic cerebellar degeneration (PCD) is the most frequently seen paraneoplastic syndrome affecting the brain. PCD is most commonly associated with cancers of the ovary, breast, and lung. The anti-Purkinje cell antibodies (anti-Yo) that specifically damage the Purkinje cells of the cerebellum are found in the patient's serum and cerebrospinal fluid. The typical presentation of PCD includes limb and truncal ataxia, often along with dysarthria. This report describes the case of a 47-year-old woman without significant medical history who developed new onset of unsteady gait, headache, and vertigo. The imaging studies suggested rhombencephalitis. The patient initially responded to corticosteroid treatment. Unfortunately, her gait ataxia worsened and she developed dysarthria, neither of which responded to increasing dosages of corticosteroids. Extensive imaging studies showed no evidence of tumor, but the patient was found to have positive anti-Yo antibodies and elevated cancer antigen 125 (CA-125). Pathology results from exploratory laparotomy revealed stage III C adenocarcinoma of the ovary. This case demonstrates that PCD may be the presenting symptom of an occult malignancy. The pathogenesis, diagnosis, and treatment of PCD, and its rehabilitation implications, are reviewed.

Gait variables of patients after lower extremity burn injuries

Functional ambulation is an expected outcome of physical therapy after burn injuries on the lower extremities. The purpose of this study was to document temporal and spatial gait parameters of adult patients with the use of the GAITRite system (CIR Systems Inc, Clifton, NJ) after the patients were burned on their lower extremities and to compare these results with previous data reported for normal subjects. Twenty-five adults with lower extremity burns (19 men and 6 women; mean age, 35.6+/-8.3 years) were evaluated within 5 days of discharge from an acute care facility. The GAITRite system, which consists of an electronic walkway that contains 6 sensor pads encapsulated in a rolled-up carpet, was used to collect temporal and spatial variables. The patients walked at their preferred rate of ambulation and completed 2 passes; the 2 passes were then averaged by the software to determine the patients' gait parameters. A 2-tailed t test was used for comparison of the mean values for the patients and the previously published data. The results indicated that for both men and women, cycle time and base of support were significantly higher (P < or = .01) in the patients with burn injuries than in normal subjects. For men, all of the remaining parameters were significantly lower (P < or = .01) in the patients with burns except stride length, which was not significantly different (P > .05). For women, stance time as a percentage of the gait cycle and cadence, velocity, step length, and stride length, were all significantly lower (P < or = .01) in the patients with burn injuries, whereas double support as a percentage of the gait cycle was not significantly different (P > .05) between the 2 groups. These results indicate that immediately after an acute care hospitalization, patients with lower extremity burns have significantly different gait patterns than gender-and age-matched normal subjects. Future studies are necessary to determine whether these impairments in gait limit the functional abilities of a patient.

Sciatic neuropathy secondary to a uterine fibroid: a case report

Lesions of the sciatic nerve outside the pelvis have been well described. Lesions within the pelvis, however, are far less common. We report the case of a 55-yr-old woman with a history of chronic low back pain who presented with progressive right buttock and posterolateral right lower limb pain associated with right foot numbness and tingling. She denied any associated low back or left lower limb pain. The patient was initially treated for a probable right lumbosacral radiculopathy, without improvement. A subsequent magnetic resonance image of the lumbosacral spine revealed multilevel disc degeneration at L3-4 through L5-S1, without disc herniation or canal stenosis. A magnetic resonance image of the pelvis revealed a markedly enlarged uterus, with a large pedunculated myoma impinging on the right sciatic foramen. The patient underwent a subtotal abdominal hysterectomy, with resolution of her right lower limb pain. This case illustrates the importance of considering intrapelvic causes of sciatic neuropathy. To our knowledge, this is the first reported case of sciatic neuropathy secondary to a uterine fibroid.

The physical, functional, and developmental outcome of pediatric burn survivors from 1 to 12 months postinjury

Fifty-one children with an average age of 27 months and who had sustained a burn injury were tested at 1, 6, and 12 months postinjury to determine their physical, functional, and developmental outcomes. Most parents were either African-American or Hispanic, lived on public assistance, and had a high school education or less. Most children had normal range of motion and were appropriate for their age in self-care skills. On the basis of the Home Screening Questionnaire, 48% of the children came from suspect home environments. Developmental delays were noted in language acquisition that persisted over the first year postburn. Although the outcomes of these burn injuries were good in physical and functional areas, the developmental findings raised concerns. The results alert clinicians to screen for potential developmental problems during the burned child's recovery phase and to include appropriate developmental activities and parental guidance in the treatment plan.

Pectoralis major rupture during gait training: case report

Rupture of the pectoralis major muscle is rare. The majority of cases have been reported in young, healthy athletes during strenuous activities such as weight-lifting, wind surfing, and football. The injury is thought to result from either a forceful contraction of the muscle applied to an immovable object or a sudden stretching force applied to the contracting muscle. This report describes a case of a 79-year-old man with a history of severe degenerative joint disease of the right hip and a recent left transtibial amputation secondary to a failed arterial bypass procedure. During prosthetic training the patient developed acute pain in the left shoulder and left axilla, which prevented him from further ambulation. Physical examination was consistent with a partial rupture of the pectoralis major. The causative factors of pectoralis major rupture in this patient are reviewed. To our knowledge, this is the first such case reported.

Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report

Spinal accessory nerve injury is most commonly reported following surgery in and around the posterior cervical triangle. Pain, impaired ability to raise the ipsilateral shoulder, and scapular winging on abduction of the arm are the most frequently noted clinical manifestations. We report the case of a collegiate swimmer who developed left-sided neck and shoulder pain secondary to a spinal accessory nerve palsy (SANP) after a "whiplash injury," which we believe to be the first such reported case in the English language literature. We review the clinical manifestations, diagnostic pitfalls, and therapeutic approaches to SANP. A high index of suspicion for SANP following whiplash-type injury will ensure its earlier detection and treatment and improve the chances of a better functional outcome.

Avascular necrosis of bilateral knees secondary to corticosteroid enemas

Avascular necrosis (AVN) is a devastating adverse effect of corticosteroid therapy rarely reported in the setting of inflammatory bowel disease. We describe a 48-year-old woman with 6 weeks of progressive bilateral knee pain resulting in the inability to ambulate. Her symptoms developed suddenly, 9 months after treatment with hydrocortisone enemas for ulcerative proctitis. On physical examination, the patient had knee tenderness, decreased range of motion, and flexion contractures. Magnetic resonance imaging showed multiple bony infarcts in bilateral distal femora and proximal tibias, consistent with advanced AVN. Initial therapy included pain management, serial casting, gentle flexibility and strengthening, and limited mobility training. The rehabilitation efforts led to functional improvement. Ultimately, bilateral total knee arthroplasties were recommended to treat her advanced AVN. This is the first reported case of AVN secondary to hydrocortisone enemas. We review the literature and discuss the pathophysiology and management of corticosteroid-induced AVN.

Conservative management of lumbar spinal stenosis. Identifying patients likely to do well without surgery

Lumbar spinal stenosis is a painful condition that often leads to irreversible neurologic damage and functional disability. Thus, early diagnosis and management are important. Conservative therapy, which is appropriate for many patients, minimizes invasive intervention and decreases the risks of morbidity. As more people live to older ages, the incidence of lumbar spinal stenosis will likely increase. If results of a thorough history and physical examination suggest the disorder, a course of appropriate physical therapy should be started promptly; more expensive tests and treatments are reserved for patients whose pain is refractory to early conservative intervention. However, if pain is severe, if the origin is not clear, or if neurologic deficits quickly become worse, immediate neuroradiologic studies should be considered, including timely EMG. Strong guidance by the primary care physician is of paramount importance because the therapeutic program is lengthy. Additional help from a physiatrist, neurologist, or orthopedic surgeon may be indicated as treatment progresses.

Transient osteoporosis of the hip during pregnancy: a case report

Transient osteoporosis associated with pregnancy is a rare, self-limiting skeletal disorder, the origin of which remains unclear. We report the case of a 36-year-old Japanese woman who developed pain in the left hip, groin, and knee in the seventh month of pregnancy. The pain gradually worsened and prevented weight-bearing. The hip and knee pain progressed to bilateral involvement and persisted after an emergent cesarean section at 35 weeks. Radiographs after delivery revealed gross osteopenia of both the femoral heads, left distal femur, and proximal tibia, consistent with transient osteoporosis associated with pregnancy. The patient remained mostly wheelchair-dependent because of severe hip and knee pain. Several weeks later, the patient was started on alendronate, a biphosphonate, which provided dramatic relief of hip and knee pain. The patient's ambulatory function subsequently improved dramatically as a result of pain relief and assistance with gait training. This case is unique for several reasons. First, it is rare for transient osteoporosis associated with pregnancy to involve both hip joints, and it rarely involves the knee. Second, this is the first reported case of pain management of transient osteoporosis associated with pregnancy being successfully treated with an antiresorptive agent. Finally, the use of alendronate in transient osteoporosis associated with pregnancy may help shorten disability by providing pain relief and decreasing the fracture risk associated with this disease.

Recurrent spontaneous hemarthrosis associated with reflex sympathetic dystrophy

Reflex sympathetic dystrophy is a mysterious entity with unclear pathogenesis. The diagnosis is largely clinical and based on signs and symptoms of pain and vasomotor dysfunction. Treatment is a challenge because the underlying mechanism remains unknown. Our patient is a 75-year-old woman 2 years after left total knee replacement who presented with her second spontaneous hemarthrosis in 3 months. After arthrocentesis, dusky discoloration, edema, hyperesthesia, and decreased range of motion of the left knee and entire distal extremity were noted. Despite analgesia and physical therapy her symptoms worsened. Radiographs of her left knee showed severe periprosthetic osteopenia and a triple phase bone scan was negative. Clinically, reflex sympathetic dystrophy was considered likely and a lumbar sympathetic block was performed. The patient improved and continued to do well after a series of blocks. This is the first reported case of recurrent atraumatic hemarthrosis associated with reflex sympathetic dystrophy.

Multiple sclerosis presenting as a spinal cord tumor

Multiple sclerosis, a disorder of central nervous system demyelination, is a leading cause of disability in young people. Lesions of the spinal cord are usually less than two vertebral body segments long, peripherally located, and found in the cervical region. A 30-year-old woman had a 2-month history of back pain, urinary incontinence, and bilateral lower extremity weakness. Magnetic resonance imaging (MRI) of the spine showed an intramedullary spinal cord tumor from T4 to T8 with an intramedullary cyst from T1 to T4. After thoracic decompressive surgery, findings from biopsy of the cord lesion were consistent with multiple sclerosis. Postoperatively, the patient required an intensive rehabilitation program. This is the first reported case of histopathologically confirmed spinal cord demyelination presenting as an intramedullary thoracic cord tumor. Physiatrists should be alerted that demyelinating disease can mimic a spinal cord tumor, even on MRI, and must be considered in the differential diagnosis of a symptomatic spinal cord mass.

Herpes zoster polyradiculopathy

Herpes zoster infection, resulting from reactivation of the dormant varicella zoster virus in the dorsal root ganglia, usually causes a painful dermatomal vesicular rash. Rarely, associated peripheral motor weakness is present, the mechanism of which is unclear. Three patients are reported who had focal limb muscle weakness associated with zoster infection. Physical and occupational therapy played a key role in motor function recovery of the patients, yet emphasis on the rehabilitation of postherpetic motor weakness is lacking in the literature. Physiatrists evaluating patients with limb muscle weakness following herpes zoster infection should be alert to this condition. The clinical syndrome of herpes zoster radiculopathy and the rehabilitation of these patients are discussed.

Autonomic dysfunction as the presenting feature of Guillain-Barré syndrome

Autonomic dysfunction has been demonstrated in various conditions associated with peripheral neuropathy such as acute intermittent porphyria, amyloidosis, and Guillain-Barré syndrome (GBS). In the latter, hypertension is an associated complication that typically occurs after neurological signs are already present. We report a case of a patient with autonomic dysfunction as the presenting feature who was admitted to the coronary unit with chest pain and hypertension. Subsequently, he developed progressive symmetric muscle, weakness, sensory changes, and areflexia. GBS was then diagnosed based on the clinical picture, albuminocytologic dissociation in the cerebrospinal fluid, and electrodiagnostic abnormalities suggestive of demyelinative polyneuropathy with conduction block. Few cases in the literature have reported autonomic dysfunction as the presenting feature of GBS, such as in this case. In a previously asymptomatic patient, acute onset of autonomic dysfunction should alert the physician to the possibility of an acute polyneuropathy, such as GBS.

Cerebral diaschisis following cerebellar hemorrhage

In 1914, Von Monakow described diaschisis, the recovery of lost cortical function in regions positionally distant from, but linked by neuronal tracts to, the primary site of cortical damage. Cerebellar diaschisis after cortical insult is detailed in the literature; however, cortical diaschisis after cerebellar insult remains a rarely reported occurrence. We describe a 36-year-old woman with rupture of a right-sided cerebellar arteriovenous malformation who developed such expected cerebellar signs as ataxia, dysmetria, and nystagmus. Days later, the patient developed profound impulsivity, disinhibition, and psychomotor agitation. Single photon emission computed tomography (SPECT) showed decreased perfusion of the bilateral frontal and temporal lobes, consistent with regional loss of neural activity. Eventual clinical improvement corresponded with reperfusion of those regions, identified on follow-up SPECT. This case documents cortical diaschisis following cerebellar insult and shows that diaschisis must be considered in patients with cerebral injury manifesting cortical deficits remote from the site of primary pathology.

The value of pain drawings in the care of neck and back pain

The magnetic resonance imaging (MRI) reports and pain questionnaires of 100 patients with complaints of lower back or neck pain were reviewed. Prior to physician examination, each patient had completed a questionnaire which included pain drawings and a rating on a pain scale. The information given on the drawings and questionnaires was compared to the MRI reports. The levels of agreement between them were analyzed. The results show that the pain questionnaire with drawing is a useful tool in the evaluation of patients when the diagnoses of herniated nucleus pulposis (HNP) or spinal stenosis are in question. The levels of agreement between the pain drawings and the MRI findings were stronger for the cervical spine than for the lumbar spine and also stronger for the presence of HNP than for central canal spinal stenosis. Particularly useful was the negative predictive power for ruling out cervical and lumbar pathology.

Selective language aphasia from herpes simplex encephalitis

We report the case of a 16-year-old right-handed Chinese/English bilingual patient who developed herpes simplex encephalitis involving the left temporal lobe, with resultant aphasia. His native language was Mandarin, but he had received extensive training in English for 6 years after moving to the United States and was fluent in English. One week after admission, he could not speak, comprehend, repeat, name, read, or write in English, but he had relative preservation of most of these facilities in Mandarin. He could not write in Mandarin, and his syntax was simplified. Two months later, along with intensive bilingual speech therapy, his reading, writing, and naming in English had almost recovered.

Upper limb reflex sympathetic dystrophy associated with occult malignancy

Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressive physical therapy measures, the patients' symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases, medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.

Balint's syndrome arising from bilateral posterior cortical atrophy or infarction: rehabilitation strategies and their limitation

Balint's syndrome is characterized by faulty visual scanning, dysmetria secondary to a visual perceptual deficit, and an inability to recognize more than one object at a time. We report three cases of Balint's syndrome and the individualized rehabilitation they received. One patient developed symptoms of Balint's syndrome caused by bilateral occipitoparietal infarcts. In the two other cases the symptoms arose secondary to posterior cortical atrophy, a slowly progressive dementia with alexia and agraphia. All three patients initially responded to a multicontext treatment approach with intensive verbal cueing and organizational strategies with subsequent improvement in visual recognition, reaching and scanning. Continued deterioration from posterior cortical atrophy or a second infarction resulted in worsening dementia in two patients. Cognitive remediation was required as visual perceptual rehabilitation became ineffective. Clinicians should be familiar with Balint's syndrome and its various aetiologies. Lack of awareness of this syndrome may lead to a misdiagnosis and resulting inappropriate or inadequate treatment.

Pelvic insufficiency fractures after irradiation: diagnosis, management, and rehabilitation

Insufficiency fractures of the pelvis are commonly overlooked as causes of severe hip and low back pain. Predisposing factors include postmenopausal osteoporosis, corticosteroids, and local irradiation. Differential diagnosis includes metastatic disease to bone. We present the case of a 65-year-old woman who had a two-month history of low back pain and left groin pain. Her medical history included osteoporosis and endometrial cancer that was treated with radiation therapy to the pelvis 1 year prior to presentation. Despite bed rest, analgesics, and therapeutic modalities, her pain remained intractable and prevented ambulation. Plain radiographs showed no fracture. Computed tomography (CT) and magnetic resonance imaging showed fractures of the pelvis but were suggestive of malignancy. CT-guided bone biopsy was consistent with radiation osteonecrosis. After diagnosis and continued therapy, the patient progressed to ambulation with moderate discomfort. Failure to diagnose insufficiency fractures could lead to further pelvic irradiation, compromising already weakened bones and causing prolonged disability.

Lumbosacral radiculopathy secondary to L5 metastatic melanoma of unknown primary

Lumbosacral radiculopathy secondary to spinal malignancy is rare. Spinal melanoma without cutaneous manifestations is even more unusual. We present the case of a 45-year-old physician with a history of degenerative disease of lumbar spine and chronic back pain who presented with increasing back pain with right radiculopathy despite conservative management for 6 months. Computed tomography showed a destructive lesion of the L5 vertebral body. Results from a biopsy guided by computed tomography suggested neoplasm of unknown origin. The patient underwent anterior vertebrectomy with instrumentation and fusion. Surgical pathology study results showed metastatic melanoma of unknown primary. The patient had no cutaneous manifestation of the disease. This is the first reported case of radiculopathy due to melanoma metastatic to the lumbar spine. In view of the atypical presentation of our patient's malignancy, we emphasize the importance of including malignancy of lumbar spine in the differential diagnosis of progressive lower back pain with radiculopathy.

Neurosarcoidosis of the conus medullaris and cauda equina presenting as paraparesis: case report and literature review

Sarcoidosis is a multi-system, non-caseating granulomatous disease of unknown etiology. Although spinal cord involvement is rare, it may cause severe neurological complications. We report the case of a 52-year-old woman who developed low back pain and a progressive flaccid paraparesis whose investigations revealed pulmonary and spinal sarcoidosis. To our knowledge, this is the first reported case of sarcoidosis of the conus medullaris and cauda equina diagnosed by an unusual enhancement pattern observed on magnetic resonance imaging with gadolinium. Biopsy of the lumbar nerve roots and of the lung revealed a non-caseating granuloma. Treatment with steroids and intensive rehabilitation resulted in remarkable functional improvement. Although rare, sarcoidosis of the conus medullaris and cauda equina should be considered in the differential diagnosis of flaccid paraparesis, particularly in patients with non-diagnostic evaluations.

Severe polyneuropathy: initial manifestation of Castleman's disease associated with POEMS syndrome

Castleman's disease is a rare clinicopathological entity characterized by multicentric angiofollicular lymph node hyperplasia. Peripheral neuropathy has infrequently been described in patients with Castleman's disease. A patient is described who presented initially with severe painful sensorimotor polyneuropathy of his lower limbs diagnosed as a plasma cell variant of Castleman's disease associated with features of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin change). The patient was treated with plasmapheresis, immunosuppressive agents, and intensive rehabilitation. His functional status improved from being wheelchair bound to ambulating independently with crutches. Clinicians should be alert to the relationship of Castleman's disease and mixed polyneuropathy because physical improvement is possible with treatment. Also, the evaluation of patients presenting with peripheral neuropathy of unknown etiology and lymphadenopathy should include lymph node biopsy to rule out Castleman's disease.

A survey of the prevalence and application of chest physical therapy in U.S. burn centers

The purpose of this study was to determine the prevalence and application of chest physical therapy (CPT) in burn centers. Respiratory therapists primarily administered CPT, and suctioning and coughing were the most frequently used modalities. Further study of the efficacy of treatment techniques is needed to develop congruous standards for CPT after a burn injury.

Pectoralis major muscle rupture in windsurfing

Board sailing (windsurfing) has become a popular water recreational activity. However, there is little in the medical literature concerning musculoskeletal complications resulting from participation in this sport. We present the first reported case of pectoralis major rupture sustained during board sailing. The patient was initially misdiagnosed, which happens commonly when this muscle ruptures. Only after conservative management failed was the correct diagnosis made and appropriate surgical intervention provided. Proper technique in board sailing requires sustained isometric contraction of the pectoralis major, deltoid and scapular stabilizers to maintain appropriate pull of the sail against wind resistance. Sharp increases in wind speed underly the mechanism of injury. Ruptures of the pectoralis major are usually complete, occur at or near the humeral insertion, and can be associated with misleading physical signs. Therefore, anatomy, clinical findings, surgical technique, and the postoperative rehabilitation program are stressed as to expedite diagnosis and maximize functional outcome.

Compliance with pressure garment use in burn rehabilitation

Pressure garment use is recommended 23 to 24 hours a day for hypertrophic scar control after a burn injury. Compliance with this treatment has not been documented. A 52-question survey was administered to 101 adult outpatient burn survivors to rate compliance with this program. The average compliance of each patient was assessed. The framework of the Health Belief Model was used to identify the patients' beliefs and factors reported to interfere with compliance. Strategies patients believed to enhance garment use were identified. Forty-one percent of the patients reported total compliance. The difficulties with garment use such as discomfort and activity limitations appeared to promote low compliance. The primary strategies patients believed would enhance compliance were seeing outcome pictures of scars and having contact with other survivors. This step toward identifying compliance rates and factors that affect them will guide the health care worker in techniques to facilitate adherence to the scar management program.

Delayed femoral nerve palsy following femoral vessel catheterization

We report two cases with a delayed complication of femoral vessel catheterization: femoral nerve entrapment by iliacus hematoma. Both patients had femoral artery catheterization and postoprocedural anticoagulation, followed by iliacus hematoma eruption on the side of catheterization. Diagnosis was confirmed by computed tomography and electrodiagnostic studies. The pathogenesis of iliacus hematoma-induced femoral neuropathy has been studied in detail; however, the authors could find no previous reports of catheterization causing this phenomenon. The association is probably under reported because of the delayed manifestation. Awareness of this complication could (1) minimize the neuropathy, by insuring early diagnosis and treatment and (2) reduce its incidence, by avoiding trauma to the iliacus muscle during catheterization.

Physiatric evaluation of the cancer patient

As time goes on, so do the advancements in medical treatment. Today we are faced with a population of cancer patients living longer and developing unique problems as a consequence of both treatment and progression of disease. The physiatrist is in a unique position to enhance independence and quality of life of cancer patients. Often this is simply a matter of applying well-established physiatric principles to a unique population. However, few physiatrists in clinical practice have the opportunity to treat large numbers of cancer patients, especially in an acute care setting. Experience is key for optimal physiatric management of the cancer patient. The purpose of this article is to familiarize physicians and therapists with evaluation and subsequent application of rehabilitation principles to cancer patients. It is beyond the scope of this manuscript to discuss all the specifics of the cancer patient's rehabilitation; however, references are available.1-4Functional deficits in the cancer patient can arise from disease progression as well as its treatment. The scope of complications include: osseous disease, myelosuppression, multiple manifestations of neurological deficit, deconditioning, pain syndromes, lymphedema, gait abnormalities, amputation, cardiopulmonary complications, psychiatric issues, and others. A survey of 50 rehabilitation consultations seen over a 6-month period reveals the diversity of problems (see Table 1). Although a small sample, it correlates with our experience. Of note, many patients had more than one disability, as illustrated in Table 2.

Complications associated with intermittent pneumatic compression

The intermittent pneumatic compression device (IPCD) is prophylaxis for prevention of deep-venous thrombosis (DVT). This pneumatic leg sleeve has been used extensively in high-risk surgical patients, without complication. We describe two cases, one with peroneal neuropathy and the other with compartment syndrome, associated with IPCD use during surgery. Case 1 involves a patient with pancreatic cancer and weight loss who developed bilateral peroneal nerve palsies during surgery. Case 2 involves a patient with bladder cancer who developed lower leg compartment syndrome during prolonged surgery in the lithotomy position. These cases are unusual for several reasons. First, patients wearing IPCDs during surgery are at increased risk of neurovascular compression. Second, significant weight loss may predispose the peroneal nerve to injury from intermittent compression garments. Third, patients undergoing surgery in the lithotomy position are at risk of compartment syndrome. Therefore, physicians may wish to use another method of DVT prophylaxis in surgical patients with cancer or significant weight loss, or those who are undergoing procedures in the lithotomy position.

The neuromotor behavior of preterm and full-term children by three years of age: quality of movement and variability

Thirty-six preterm and full-term children were seen during the first year of life and at 3 years old. The Neuromotor Behavioral Inventory (NBI)-Version for 3 Year Olds (a 5-category measure of Gross Motor and Fine Motor Development, Reaction to Movement, Neurological Reflexes and Reactions, and Neuromotor Outcome) was used with three groups: healthy preterm, sick preterm, and healthy full term. The groups differed in gross motor, fine motor, reaction to movement, and neuromotor outcome at 3 years of age with the greatest difference between the sick preterm group and the other groups. Quality of movement deteriorated between 12 months and 3 years. Increased frequency of "suspect" or "abnormal" outcomes during the first year was associated with an unfavorable outcome at 3 years of age. Variability, i.e., a change in outcome from one time to another, was not associated with an unfavorable outcome when frequency of unfavorable outcome during the first year was taken into account. Prematurity, perinatal illness, and frequency of unfavorable outcome during the first year were found to have an adverse impact on neuromotor behavior.

Spinal accessory nerve palsy: an unusual complication of coronary artery bypass

The neurologic complications of coronary artery bypass surgery have been well documented, with a reported incidence of 61% in one large study. Most injuries to the peripheral nervous system involve the brachial plexus. We report the first case of a spinal accessory nerve lesion after coronary bypass surgery. The patient presented with progressive right shoulder weakness. Electrodiagnostic studies revealed a partial lesion of the right spinal accessory nerve. Physical therapy, including strengthening, range of motion, and electric stimulation to the right shoulder, was prescribed to assist recovery of strength and function. Repeat electrodiagnostic studies confirmed nerve regeneration. Prompt recognition of spinal accessory nerve damage after coronary bypass surgery is essential. Early rehabilitation will improve the chances of a better functional outcome.

Investigating the impact of deconditioning anxiety on weight loss

The effectiveness of a new model for the treatment of obesity was studied. This model assumed that obesity was not an eating disorder but a "not eating" disorder. Obese individuals do not have a problem eating, they are overly good at it. Obese individuals have a problem not eating. They experience difficulty or anxiety when they do not eat. The model assumed that removal of anxiety associated with "not eating" would allow obese subjects to lose weight. Wolpe and Lazarus' progressive relaxation techniques were used to decondition anxiety assumed associated with "not eating" in subjects. Inferred anxiety was deconditioned under conditions of "not eating" when imagining hunger, emotions, and cravings. Twenty-five subjects were instructed not to follow a diet after deconditioning but to eat less and be hungry to lose weight. A control group of 10 was instructed to follow a balanced 1000-calorie diet to lose weight. The former group lost a statistically significant amount of weight (7.5% of their body weight) over 11.9 months, while the control group subjects gained 6.5% of their weight. The model appears to be effective for the treatment of some individuals who wish to lose weight, based upon this preliminary study. Replication with other and larger groups is essential.

Neuromotor development of preterm and full-term infants

The Neuromotor Behavioral Inventory (NBI), a 16-category measure of muscle tone, developmental motor abilities, quality of movement, neurological reflexes and reactions, and neuromotor outcome was used with 38 infants divided into three groups: healthy preterm (HPT), sick preterm (SPT), and healthy full-term (HFT) infants. Infants were tested at five time points: 40 weeks postconception (newborn) and 3, 6, 9 and 12 months of age post-term. The intent of the study was two-fold: to determine whether there are developmental differences among the groups of infants and whether the differences persist during the first year of life. Results indicate that HFT and HPT infants score higher than SPT infants in the neuromotor categories of: muscle tone, upper extremity development, head control, and neuromotor outcome rating. HFT infants scored higher than both preterm groups in: trunk rotation, reaction to movement, visual and auditory attention, and fixing. Differences persisted among the groups during the first year of life in the following: the developmental motor ability of trunk rotation, fixing, adaptability, and the neuromotor outcome rating. It appears that neonatal health status is a contributing factor to infant neuromotor development, particularly in the quality of movement reactions.

Evaluation of an exercise program for back pain

A six-week exercise program for people with low back pain was established at YMCAs throughout the United States. Classes met twice weekly with trained instructors. Participants exercised at home as well. About 80 percent of the nearly 12,000 participants reported a decrease in discomfort, including those who had previously undergone back surgery. A decrease in pain correlated with adherence to the program and with measured improvement in strength and flexibility.

Dumbbell neurilemoma simulating lumbar disk disease

The beneficial response to a nonsurgical program for lumbar disk disease in a 56-year-old woman seemed to obviate invasive procedures. Fourteen months later, the previous symptoms and findings recurred. A myelogram showed a block at T12-L1 and a small herniated disk at L4-L5. A neurilemoma was removed. The patient is well 4 years later.

Tennis elbow

The evidence that tennis elbow is caused by poor muscle strength and improper tennis stroke is strong. The lesion may be at the lateral epicondyle (70 to 80% of patients), at the musculotendinous junction at the level of the radial head or, rarely, at the medial condyle. Anti-inflammatory steroid injections in the condylar lesions are helpful. Sinusoidal wave stimulation of the affected muscles, or repetitive active wrist dorsiflexion, is important in the early stages. The recurrence rate drops sharply when patients adhere to a progressive exercise program.