Evaluation and reporting requirements of the disability examiner.

Critics of the system within which IMEs occur might argue that there is in fact no such entity as a truly impartial evaluation because the practitioner always is aware of the source of payment for the visit and will color opinions in favor of that payor. Nonetheless, the ethical practitioner has no problem whatsoever refuting that rather cynical attitude. First, payment for any type of clinical visit must come from somewhere. Most importantly, always keep in mind what is in the best medical interest of the person you are examining, and you will avoid virtually all ethical dilemmas. To illustrate obvious examples, if a claimant has the objective impairments of herniated disc with associated radiculopathy, it makes no medical sense, and would certainly be unethical, to allow unrestricted RTW to a physical job. That clearly would not be in the best interest of a patient you were treating, nor should that be your opinion for an IME. Similarly, a person without any objective impairment documented after careful search is not well served by a continuing program of medications, time off work, useless modalities, and a growing "sickness" frame of mind. That would definitely not be in their best interest, and your opinion for a treatment case or for an IME should reflect that without hesitation. Once you make a consistent habit of always invoking what you truly believe to be in the best medical interest of the examinee, the long-term interests of the other involved parties will also be well served as a consequence. The insurance company will not be asked to either continue paying treatment and wage replacement costs for someone who could safely work, nor will it be forced to accumulate the unnecessary expenses of recurrent injuries to an injured worker returned to work prematurely. By faithfully adhering to the simple principle of not swaying from the best interest of the examinee, you might lose referral business from some sources. Certain employers, case managers, insurance carriers, attorneys, or others might want to rely on your opinion in all cases, perhaps to conclude that claimants are rarely if ever impaired (or at least not from work or auto accident-related events). Your practice and your reputation are much better off without that business. A well-planned and carefully performed IME, resulting in a detailed, understandable, and defensible report with the elements outlined in this article, will serve you and your referring sources well.

The biomechanics of running.

Correct diagnosis and successful treatment of running related injuries are based on a firm understanding of the biomechanics of running. The sports medicine practitioner, knowing the principles of the bone and muscular interactions of the structures involved in running, can generate specific, accurate diagnosis and detailed, individualized treatment and prevention protocols. Intrinsic biomechanical factors and extrinsic influences will be examined for their effects on running and related injuries.

Sports medicine. 2. Upper extremity injuries.

This self-directed learning module highlights recent advances in this topic area. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. In this article, shoulder and elbow problems of the throwing athlete are emphasized. Common injuries involving the wrist and hand are also covered.

Sports medicine. 3. Lower extremity injuries.

This self-directed learning module highlights new advances in sports-related injuries of the lower extremity. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on injuries of the hip and thigh, knee and leg, and ankle and foot. The most common injuries are primarily addressed, while less common injuries are more briefly discussed. New advances that are covered in this section include closed kinetic chain strengthening exercises and recent advances in rehabilitation after anterior cruciate ligament reconstruction.

Sports medicine. 1. The physiatric approach.

This self-directed learning module highlights key elements in this topic area. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article covers the role of the physiatrist in sports medicine and presents an overview of the diagnosis, treatment, and prevention of sports-related injuries. We describe how the physiatrist relates to other sports medicine practitioners and detail the stepwise physical examination of an injured athlete by a physiatrist.

Bilateral phrenic nerve palsy associated with open-heart surgery.

The incidence of phrenic nerve palsy after open-heart surgery has been estimated at 10%, but it is usually unilateral and does not cause symptoms. Bilateral phrenic nerve injury after coronary artery bypass surgery is a rare complication. This case report describes a patient who developed bilateral phrenic nerve palsies and required prolonged ventilatory support. Denervation of both hemidiaphragms was documented by needle electromyography four weeks after bypass surgery. The patient required total ventilatory support for three months and partial ventilatory support for an additional three months. This case demonstrates the usefulness of electromyographic screening for documentation and prognostication after phrenic nerve injury. The cause of the lesion was unclear, but hypothermia and stretch were leading hypotheses. This patient developed the phrenic nerve palsies despite using a cardiac insulation pad.

Magnetic resonance imaging of avascular necrosis of the lunate.

Avascular necrosis (AVN) of carpal bones, particularly the lunate, is often an elusive cause of wrist pain. Physical examination can be indistinguishable from that of a simple wrist sprain, and standard radiographic evaluations are frequently normal. Early diagnosis is critical, since late treatment is often simple observation of the natural history of the disease, which includes progressive collapse of the lunate and derangement of the carpal architecture. Magnetic resonance imaging (MRI) produces images of high contrast, demarcating necrotic from normal bone. We present a case of lunate AVN ("Kienböck's disease") to illustrate the ability of MRI to identify necrotic bone in the wrist. We suggest that MRI is useful in diagnosing AVN in the wrist and that it may allow an earlier diagnosis of lunate AVN than is possible with standard radiographs.

Physiatric therapeutics. 1. Physiatric evaluation.

This self-directed learning module highlights advances in physiatric evaluation. It is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses goniometry, muscle strength testing, and functional and disability evaluation.

Physiatric therapeutics. 3. Traction, manipulation, and massage.

This self-directed learning module highlights advances in this topic area. It is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses physiologic effects of, and indications and contraindications for, traction, manipulation, and massage. Advances covered in this section include hypotheses of pain relief in manipulation.

Physiatric therapeutics. 5. Pain.

This self-directed learning module highlights advances in the management of pain. It is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses neuroanatomy and neurophysiology pertaining to pain, gating theories, therapeutic measures, transcutaneous electrical nerve stimulation, acupuncture, and behavioral methods. Advances that are covered in this section include various neural pathways involved in pain transmission, descending "pain control" neural networks, pain-modulating neurotransmitters, and the therapeutic use of pharmacologic agents and nonpharmacologic measures for pain management.

Physiatric therapeutics. 6. The rehabilitation team/behavioral management.

This self-directed learning module highlights advances in the rehabilitation team and behavioral management. It is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses the patient-care team, the physician as team leader, successful team management, behavior and change in behavior, and behavioral medicine applications. Advances covered in this section include barriers to patient autonomy in the patient-care setting, the process of behavioral change, and available therapeutic methods.

Injection-related ulnar neuropathy.

Two previously healthy people sustained mild ulnar mononeuropathies at the level of the upper arm after injections by the same nurse. In both, the nurse was attempting to inject into the middle deltoid; the ulnar nerve was presumably reached by standing at the patient's side and injecting "sidearm" into the upper arm. These cases point out the careful attention to local anatomy required for those administering injections, and the importance of proper positioning.

Objective evaluation of grip strength.

The objective and subjective components of industry-related injuries can lead to difficulties in diagnosis and treatment efforts. Grip strength determinations provide an objective measure that facilitates the evaluation of many occupation-related injuries. In this current study, healthy volunteers were evaluated with standard grip strength measurement and electromyographic recordings in order to characterize normal patterns. These recordings were found to be relatively uniform and reproducible.

Posterior interosseous palsy after dental treatment: case report.

Unilateral posterior interosseous nerve palsy occurred in a woman after deep palpation by her dentist during treatment for temporomandibular joint (TMJ) syndrome. Weakness of wrist and finger extension was noticed by the patient after the dentist used techniques of "applied kinesiology," including "pressure-point palpation." Electromyography confirmed the localization. This case exemplifies nerve damage caused by unorthodox treatment directed at the musculoskeletal system.

Acoustic myography: a noninvasive monitor of motor unit fatigue.

Acoustic myography is the recording of sounds produced by contracting muscle. These sounds become louder with increasing force of contraction. We have compared muscle sounds with surface EMG to monitor the dissociation of electrical from mechanical events (presumably, the loss of excitation-contraction coupling) which occur with motor unit fatigue. Acoustic signals were amplified using a standard phonocardiograph, recorded on FM magnetic tape, and digitally analyzed. Muscles were examined at rest, with intermittent contractions, and with sustained contractions. We found that with fatigue, the acoustic amplitude decayed, but the surface EMG amplitude did not. With decreased effort, however, the acoustic and the surface EMG amplitudes declined simultaneously. By simultaneously recording acoustic signals and needle EMG, individual motor units were resolved acoustically in two muscles with decreased numbers of motor units and increased motor unit size. Fasciculations also produced acoustic signals, although no acoustic signal has yet been found that correlates with fibrillations. Analysis of acoustic signals from muscle provides a noninvasive method for monitoring motor unit fatigue in vivo. It may also be useful in distinguishing muscle fatigue from decreased volition.