Roadmap to physical medicine and rehabilitation: answers to medical students' questions about the field.

Medical specialty training has undergone dramatic changes in the last 5 yr. This article was prepared by the Undergraduate Education Committee of the Association of Academic Physiatrists in an attempt to help guide medical students who are considering a career in physical medicine and rehabilitation. This report is an update of two previous articles addressing medical students' questions to assist them in making educated decisions about residency training and medical practice.

Manipulation efficacy: Upper body.

Manipulation, or manual medicine, is a highly utilized form of treatment for many types of musculoskeletal disorders, but there are many questions about the efficacy and safety of this form of treatment. This review of published trials for treatment of the upper body (cervical, thoracic, and upper limb) describes the patient groups that have been studied and may benefit from manual treatment, their outcomes, and their limitations. Cervical manipulation in particular has historically received criticism regarding safety, and the incidence of side effects, severe complications, and contraindications are discussed. The number of studies published for the upper body is small compared to the lumbar spine, and the lack of uniformity of the information still leaves the individual practitioner to decide if and when manipulation fits into his or her treatment algorithms for this region of the body.

Manipulation for the treatment of occupational low back pain.

Manual medicine techniques are performed to correct abnormal structural findings of tenderness, asymmetry, restricted range of motion, and tissue texture changes. Nonthrusting methods include articulatory, muscle energy, functional, counter-strain, and soft tissue manipulations.

Hiccups associated with lateral medullary syndrome. A case report.

We present a case of persistent hiccups (singultus) after a lateral medullary cerebrovascular accident. The patient presented with a two-day history of nausea and vomiting. Clinically, the patient had a loss of pain and temperature on the left side of the face, a loss of pain and temperature on the right side of the trunk, a mild left hemiparesis, and a left-sided ataxia. Nystagmus, diplopia, and hiccups were also evident. A left lateral medullary syndrome in the vascular distribution of the posterior inferior cerebellar artery was diagnosed. Work-up included a magnetic resonance imaging angiogram, which revealed an occlusion v high-grade stenosis of the basilar artery. The patient reported that the most distressing symptom was the chronic hiccups (25/min), which interfered with nutrition, sleep, and activity. While in the acute care hospital, the patient was treated with prochlorperazine, promethazine, and chlorpromazine. Each of these medications was unsuccessful in stopping the hiccups. After a search of the European literature revealed that baclofen was recommended as the drug of choice for stopping persistent hiccups, the patient was given 5 mg of baclofen by mouth three times per day, and the hiccups abated within 48 hours. The baclofen was discontinued after one week of therapy, and the hiccups did not return. We recommend consideration of baclofen for the treatment of persistent hiccups after lateral medullary syndrome because of its desirable side effects and reported success rate compared with other drugs used to treat chronic hiccups.

Interest in manual medicine among residents in physical medicine and rehabilitation. The need for increased instruction.

Manual medicine is an important part of the practice of physical medicine and rehabilitation (PM&R). Using a two-part questionnaire, we surveyed PM&R residents to determine their level of interest in manual medicine, their attitudes about this type of treatment, and the amount of formal training in manual medicine offered in PM&R residencies. Questionnaires were sent to all 75 PM&R residency training programs. Responses were received from 470 residents (41.6%) of 1126 potential respondents; this represented 55 (73%) of the programs surveyed. Of the 470 respondents, 363 (77.2%) believed that manual medicine should be a part of PM&R, 386 (82.1%) wanted more training in manual medicine, 389 (82.8%) believed that manual medicine is useful in the treatment of back/neck pain, and 392 (83.4%) would refer patients for manual medicine treatment. However, only 124 (27.3%) were receiving formal instruction in manual medicine during their PM&R residency training. Most of the 305 respondents who had received some exposure to manual medicine had done so through conferences (88.7%) and independent reading (66.9%). The results of this survey of PM&R residents demonstrate both a widespread interest in the use of manual medicine and an unmet desire for more instruction. Educational experiences in manual medicine should be provided so that, as residents become practicing physiatrists, they can either utilize this form of treatment or appropriately refer patients to other practitioners.

Dysphagia: diagnosis and treatment in Kentucky.

Dysphagia, a disorder of swallowing, is commonly associated with neurological and neuromuscular disorders. Damage to the sensation or muscles of the swallowing mechanism leads to unsafe oral motor or pharyngeal movement patterns, placing a patient at risk for development of aspiration pneumonia. At present, multidisciplinary Dysphagia Teams are being used to improve the diagnosis and treatment of swallowing disorders. A survey including all 112 hospitals in the Commonwealth of Kentucky indicates 33 (29%) presently have such a team, while 42 (38%) offer outpatient dysphagia services. In addition, 56 (50%) of the hospitals indicate they perform modified barium swallows which is an essential test for diagnosing and treating dysphagia. An example of how a Dysphagia Team works in one Kentucky rehabilitation hospital is presented to illustrate how to provide early diagnosis and treatment of these problems.

Compression syndrome involving the lateral antebrachial cutaneous nerve in high level quadriplegia.

This report describes an etiology for a compression syndrome involving the lateral antebrachial cutaneous nerve (LACN) that is unique to high level quadriplegia. Two cases are presented that involve this syndrome in C5-C6 quadriplegia. Electrodiagnostic techniques and normal values have previously been established for the LACN, but not involving high-level spinal cord injured patients. A series of asymptomatic high-level quadriplegics at various times since their spinal cord injury was studied for appropriate comparison with the symptomatic cases and previously reported normal values. In the cases described, electrodiagnostic evidence of compression was documented and a diagnostic block was performed by injecting a local anesthetic at Olson's point. Once the diagnosis was established, injection with a long-acting local anesthetic and corticosteroid was therapeutic.

The use of exercise in the elderly to enhance functional mobility and prevent falls.

Many studies have been conducted to document the positive effects of exercise in the elderly. Initially, the focus was on the benefits of aerobic training, however, more recent studies have shown that the elderly respond to isometric, isotonic, and isokinetic programs. Strength and mobility are two of the key factors in assessing a person's risk for falling. Studies have shown that people who fall frequently have weaker ankle dorsiflexors and knee extensors than persons who do not fall. As a result, it has been speculated that exercise programs to strengthen these muscle groups will improve functional mobility and reduce the risk of falling. At present ongoing trials are trying to provide documentation to support this idea.

Hyponatremia-associated cognitive impairment in traumatic brain injury.

The case of a traumatic brain injury (TBI) patient with dramatic cognitive deterioration in the absence of medical aetiology other than simultaneous decline in serum sodium led to an investigation of the association between declines in sodium levels and cognitive status. In a population of 50 persons undergoing TBI rehabilitation, 12 (24%) had relative (3 mEq/L) decreases in serum sodium while five (10%) experienced absolute hyponatremia (136 mEq/L). Correlation with cognitive status was significant when the absolute hyponatremia group was compared with those whose sodium levels remained above 136 mEq/L. A case-matched study of the relative hyponatremia group yielded no significant association between sodium-level decreases and cognitive status. These data support previous conclusions indicating wide variation in individual responses to changes in serum sodium. The threshold for significant effects of hyponatremia may be higher in patients with TBI than in populations studied previously.

Hepatic encephalopathy mimicking stroke. A case report.

This case demonstrates focal neurologic deficit mimicking stroke with underlying hepatic encephalopathy. Unilateral weakness in patients with hepatic encephalopathy has not been previously described in the English language literature. A 46-yr-old white woman was admitted to an acute care hospital for left shoulder manipulation, underwent general anesthesia and appeared to have had a right cerebrovascular accident. At transfer to the rehabilitation hospital, in addition to the left hemiparesis, there were inconsistencies in the neurologic examination and signs of cognitive impairment and liver failure. The patient's response to an intensive, multidisciplinary inpatient rehabilitation program along with treatment of the liver dysfunction led to resolution of left-sided weakness and flapping tremor with independence in ambulation and activities of daily living. Relevant literature is reviewed. A thorough history and physical examination with liver function assessment should always be performed in patients with cerebrovascular accident and unusual recovery.