Acupuncture education and integration in the physical medicine and rehabilitation residency.

Acupuncture is a growing field of interest to patients, medical students, and physicians. This article outlines the educational efforts and requirements to teach and practice acupuncture in the United States. A rationale for integrating acupuncture into physical medicine and rehabilitation residency programs is included. This article provides a structure for determining the type of education goals and plans most suited to a particular residency.

A multidisciplinary TBI inpatient rehabilitation programme for active duty service members as part of a randomized clinical trial.

OBJECTIVE: To design and describe an effective rehabilitation programme for use in an ongoing trial on the efficacy of multidisciplinary brain injury rehabilitation for moderately head injury military service members. DESIGN: Treatment arm of a randomized control trial. SETTING: US military tertiary care hospital inpatient rehabilitation programme. PATIENTS: Sixty seven active duty military with moderate to severe TBI who were randomized to the treatment arm of the protocol. INTERVENTION: Eight week rehabilitation programme combining group and individual therapies with an inpatient milieu-oriented neuropsychological focus. Group therapies included fitness, planning and organization, cognitive skills, work skills, medication, and milieu groups, and community re-entry outings. Individual therapy included neuropsychology, work therapy, occupational therapy, and speech and language pathology. MAIN OUTCOME MEASURES: Successful return to work and return to duty. RESULTS: At 1 year follow-up, 64 patients returned to work (96%) and 66% (44/67) returned to duty. CONCLUSION: The described rehabilitation programme demonstrates one successful effort to rehabilitate active duty military service members with TBI who have the potential to return to duty.

Speech dysfunction due to trazodone--fluoxetine combination in traumatic brain injury.

New serotonin reuptake inhibitors are available for the treatment of affective disorders and sleep dysfunction in traumatic brain injury (TBI) patients. Commonly reported serotonergic side-effects include nausea, headache, dizziness, nervousness and orthostatic hypotension. Trazodone, a non-selective serotonin reuptake inhibitor, is often used in conjunction with fluoxetine, a selective serotonin reuptake inhibitor, in order to combat the insomnia associated with fluoxetine. Successful use of this combination is generally limited by the cumulative serotonergic side-effects of the two medications. This paper describes the first reported case of speech dysfunction as a complication of combined trazodone and fluoxetine use. A 43-year-old male suffered bilateral wrist fractures and a moderate TBI during a fall. Within 1 week of adding fluoxetine to trazodone the patient developed new-onset dysarthria and speech blocking. Upon discontinuation of fluoxetine, speech returned to normal. Possible mechanisms include inhibition of hepatic metabolism, unmasking of caudate nucleus injury, increased noradrenergic activity or previously unreported serotonergic effects. This case illustrates the importance of monitoring drug combinations for unexpected side-effects in the TBI population.

Potential drug interactions in a physical medicine and rehabilitation clinic.

Potentially preventable adverse drug-drug interactions increase morbidity and financial costs to hospitals and third party payers. This study's purpose is to document the prevalence of potential drug-drug interactions (PDDI) in patients referred to a Physical Medicine and Rehabilitation (PM&R) clinic, to identify risk factors associated with PDDI, and to evaluate physicians' ability to correctly identify these PDDI. Current medication lists were obtained by questionnaire and confirmed by chart review for 121 consecutive new patients. The physician-identified PDDI were compared with computer-identified PDDI. Twenty-seven patients (22%; 95% confidence interval, 15-31%) had PDDI. PDDI were associated with number of medications (P = 0.0011) and PM&R subspecialty clinic (P = 0.012). Twenty-nine of the 46 computer-identified interactions (63%) were not identified by the physicians, and the physicians falsely identified 28 other drug combinations as PDDI. Potential drug-drug interactions occur at high rates in PM&R outpatient populations, and physicians are inadequately prepared to identify these PDDI.

Persian Gulf War amputees: injuries and rehabilitative needs.

This study describes the injuries, complications, functional limitations, and rehabilitative needs of amputees managed at Walter Reed Army Medical Center during the Persian Gulf conflict (1991). Fourteen amputees were treated sustaining 21 amputations with 18 lower-limb and 3 upper-limb amputations. In six casualties there were multiple amputations. Battle injuries were the cause in 79%. Nerve injuries occurred in 79%, phantom pain in 64%, and functional limitations (ambulation and activities of daily living [ADLs]) were present in all casualties. Contractures were noted in 86%. Skin traction for open wounds was lacking in all but one case. With comprehensive rehabilitation, all casualties achieved independent ambulation, and 93% were independent in all ADLs at discharge, with one below-knee amputee successfully returning to duty. These findings highlight the need for education of military health care providers in skin traction techniques, and provision of multidisciplinary rehabilitative care for these casualties.

Analysis of casualties referred to Army physical medicine services during the Persian Gulf conflict.

This study describes the casualties referred during the Persian Gulf War and underscores the valuable role of Army physical medicine and rehabilitation (PMR) services in evaluation and early rehabilitation of wartime casualties. Data regarding demographics, injury types, medical complications, complications of immobility and functional limitations were collected by military physiatrists at five Army Medical Centers with PMR services. Active duty soldiers injured in the Persian Gulf War who were referred totalled 222. Musculoskeletal injuries occurred in 57%, peripheral nerve injuries in 44%, penetrating wounds in 32%, fractures in 28%, brain injuries in 8%, amputations in 7%, burns in 6% and spinal cord injuries in 3%. The primary referral service was orthopedics (64%). Electrodiagnosis evaluations were performed for 41% of all referrals. Lower limb and upper limb contractures occurred in 10% and 9% of patients, respectively. Ambulatory impairments were seen in 48%. Nerve injuries were associated with penetrating wounds in 68%, with amputations in 67% and with fractures in 58%.

Infrageniculate bypass graft entrapment.

When failure of vein grafts is due to technical error it is usually observed in the early postoperative period. In this review we describe late failure of five bypass grafts as a result of entrapment of the vein graft caused by an improperly placed tunnel from the femoral to the popliteal artery. Vein graft entrapment may either produce no symptoms or eventually lead to limb ischemia. Pulses and pressures that vary with flexion and extension maneuvers should alert the clinician to the possibility of an entrapment syndrome. The characteristic arteriographic findings observed in these patients include an aberrant course of the vein graft outside the anatomic course of the popliteal artery and position-dependent compression of the graft. The ability of magnetic resonance angiography to demonstrate the arteriographic appearance of the graft as well as the precise location of the compression and to identify structures involved in the entrapment, make it a valuable noninvasive tool in the preoperative assessment of these patients. Treatment options include division of the gastrocnemius muscle, division of the vein graft, or replacement of the vein graft. Familiarity with vein graft entrapment should facilitate its recognition. Careful placement of bypass grafts along the anatomic course of the popliteal artery within the popliteal space will prevent this complication.