Serratus posterior muscles: anatomy, clinical relevance, and function.

The serratus posterior superior and inferior muscles are generally considered clinically insignificant muscles that, based on attachments, probably function in respiration. Interestingly, however, there is no evidence supporting a respiratory role for these muscles. In fact, some electromyographic data refute a respiratory function for these muscles. We suggest that the serratus posterior muscles function primarily in proprioception. Further, these muscles, especially the superior, have been implicated in myofascial pain syndromes and therefore may have greater clinical relevance than commonly attributed to them.

Precision diagnostic disc injections.

Spinal pain is an important public health problem affecting the population indiscriminately. The structures responsible for pain in the spine include the vertebrae, intervertebral discs, spinal cord, nerve roots, facet joints, ligaments, muscles, atlanto-occipital joints, atlanto-axial joints, and sacroiliac joints. Even though disc herniation, facet joints, strained muscles, and torn ligaments have been attributed to be the cause of most spinal pain, either in the neck and upper extremities, upper and mid back, or low back and lower extremities, disorders of the disc other than disc herniation have been implicated more frequently than any other disorders. Once stifled by misinformation, discography now has applications in a number of clinical settings. While cervical and lumbar discography is well studied and well known, thoracic discography is in its nascent stages of clinical application. The value of discography lies in its ability to produce pain and thereby identify a "pain generator." This allows treatment to be based on the specific cause of pain. The three primary components of diagnostic disc injection are: provocation/analgesia, discometry, and nucleography. Despite the recent exponential growth of noninvasive spinal technology, diagnostic disc injection remains the sole direct method for definitively determining whether a disc is a physiological pain generator. It is clear that discography is a safe and powerful complement to the overall clinical context.

Internal disc disruption and low back pain.

Internal disc disruption is a common cause of disabling low back pain in a substantial number of young, healthy adults. Crock described this painful entity and reported annular fissures that distort the internal architecture of the disc; Externally the disc appears relatively intact and undeformed. A clinical diagnosis of internal disc disruption, in absence of objective clinical findings, is extremely difficult. The only convincing means to establish the diagnosis is provocation discography. Unfortunately, this procedure is controversial, making the existence of internal disc disruption suspect. Recent studies indicate the existence of a biochemical/ biomechanical model of discogenic pain, which explains the disabling low back pain in some subjects with no objective evidence of nerve-root compromise. However, a reluctance to acknowledge internal disc disruption as a valid clinical entity delays diagnosis and treatment. Failure to identify and treat this entity early and aggressively results in longterm disability, thereby perpetuating the enigma of chronic low back pain.

Sacroiliac joint innervation and pain.

The present paper reviews current knowledge on the innervation of the human sacroiliac joint (SIJ). We conclude, based on a recent anatomic study on adult cadavers, with fetal correlation, that the joint is predominantly, if not entirely, innervated by sacral dorsal rami. This conclusion is in agreement with patterns of referred pain reported by asymptomatic volunteers upon direct SIJ capsular stimulation and with a reduction in pain in patients treated for (presumptive) SIJ pain by injection of an anesthetic into the SIJ. We also present preliminary data suggesting that the periarticular tissues of the SIJ, like those of other synovial joints, contain mechanoreceptors and nociceptors that function to inform the central nervous system about the state of the joint.

Three pathways between the sacroiliac joint and neural structures.

BACKGROUND AND PURPOSE: Despite ongoing clinical suspicion regarding the relationship between sacroiliac joint (SIJ) dysfunction and lower extremity symptoms, there is a paucity of scientific literature addressing this topic. The purpose of this study was to describe patterns of contrast extravasation during SIJ arthrography and postarthrography CT in patients with lower back pain and to determine whether there are pathways of communication between the SIJ and nearby neural structures. METHODS: Fluoroscopically guided SIJ arthrography was performed on 76 SIJs. After the injection of contrast medium, anteroposterior, lateral, and oblique radiographs as well as 5-mm contiguous axial and direct coronal CT images were obtained. Contrast extravasation patterns were recorded for each joint. These observations included a search for contrast extravasation from the SIJ that contacted nearby lumbosacral nerve roots or structures of the plexus. RESULTS: Sixty-one percent of all joints studied revealed one of five contrast extravasation patterns. Three of these observed patterns show a pathway of communication between the SIJ and nearby neural structures. These included posterior extravasation into the dorsal sacral foramina, superior recess extravasation at the sacral alar level to the fifth lumbar epiradicular sheath, and ventral extravasation to the lumbosacral plexus. CONCLUSION: Three pathways between the SIJ and neural structures exist.

[Assaults in psychiatric wards : Experience and perceptions of mental health workers at the Pavillon Roland-Saucier du Complexe hospitalier de la Sagamie.]. / Les agressions en milieu psychiatrique. Vécu et perceptions des intervenants du Pavillon Roland-Saucier du Complexe hospitalier de la Sagamie.

This article presents results of a study conducted at the Pavillon Roland-Saucier, the psychiatric ward of the Complexe hospitalier de la Sagamie. The objective was to explore with a phenomenological approach the issue of assaults by patients of mental health workers and in particular the impact of theses assaults on their professional life. Thirty workers of various professional categories, selected by a stratified random procedure, have accepted to be interviewed. The analysis of theses interviews has allowed to draw important elements on the basis which various recommendations have been suggested in order to improve the situation.

An analysis of risk assessment tools for falls in the elderly.

The authors entered into a collaborative project with the staff of a visiting nurse service to evaluate the utility of a risk assessment inventory (RAI) in identifying factors that lead to falls in elderly persons receiving home care. Although no clear pattern emerged among personal factors, the majority of patients who experienced a fall used one or more assistive devices for ambulation.

The Fortin finger test: an indicator of sacroiliac pain.

Simple and reliable diagnostic aids need to be available for clinicians to consider sacroiliac joint dysfunction in the differential diagnosis of low back pain. The Fortin finger test was used as a means to identify patients with low back pain and sacroiliac joint dysfunction. Provocation-positive sacroiliac joint injections were used to ratify or refute the applicability of this new clinical sign for identification of patients with sacroiliac joint dysfunction. Sixteen subjects were chosen from 54 consecutive patients by using the Fortin finger test. All 16 patients subsequently had provocation-positive joint injections validating sacroiliac joint abnormalities. A subset of 10 individuals underwent additional evaluation to exclude the possibility of confounding discogenic or posterior joint pain sources. All 10 patients had no indication of either discogenic or zygapophyseal joint pain generators. These results indicate that positive findings of the Fortin finger test, a simple diagnostic measure, successfully identifies patients with sacroiliac joint dysfunction.

[Reconsidering the approach to native peoples]. / Pour un réajustement des approches auprès des autochtones.

Reconsidering nursing interventions among native people. The object of this study was to develop appropriate material to illuminate ways of enhancing interactions between native clients and clinical nurses. The chosen site was Roberval Hospital in Quebec, which serves the western and northern shores of Lac-Saint-Jean as well as the Chibougamau-Chapais region. A survey, using both a questionnaire and semi-structured interviews, was conducted among a sample of 48 nurses working at that hospital and 29 native clients representing three distinct generations of the Montagnais people residing on an Indian reserve located eight miles from the hospital. Results underline that various cultural elements are at play when nurses and native people interact with each other. On the one hand, natives view the main problems as relating to communication, definition of values and family dynamics. For most nurses, communication is the main stumbling block. They readily recognize that their initial training has not prepared them to maintain effective relationships with native people. To enhance nursing competency and smooth over cultural barriers, the authors recommend appropriate transcultural training for nurses. Meanwhile, native people would benefit from information sessions on the functions of various health professionals in a hospital setting as well as the role and organizational structure of such an institution.

Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers.

STUDY DESIGN: Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine. OBJECTIVES: To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals. SUMMARY OF BACKGROUND DATA: All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthesia running caudally from the posterior superior iliac spine. METHODS: Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns. RESULTS: Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection. CONCLUSION: A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.

Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation.

STUDY DESIGN: A pain referral map generated from Part I of this study was tested in 54 consecutive patients. Pain diagrams, completed by each patient, were compared to the map generated from sacroiliac injections in 10 volunteers (Part I). Two clinicians, blinded to the examination of each individual, selected the diagrams most consistent with the pain map. OBJECTIVES: To determine the applicability of a pain referral map as a screening tool for sacroiliac joint dysfunction. SUMMARY OF BACKGROUND DATA: Two independent examiners, blinded to the patients' examinations, selected 16 individuals whose pain diagrams most represented the map generated in Part I. There was a 100% concordance of patients selected. All 16 patients selected had a provocation-positive SI joint injection. Ten of these individuals also received lumbar discography and lumbar facet injections. Only the SI injection on the symptomatic side was provocation positive. METHODS: Patients selected for evaluation based on pain mapping received sacroiliac joint injection. Provocation-positive injections were used to confirm the diagnosis of sacroiliac joint dysfunction. Ten subjects subsequently underwent lumbar discography and lumbar facet joint injections to further confirm the diagnosis. RESULTS: Few studies involving low back pain have used pain referral maps. In the present study, patients were successfully screened for sacroiliac joint dysfunction using a pain referral map generated from provocation of asymptomatic volunteers. CONCLUSION: Patients can be successfully screened for sacroiliac joint dysfunction based on comparison with a pain referral map. Further study on the false negative rates of sacroiliac pain maps is needed.

[Intercultural care]. / Les soins interculturels.

Increased immigration into Canada over the last several years has created a country even more culturally diverse than before. And while multiculturalism is beneficial to Canadians, it can also present challenges. One of the main challenges is faced by health professionals daily: that of attempting to meet the various cultural needs of newly arrived immigrants. Essential to the task are relevant knowledge and appropriate attitudes and behavior. Toward these ends, the authors call for an increase in nursing research, and a focus on continuing education and nursing practice information--all relating specifically to multicultural issues.

Client-nurse interaction: testing for its impact in preoperative instruction.

This study tests for the impact of client-nurse interaction, an essential element lacking in earlier research on preoperative instruction. An experimental design compared the effects of three models of intervention: Facilitator, Informational and Routine Treatment on postoperative pain and anxiety in 91 cholecystectomy patients. Planned comparisons showed that subjects in both experimental conditions reported significantly less postoperative anxiety than subjects who received the routine treatment. There were no differences in anxiety levels between the two experimental groups or in pain scores among the three groups. Refinements in the facilitator model are recommended to enhance the problem-solving nature of the interaction and to strengthen future research. The findings support the importance of providing the patient with sensation information and postoperative exercise instruction.

Sacroiliac Joint DysfunctionA New Perspective.

The sacroiliac (SI) joint as a primary source of low back pain is a resurgent, yet controversial subject. In 1905, Goldthwaite proposed that the sacroiliac joint could be a physiologic pain generator independent of pregnancy.1 The role of the sacroiliac joint fell into obscurity over the ensuing decades, with the discovery of such tangible entities (with accepted pathophysiology) as the herniated nucleus pulposus,2 and spinal stenosis.3 Accordingly, there is a paucity of basic and clinical science information available to aid physicians in understanding the biomechanics, diagnosis, and rehabilitation of sacroiliac joint dysfunction.

The postoperative pain experience: a description based on the McGill Pain Questionnaire.

In surgical nursing practice, postoperative pain is of particular concern because of its documented effect on recovery and behaviors associated with recovery. Yet, little is known about the nature of this pain, other than its intensity. In this study, a description of the nature of the postoperative pain experience was generated from analysis of patient responses to the McGill Pain Questionnaire in four nursing intervention studies. The combined sample included 246 adult cholecystectomy patients. Patient descriptions of pain on the third postoperative day suggest a circumscribed sensory experience of moderate intensity. Sensory descriptors selected reflect two levels of noxious stimulation, one at the deeper somatic level (e.g., throbbing, stabbing, cramping, pulling, and burning) and one at a more superficial level (e.g., pricking, sharp, pinching, itching, sore, and tender). Descriptors of deeper pain tended to reflect greater intensity. The overall experience was characterized by 16 descriptors, selected by more than 30% of the sample and reflecting sensory, affective, and evaluative dimensions of the pain experience. Comparison of the findings from this combined sample drawn from hospitals in the northeastern United States were remarkably similar to those reported by Taenzer in Canada. The descriptors selected support, extend, and validate the kind of "sensation information" needed in preoperative instruction used in nursing practice and for abdominal surgery and can be useful in the assessment and management of postoperative pain.