Prevention of musicians' hand problems.

A significant proportion of musicians suffer musculoskeletal problems as a result of playing their instruments. The author describes the British Performing Arts Medicine Trust founded by Dr. Ian James 12 years ago to address these problems in Great Britain. The author, a rheumatologist consultant since its inception, reviews over a thousand cases seen at these clinics. Almost half of these patients had no obvious structural abnormality sustaining symptoms through poor posture, bad practice techniques, unfitness and overuse. Lack of full rehabilitation after injury was the most common cause of structural disorders. The responsibilities for prevention of injuries is described for the three components of the profession: musicians, teachers, and administrators.

The clinical experience of novice students in nursing.

The learning experience of nursing students in their first clinical laboratory in a hospital was examined in a qualitative investigation. Graduate students in a nursing research seminar course participated as co-investigators in the study of clinical learning among sophomore nursing students. Findings revealed that sophomore students in nursing reflected on their role in the clinical setting and in nursing; pursued ways to learn in clinical settings; actively sought mentors; made connections to staff, patients, and peers; and searched for ways to validate the competence of their beginning skills. Parallels of the students' behaviors to the novice-to-expert paradigm were found. The study was valuable for both undergraduate and graduate students involved in the investigation.

Thoughts on the rehabilitation of patients with brachial plexus lesions.

This article concerns traction lesions of the brachial plexus in adults, focusing on management and recovery. Open wounds of the plexus are now treated surgically as soon as possible. The subsequent rehabilitation is the same as that for closed traction lesions of the brachial plexus in which significant recovery is expected.

Mechanical back pain and the facet joint syndrome.

Mechanical back pain is a common disability often associated with the facet joint syndrome. Treatment is based on early, adequate pain relief with simple techniques of regional analgesia. In a few cases this is not enough and more sophisticated methods, such as radiofrequency denervation, cryo-analgesia and possibly intrathecal midazolam, are necessary. However, the main thrust of our approach is to treat the underlying structural disorder with strengthening of the back muscles and correction of postural abnormalities responsible for the mechanical back pain. Our report is based on an analysis of 83 patients who failed to respond to long periods of rest, suitable analgesic and allied drugs and other non-invasive measures. There had been no overriding indication for major surgery. A large number of these patients have been improved by our methods, but further work is in progress to extend the proportion of satisfactory results.

Orthotics and rehabilitation after extensive upper limb paralysis.

The author reviews the progress that has been made in the development of orthotics and rehabilitation techniques for patients with extensive paralysis of the upper limb after injury and disease. Splint components and their variations are described with regard to patients with less extensive or recovering lesions.

Management of causalgia after peripheral nerve injury.

The authors report on a series of patients with severely painful disorders of peripheral nerves--they review the modern theories on the nature of causalgia and reflex sympathetic dystrophy. Peripheral causes include spontaneous discharges from neuroma sprouts, their sensitivity to adrenergic compounds, ectopic generator activity in abnormally myelinated fires and increased firing in dorsal root ganglia. Central causes include spontaneous activity of deafferented nerves in the dorsal horn and development of response to new receptive fields. The natural history of such disorders is poor--many patients suffering pain for 10 years or more--the clinical picture is characterized by spontaneous burning pain and allodynia and hyperpathia, chronicity, osteoporosis, skin and nail changes and deformities. The basis of treatment is sympathetic blockade using intravenous guanethedine on alternate days. At least 6 blocks are given as the majority of patients do not respond until the 5th or 6th block. Each block is followed by desensitization and intensive rehabilitation. The authors emphasize that sympathetic blockade is only one, albeit the most important, modality in a multi-faceted treatment programme. Surgical attempts to relieve pain almost uniformly failed--causing as they do further neuronal changes peripherally and centrally. Recurrences depend on the degree of initial response. Those who obtained virtually complete relief of pain had a lower recurrence rate but a high proportion needed repeated sessions of treatment at yearly intervals. Follow-ups must therefore be indefinite.

Update on peripheral nerve injuries.

Experimental work relating to factors affecting nerve regeneration is reviewed. There is increasing evidence that the nerve sprouts are preprogrammed for their peripheral reinnervation; old endoneurial tubes being discarded. Fascicular suture shows no significant improvement in function compared with epineural suture. The importance for sensory re-education and the need for repeatable sensory function tests is emphasized. Recent experimental work on the mechanisms of causalgia is reviewed and management of painful peripheral nerve disorders discussed. Striking advances have been made in the diagnosis, surgical treatment and rehabilitation of traction lesions of the brachial plexus. These are discussed with special reference to electrodiagnosis, functional splinting and management of pain. Surgery for obstetric palsies is now being undertaken and similar lesions to those in the adult being repaired with success. Reconstructive procedures for permanent paralysis are reviewed. Postirradiation plexus lesions present a formidable challenge but surgery can sometimes alleviate pain.

The assessment and management of the failed back, Part I.

The 'failed back' represents a major clinical problem. Among the causes recognized for the 'failed back' is lateral root stenosis which has led to the use of electromyography (EMG) in the diagnosis of root compression. One hundred and thirty-two patients selected for surgical decompression were compared with 25 undergoing spinal fusion. EMG was found to be diagnostic in 95% of patients with bony canal stenosis, but only gave positive results in 62.5% of prolapsed disc patients. EMG improved in those patients who made a good recovery after surgery.

The assessment and management of the failed back, Part II.

Despite adequate surgery a number of patients have a return of back pain and sciatica following operation, the so-called failed back. The results of a prospective study of 101 patients entering an intensive rehabilitation programme for the failed back is described. The programme consists of a team approach to the patient and his problems, using a variety of techniques to produce pain relief. Non-organic pain represents a significant problem in the failed back; 58% of patients were completely or substantially relieved of their pain. Transcutaneous nerve stimulation was found to be the single most useful treatment with exercise second. Non-organic pain was able to be relieved by this programme.

Rehabilitation of conversion paralysis.

Three patients referred for rehabilitation of brachial plexus lesions and two referred with leg weakness associated with sciatica were found to have conversion paralysis. The diagnosis was made by demonstrating normal motor nerve conduction to the clinically weak muscles. The weakness was treated by intensive physical rehabilitation with complete and sustained recovery in all cases.

Pain in avulsion of the brachial plexus.

The author reviews the diagnosis and treatment of avulsion injuries of the brachial plexus. He discusses the nature of the pain and the use of transcutaneous nerve stimulation for its relief.