1/8. Acute abstinence syndrome following abrupt cessation of long-term use of tramadol (Ultram): a case study.We report on a patient who had taken the centrally acting analgesic tramadol for over 1 year. The compound had proven to be sufficient to treat her painful episodes related to fibromyalgia. Due to lack of supply while being on a trip, intake of the drug was stopped abruptly, resulting in the development of classical abstinence-like symptoms within 1 week. Abstinence-like symptoms consisted of restlessness and insomnia for which the benzodiazepine lorazepam was given. Diarrhoea and abdominal cramps were treated with the peripherally active opioid loperamide, while bouts of cephalgia were treated with sumatriptan. Diffuse musculoskeletal-related pain and restless leg syndrome (RLS) were treated with dextromethorphan. All these different medications proved to be efficacious as they resulted in the cessation of symptoms. Within 1 week symptoms ceased and the patient regained her normal activities without any sequelae. Although tramadol is considered a non-habit- and non-dependence-forming analgesic, abstinence symptoms are likely to develop following abrupt cessation of intake, especially when the compound had been taken over 1 year. Therefore patients should be advised of such an effect whenever they decide to stop intake or their physician is planning to switch to another medication. To avoid abstinence-like symptoms doses should be slowly tapered down.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/8. Determining foot and ankle impairments by the AMA fifth edition guides.The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/8. dermatomyositis: evolution of a diagnosis.BACKGROUND AND PURPOSE: As direct access evolves, physical therapists will increasingly encounter patients with pathology that might have an underlying systemic origin. The purpose of this case report is to describe the diagnostic process that led a patient's physical therapist to recognize signs and symptoms of dermatomyositis. CASE DESCRIPTION: The patient was an 18-year-old woman who was referred for physical therapy by her primary care physician on 3 occasions with 3 separate musculoskeletal diagnoses. During the third episode, the physical therapist recognized signs and symptoms that could be indicative of dermatologic disease and referred the patient to a dermatologist. OUTCOMES: A rheumatologist diagnosed the patient's condition as dermatomyositis and referred her for physical therapy. The physical therapy plan of care focused on strengthening and stretching, with an emphasis on a home exercise program. The Medical Outcomes Study 36-Item Short-Form health Survey (SF-36) indicated that the patient continually made functional improvements over an 18-month period. DISCUSSION: Although diagnosis of diseases such as inflammatory myopathies is not within a physical therapist's scope of practice, this case demonstrates the role a physical therapist can play in recognition of underlying systemic pathology by using the diagnostic process.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/8. Common scenarios to clarify the interpretation of cardiac markers.The authors present a practical approach for physicians in clinical practice to use cardiac troponins in the interpretation of heart disease and myocardial damage. Laboratory results that fall within the intermediate area of facility-specific cutoff reference values for elevated troponin levels confer lower risks to patients than do higher levels of cardiac troponin. Perhaps not surprisingly, the actual anatomy of the vessels at cardiac catheterization does not correlate well with the troponin level. In the six cases presented here, the patients' low levels of troponin release are discussed using the new term minimal myocardial infarction, which is synonymous with conditions that would previously have been diagnosed as unstable angina. Elevated levels of cardiac troponin provide a very sensitive measure for clinicians diagnosing patients with myocardial necrosis, but such measures are also useful in defining a broad spectrum of disease. Whenever the troponin levels are elevated (barring laboratory error), the patient has a poorer prognosis. The greatest challenge for physicians is in determining which patients with cardiac troponin elevation will best benefit from heart catheterization and percutaneous intervention.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
5/8. Physical medicine and rehabilitation in the military: Operation Iraqi freedom.This article describes the role of a physical medicine and rehabilitation (physiatry) physician (physiatrist) as a general medical officer within a forward support battalion during the invasion and nation-building phases of Operation Iraqi freedom. Between March 10 and May 3, 2003 (invasion phase), 364 patients were evaluated. Thirty-two percent had musculoskeletal noncombat injuries, 9% had combat-related traumatic injuries, and the remaining 59% had nontrauma/nonmusculoskeletal conditions. Between May 4 and July 25, 2003 (nation-building phase), 1,387 patients were evaluated. Of these, 19% had musculoskeletal injuries, 1% had combat-related traumatic injuries, and the remaining 80% had nontrauma/nonmusculoskeletal conditions. During this nation-building phase, the musculoskeletal workload seen at the division-level combat support hospital was 4 times the workload seen in the forward support battalion. This experience underscores the role of physiatry in wartime casualty management and profiles the combat support hospital as the most suitable place for the physiatrist during wartime. Interventions focused on acute management and rehabilitation counseling for all musculoskeletal injuries, as well as consultation services to the combat support hospital and local civilian hospitals for the evaluation of complex neuromusculoskeletal trauma cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/8. Musculoskeletal origins of chronic pelvic pain. diagnosis and treatment.Musculoskeletal dysfunctions often contribute to the signs and symptoms of chronic pelvic pain and in many cases may be the primary cause. The traditional team approach to chronic pelvic pain has not, however, routinely included a practitioner skilled in musculoskeletal examination and treatment. Characteristics of musculoskeletal pain are reviewed as are specific dysfunctions commonly found to produce lower abdominal and pelvic floor pain. A screening examination is presented to assist the gynecologic physician in identifying patients who may benefit from physical therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/8. Musculoskeletal problems of performing artists.We have reviewed the frequency and variety of rheumatic problems among performing artists. For instrumentalists, injuries are related to the type of instrument played, the technique used and the effort expended in the quest for excellence. For dancers, musculoskeletal problems too reflect technique and effort. We should not be surprised at the frequency of these problems. Rheumatologists, as well as orthopaedic surgeons, physiotherapists, neurologists and other physicians, encounter performing artists as patients. We should be familiar with their problems and be able to knowledgeably diagnose and manage them. This may include observing the artist during actual performances. How is the instrument being held? What is the posture of the artist? What are the comments of the coach or teacher. What type of shoes does the ballerina wear? What movements in particular cause discomfort? These and similar observations will have direct bearing on the musculoskeletal problems of these artists. Published studies have related the variety, frequency and disabling nature of performance-related musculoskeletal problems. Unfortunately few if any of these are controlled, blinded or prospective. We need more and better information. We will want clear information about prevalence of problems, better definition of the musculoskeletal ailments, classification of the relationship of problems with performance and individual biomechanical features, information about response of specific problems to interventions, and data about the long-term consequences, if any, of these rheumatic problems to the musculoskeletal system. Artists as patients are unique. Minor problems can become potentially career-ending disabilities. Making music or performing dance may provide us with delightful entertainment but represents a source of livelihood to artists. Understanding their medical needs and enabling them to continue to perform is the challenge before us.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/8. Factors prolonging disability in work-related cumulative trauma disorders.workers' compensation costs for management of soft tissue disorders continue to increase. The complexity of medical management of these cases has increased due to social factors. The purpose of this study is to improve the physician's ability to recognize nonmedical issues that prevent a rapid return to employment. A classification system is presented that will allow the clinician to identify administrative and pyschosocial issues that prolong disability. Additionally, the patients' job demands were classified by known ergonomic risk factors. The system was applied retrospectively to 50 random cases referred to two occupational hand clinics over a 1-year period. The results indicated that the psychosocial classification of the patient and the current employment status are the most important factors in prolonging disability workers.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |