1/11. Opioids in non-cancer pain: a life-time sentence?There is continuing reluctance to prescribe strong opioids for the management of chronic non-cancer pain due to concerns about side-effects, physical tolerance, withdrawal and addiction. Randomized controlled trials have now provided evidence for the efficacy of opioids against both nociceptive and neuropathic pain. However, there is considerable variability in response rates, possibly depending on the type of pain, the type of opioid and its route of administration, the time to follow-up, compliance and the development of tolerance. Five patients were selected with nociceptive or neuropathic pain in whom other pharmacological or physical therapies had failed to provide satisfactory pain relief. They received transdermal fentanyl (starting dose 25 microg/h) for at least 6 weeks. Transdermal fentanyl dosage was titrated upwards as required. Transdermal fentanyl provided adequate pain relief in patients with nociceptive pain (diabetic ulcer, osteoporotic vertebral fracture, ankylosing spondylitis) or neuropathic pain with a nociceptive component (radicular pain due to disc protrusion, herpetic neuralgia). The duration of treatment ranged from 6 weeks to 6 months for four cases. In the case of ankylosing spondylitis, treatment was carried out for 2 years, stopped and then restarted successfully. There were no withdrawal effects or addictive behaviour on treatment cessation, regardless of duration of the treatment. In conclusion, strong opioids may provide prolonged effective pain relief in selected patients with nociceptive and neuropathic non-cancer pain. Transdermal fentanyl treatment can often be temporary and can easily be stopped following adequate pain relief without withdrawal effects or any evidence of addictive behaviour.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/11. One pair must last a lifetime. Case studies of foot care in diabetes.Neuropathy is the second most important of the four major 'traffic light' warnings for future foot problems (vascular, neuropathy, structural, self care). Peripheral neuropathy is a significant clinical problem in 20% of patients with diabetes. Painful neuropathy can disrupt patients lives but simple effective interventions are available. Painless neuropathy is often not perceived to be a problem by the patient or their doctor but puts the foot at risk from trauma (physical, chemical and thermal). patients with neuropathy need systematic reassessment of self and professional diabetes care, and education about footwear and foot care. A podiatrist can be invaluable in prescribing appropriate footwear and orthotics to distribute foot pressure and in educating patients about self care. patients with the 'double whammy' of neuropathy and vascular disease are at extreme risk of limb threatening problems and should have a regular monitoring program by themselves (or their carers) and their professionals as well as an 'action plan' to detect and deal with problems early.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
3/11. Toxic effects of epidural analgesia with ropivacaine 0.2% in a diabetic patient.A 51-year-old ASA physical status II, non-insulin-dependent diabetic male patient manifested lower limb nerve injury after receiving postoperative epidural analgesia with ropivacaine 0.2%. The case is presented, including a discussion of the relation between local anesthetic toxicity and diabetic neuropathy.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
4/11. Diabetic thoracic polyradiculopathy.Diabetic thoracic polyradiculopathy usually causes severe, chronic abdominal pain in patients with type 2 diabetes of variable duration. Other diabetic complications, weight loss and paretic abdominal wall protrusion are common. Sensory, motor and autonomic functions are affected. The diagnosis can be made from the characteristic history, physical examination findings, paraspinal electromyography, and other procedures. The differential diagnosis includes postherpetic neuralgia, abdominal wall pain, malignancy, and other spinal disorders. The pathology appears to be immune-mediated neurovasculitis resulting in ischemic injury. Traditional therapy is symptomatic, but recent pathological findings and clinical experience suggest that immunotherapy may be effective.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
5/11. Diabetic neuropathy, the great masquerader: truncal neuropathy manifesting as abdominal pseudohernia.OBJECTIVE: To describe a patient with diabetic truncal neuropathy and suggest a helpful diagnostic approach to this entity. methods: We present a case report, with a focus on physical, computed tomographic, and electromyographic findings. RESULTS: Because of an extensive differential diagnosis, diabetic truncal neuropathy is a rarely recognized and often misdiagnosed condition in patients with diabetes mellitus. In a 55-year-old man with a 13-year history of diabetes but no retinopathy, vasculopathy, or nephropathy, pain and a visible bulge in the left lower abdominal quadrant prompted radiographic assessment of the abdomen. A computed tomographic scan of the abdomen disclosed no mass but a weakening of the abdominal musculature suggestive of a pseudohernia. Subsequent electromyography showed evidence of polyradicular neuropathy. The patient was given treatment for pain control, and the pseudohernia resolved within 1 year. CONCLUSION: In patients with diabetes who have a painful abdominal mass, the potential presence of a diabetic truncal neuropathy should be considered.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
6/11. Biomechanical treatment approach to diabetic plantar ulcers. A case report.The purpose of this case report is to describe a physical therapy approach designed to reduce the mechanical pressure at the site of a diabetic plantar ulcer. The patient was a 69-year-old man with diabetes mellitus for 24 years, insensitive feet, and a right plantar ulcer at the first metatarsal head for 21 months. He had a fixed equinus and rear-foot varus deformity, which seemed to place increased pressure on his forefoot. The patient was treated with total contact casting and showed progressive healing until he refused additional casting. One week later, the ulcer was considerably larger. He consented to resume casting, and the ulcer was completely healed in 85 days from the initial treatment. We provided the patient with extra-depth shoes with rigid rocker-bottom soles and a polyethylene-lined ankle-foot orthosis. The ulcer remained healed at one-week and six-month follow-up visits. The primary cause of diabetic plantar ulcers is often excessive pressure on an insensitive foot, and physical therapists should utilize biomechanical principles to reduce these excessive plantar pressures.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/11. Molded double-rocker plaster shoe for healing a diabetic plantar ulcer. A case report.The purpose of this case report is to document the successful healing of a chronic neuropathic plantar ulcer with the molded double-rocker plaster shoe (MDRPS) in a lower extremity that also had stasis changes and poor blood flow. The patient was a 67-year-old woman with insulin-dependent diabetes mellitus, insensitive feet, a right ankle-arm index of 0.48, and an ulcer beneath the right cuneonavicular joint measuring 0.94 cm2 in area and 2 mm deep. Reported onset of the ulcer was 10 months before referral for physical therapy. The MDRPS was chosen as an alternative treatment to conventional below-knee total contact casting (TCC) because of the stasis changes and fragile skin in the patient's lower extremities. The ulcer healed in 39 days after initiating treatment with the MDRPS. We consider the MDRPS the preferred treatment with those patients with neuropathic plantar ulcers who cannot tolerate the below-knee TCC.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
8/11. Diabetic Charcot spine as cauda equina syndrome: an unusual presentation.Some 6% to 21% of Charcot joints occur in the spine. The underlying disease is usually tabes dorsalis, but diabetes mellitus is another etiology. Degeneration of spinal elements is accelerated and lumbar spinal stenosis with weakness may occur, as has been reported in tabetic arthropathy. The case presented is unusual in two respects: first, the Charcot spine was secondary to diabetic complications, which resulted in a compressive cauda equina syndrome; second, the patient presented with progressive paraparesis and bowel and bladder dysfunction but physical examination by several examiners revealed no clinically evident sensory abnormality. The patient had vague and inconsistent sensory complaints for several years preceding definitive workup, but the overall picture of his disease process only could be made following multiple laboratory, electrodiagnostic, microbiologic, and radiologic testing. The patient presented with subacute paraparesis, providing a wide differential diagnosis ranging from guillain-barre syndrome to spinal neoplasm. The physical, radiologic, laboratory, electrophysiologic, histologic/pathologic findings, treatment, and recovery status are included in this report.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
9/11. Diabetic neuroarthropathy in the foot: patient characteristics and patterns of radiographic change.The diagnosis of diabetic neuroarthropathy of the foot can be difficult. A series of 96 patients (116 extremities) who had diabetes and peripheral neuropathy with bone and joint changes was reviewed. Typically, the patients were middle-aged or older, were taking insulin, and had had diabetes for more than 10 years. Retinopathy, nephropathy, and peripheral vascular disease were often present. There were abnormalities of vibratory sensation (94%) and of the gastrosoleus reflex (88%). The finding of specific radiographic abnormalities assisted but did not reliably differentiate neuropathy from infection. Three patterns of radiographic changes were noted: (1) at the metatarsophalangeal and interphalangeal joints, usually with underlying ulceration; (2) at the tarsometatarsal joints; and (3) in the anterior pillar-medial column of the foot, with talus, talonavicular, navicular, or naviculocuneiform destruction. Ulceration and infection in patients with patterns (2) and (3) were rare. When correlated, the demographic features, mode of presentation, physical signs, specific radiographic abnormalities, and patterns of change were distinctive and allowed the diagnosis of this complication of diabetes to be readily made.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
10/11. Diabetic peripheral neuropathy: review of literature and case study.Diabetic peripheral neuropathy is a secondary manifestation of diabetes mellitus. The purpose of this review of literature and case study is to increase the clinical physical therapist's understanding of diabetic peripheral neuropathy.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
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