Journal of Back and Musculoskeletal Rehabilitation - Volume 3, issue 2
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Journal of Back and Musculoskeletal Rehabilitation is a journal whose main focus is to present relevant information about the interdisciplinary approach to musculoskeletal rehabilitation for clinicians who treat patients with back and musculoskeletal pain complaints. It will provide readers with both 1) a general fund of knowledge on the assessment and management of specific problems and 2) new information considered to be state-of-the-art in the field. The intended audience is multidisciplinary as well as multi-specialty.
In each issue clinicians can find information which they can use in their patient setting the very next day. Manuscripts are provided from a range of health care providers including those in physical medicine, orthopedic surgery, rheumatology, neurosurgery, physical therapy, radiology, osteopathy, chiropractic and nursing on topics ranging from chronic pain to sports medicine. Diagnostic decision trees and treatment algorithms are encouraged in each manuscript. Controversial topics are discussed in commentaries and rebuttals. Associated areas such as medical-legal, worker's compensation and practice guidelines are included.
The journal publishes original research papers, review articles, programme descriptions and cast studies. Letters to the editors, commentaries, and editorials are also welcomed. Manuscripts are peer reviewed. Constructive critiques are given to each author. Suggestions for thematic issues and proposed manuscripts are welcomed.
Abstract: A variety of complications associated with cancer may adversely affect the spine and musculoskeletal system, resulting in physical impairment, pain, or both. Dysfunction may arise because of tissue injury at the primary site of disease; from metastatic lesions and paraneoplastic syndromes; or as the result of treatment and bed rest. This study evaluated 50 patients seen in consultation by the Rehabilitation Service at Memorial Sloan-Kettering Cancer Center (28 retrospective, 22 prospective). Patients were evaluated for functional problems resulting from their disease or therapy. Patients were noted to have an average of 1.74 physical impairments. Thirteen (26%) patients had only one…identifiable problem adversely affecting function. Fifty-four percent of patients were found to have two physical impairments. Ten patients (20%) had three or more such abnormalities. The mean Karnofsky score, a measure commonly used in assessing cancer patient function, at initial evaluation was 46.6 (standard deviation (SD) 12.05). The most frequently encountered problem limiting function was deconditioning (56%); 36% of patients had central nervous system dysfunction; 28% had peripheral neurologic disease; 22% of patients were found to have bone metastasis. Additionally, pain was present in 44% of all patients. These results suggest that it is common for cancer patients who are referred for physiatric evaluation to have more than one functional problem, and that deconditioning, neurological, and skeletal abnormalities are common causes of impairment in cancer patients. Cancer is a significant cause of morbidity and mortality in the United States.1 It is a disease process which is inherently destructive, both at the primary site as well as areas to which it may spread. Additionally, remote effects of cancer, such as paraneoplastic syndromes, may result in further compromise of the patient. Antineoplastic therapies such as chemotherapy, radiotherapy, and surgery are also potentially injurious to native tissues and organ systems. The deleterious effects of these direct and indirect consequences of cancer, whether affecting the musculoskeletal, nervous, cardiovascular, or pulmonary systems, may result in functional impairment and disability. Therefore, it is not surprising to find a high prevalence of disabilities among cancer patients.2,3 Significant functional impairment has been noted by previous authors.2,3 A variety of organ systems may be either primarily or secondarily involved, including the spine and musculoskeletal systems. These authors have demonstrated a high prevalence of functional deficits in cancer patients. Additionally, they noted that the majority of cancer patients with disabilities can be successfully treated by physical medicine intervention. The principal impediments preventing patients from obtaining optimal rehabilitation, as determined by these authors were: primary care physicians' inability to recognize functional impairment; and a lack of understanding by these same physicians in rehabilitation principles.2 The scope of musculoskeletal and neurological impairments, as well as the number of functionally compromising problems faced by the individual patient is less well known. The object of this survey was to evaluate a series of cancer patients, seen in consultation by a rehabilitation medicine service, for musculoskeletal, neurologic, and other relevant impairments.
Abstract: Chronic pain is experienced by approximately one-third of all cancer patients and as many as 70 to 90% of those with advanced disease.1 Although established pharmacotherapeutic strategies have been demonstrated to benefit most patients, undertreatment remains common.1 This unacceptable situation must be remedied; relief of cancer pain is an ethical imperative and it is incumbent upon clinicians to maximize the knowledge, skill, and diligence needed to attend to this task.2 Analgesic pharmacotherapy is the mainstay approach in the management of cancer pain.3,4 Optimal therapy depends on an understanding of the clinical pharmacology of analgesic drugs…and comprehensive assessment of the pain, medical condition, and psychosocial status of the patient. Through a process of repeated evaluations, therapy with opioid, nonopioid, and adjuvant analgesics is individualized to achieve and maintain a favorable balance between pain relief and adverse effects. An expert committee convened by the Cancer Unit of the World Health Organization has proposed a useful approach to drug selection for cancer pain, which has become known as the “analgesic ladder” (Fig. 1).3 When combined with appropriate dosing guidelines, this approach is capable of providing adequate relief to 70 to 90% of patients.5–9 Emphasizing that the intensity of pain, rather than its specific etiology, should be the prime consideration in analgesic selection, the approach advocates the following three basic steps: Step 1. Patients with mild to moderate cancer-related pain should be treated with a nonopioid analgesic, which should be combined with an adjuvant analgesic if a specific indication for one exists. Step 2. Patients who are relatively nontolerant and present with moderate to severe pain, or who tail to achieve adequate relief after a trial of a nonopioid analgesic, should be treated with a socalled “weak” opioid; this drug is typically combined with a nonopioid and may be coadministered with an adjuvant analgesic or other adjuvant drug, if there is an indication for one. Step 3. Patients who present with severe pain, or fail to achieve adequate relief following appropriate administration of drugs on the second rung of the analgesic ladder, should receive a so-called strong opioid, which may be combined with a nonopioid analgesic or an adjuvant drug as indicated.
Abstract: This article outlines the principles of pathologic fracture management and highlights the clinical features that predict impending fracture so that the nonsurgeon can recognize how to integrate orthopedic management into the overall treatment plan for patients with metastatic disease to bone. With the possible exception of carcinoma of the breast, there is little evidence that any treatment increases survival of patients with metastatic carcinoma. However, advances in chemotherapy, radiation therapy, and surgery have undoubtedly increased the quality of life in these patients and has kept them active for longer periods of time. Judicious surgical and physiatric management is needed…to optimize care.
Keywords: Pathologic fracture management, metastases to bone
Abstract: Traditionally, the regions of brachial and lumbosacral plexi have been difficult to evaluate, both by physical examination and conventional radiography. Presenting symptoms of plexus involvement may include pain, paresthesia, focal weakness, sensory deficits, and muscle atrophy. The symptomatology as well as electrodiagnostic studies are nonspecific and many conditions, such as mechanical compromise of the pathway by a benign process, inflammation, and infiltration by a neoplasm originating or metastatic to the region of plexi share similar features and cannot be differentiated. A general term “brachial or lumbosacral plexopathy” is universally used, to describe a variety of clinical syndromes, including tumor infiltration,…neuritis, postsurgical, and postradiation changes as well as idiopathic conditions. Significant progress in detection and assessment of the extent of plexus disease has been made after introduction of computed tomography (CT). Further anatomical detail and tissue characteristics have been provided by magnetic resonance imaging (MRI). However, in spite of valuable contribution from both imaging methods, the plexi frequently present a challenging problem for a clinician as well as for a radiologist.
Abstract: Back pain is a common symptom in the cancer population. For some patients, the complaint reflects a process independent of the underlying disease, such as myofascial pain, discogenic disease, or osteoporosis. Many patients, however, experience pain as the first indication of a spinal neoplasm, and this possibility increases the diagnostic challenge. This article discusses the presentation, evaluation, and treatment of spinal epidural neoplasm in patients with cancer. Symptomatic epidural neoplasm occurs in approximately 5 to 10% of patients with metastatic cancer.1–4 Without effective treatment, the tumor enlarges within the closed intraspinal space and ultimately damages the spinal cord…or nerve roots, either through direct compression or interruption of local blood supply. The consequences—weakness, sensory loss, and sphincteric dysfunction—often have a devastating impact on the patient's ability to cope with the physical, psychosocial, and financial burdens of the disease and its treatment. The prognosis for continued ambulation following presentation of epidural disease (ED) is influenced by numerous factors, among which are the radiosensitivity of the neoplasm, location of the lesion, extent of myelographic block, and tempo of neurological dysfunction.5–15 From the clinical perspective, the most salient factor is the degree of neurological impairment at the onset of treatment:3,5,10,14–18 Ambulation following treatment is retained by approximately 75% of patients who are ambulatory at the time therapy is given; 30 to 50% regain the ability to walk if treatment is given when the patient is severely paretic but not plegic, and only 10% of patients who begin treatment while paraplegic subsequently walk. These data suggest that prevention of neurological compromise is possible if ED can be identified and treated early, before ambulation is lost. Early treatment, in turn, can only be accomplished if clinicians are able to recognize the population at risk through knowledge of those clinical indicators—symptoms or signs—that suggest the existence of ED before it declares itself through progressive paraparesis. Back pain is the most important of these clinical indicators, since pain is the first symptom in up to 95% of cancer patients who develop ED (Table 1) and often precedes the development of neurological deficits by many weeks or months.1,5,13,19,20 The discovery and treatment of ED when back pain is the only symptom would yield great improvements in the overall prognosis of this population. This observation has been the impetus for the development of algorithms that guide the evaluation of cancer patients with back pain,13,14,21,22 as described below.
Keywords: Back pain, epidural disease, sphincteric dysfunction
Abstract: The role of the rehabilitation team in the management of the cancer patient with pain is not well understood by either oncologists or physiatrists. Readily available analgesic interventions at the rehabilitationist's disposal may be easily employed in this population as part of a multi modality and interdisciplinary approach to pain. This article describes the role of the rehabilitation team and highlights techniques which are appropriate for cancer pain management. Benefits realized in addition to analgesia from physiatric intervention are also described. Cancer, in all its varieties, is inherently destructive and thereby, a potentially disabling process.1,2 Typical examples of…the deleterious physical consequences associated with cancer include primary and metastatic disease of the bone and brain, epidural spinal cord compression, and invasion or compression of nerves by malignant spread. Options available for the treatment of cancer, including radical surgery, cytotoxic chemotherapy, and radiotherapy, administered individually or in combination, are also noxious to native tissues. Therefore, antineoplastic therapies may also lead to, or exacerbate, physical impairments. Examples include surgical amputation of a limb, chemotherapy induced peripheral neuropathy, and radiation osteonecrosis. Pain is one of the most common causes of disability in the cancer population.3,4 Thirty to 50% of all cancer patients suffer pain, and 70 to 90% of terminal patients have pain. Pain contributing to functional impairment has been noted in 44% of patients seen on a cancer rehabilitation service.5 The World Health Organization has developed clear guidelines for the assessment and recommended treatment of cancer pain.6 Pharmacologic and anesthetic interventions, as well as ablative and electro-stimulatory neurosurgical procedures, provide significant pain relief in the majority of cancer patients.7 These techniques, employed by a cogent multidisciplinary team including supportive and palliative care specialists, psychiatric liaison, and rehabilitation professionals may be the most efficacious approach in optimizing pain relief for this population.8–11 This article will review options available to the physiatrist for the treatment of cancer pain and related disabilities.
Keywords: Analgesia, metastases, cancer pain, physiatric intervention, orthotics, modalities
Abstract: As time goes on, so do the advancements in medical treatment. Today we are faced with a population of cancer patients living longer and developing unique problems as a consequence of both treatment and progression of disease. The physiatrist is in a unique position to enhance independence and quality of life of cancer patients. Often this is simply a matter of applying well-established physiatric principles to a unique population. However, few physiatrists in clinical practice have the opportunity to treat large numbers of cancer patients, especially in an acute care setting. Experience is key for optimal physiatric management of the…cancer patient. The purpose of this article is to familiarize physicians and therapists with evaluation and subsequent application of rehabilitation principles to cancer patients. It is beyond the scope of this manuscript to discuss all the specifics of the cancer patient's rehabilitation; however, references are available.1–4 Functional deficits in the cancer patient can arise from disease progression as well as its treatment. The scope of complications include: osseous disease, myelosuppression, multiple manifestations of neurological deficit, deconditioning, pain syndromes, lymphedema, gait abnormalities, amputation, cardiopulmonary complications, psychiatric issues, and others. A survey of 50 rehabilitation consultations seen over a 6-month period reveals the diversity of problems (see Table 1). Although a small sample, it correlates with our experience. Of note, many patients had more than one disability, as illustrated in Table 2.