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This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytren's disease.

A retrospective case-control study was performed in New Orleans, Louisiana, in 1985-1986 to test the hypotheses that 1) criminality is a risk factor for severe injury, and 2) the association between criminality and injury can be explained in terms of a common underlying factor--increased sensation-seeking tendencies. A total of 140 males with spinal cord injury were individually matched with 140 driver's license holders on age, race, sex, educational attainment, and zip code of residence and were interviewed by telephone. Criminality prior to spinal cord injury was measured by self-report and police records, and sensation seeking was measured by the Disinhibition and Boredom Susceptibility subscales of Zuckerman's Sensation-Seeking Scale (Form V). Those with spinal cord injuries were significantly more likely than controls to report a history of juvenile delinquency, adult criminality, and incarceration prior to the time of spinal cord injury. Statistically significant but modest difference were also found between cases and controls with respect to Disinhibition, Boredom Susceptibility, and the combined Sensation-Seeking Scale score. Matched-pairs logistic regression analysis indicated that the association between sensation seeking and spinal cord injury remained significant after controlling for criminality, with an estimated relative risk of 2.05 (95% confidence interval 1.67-2.53). However, the association between criminality and spinal cord injury also remained significant after controlling for sensation seeking (estimated relative risk = 2.04, 95% confidence interval 1.09-3.82). On the basis of these results, criminality and sensation seeking may be statistically significant but independent predictors of spinal cord injury.

Although non-traumatic entrapment of the posterior interosseous nerve is very uncommon, one cause of this is synovitis of the elbow due to rheumatoid arthritis. Inability to extend the fingers at the metacarpophalangeal joints is the usual presenting feature, and the main differential diagnosis is extensor tendon rupture. Treatment with a corticosteriod injection of the elbow joint has a 43% success rate, whereas early surgical nerve decompression with or without synovectomy results in good or excellent nerve recovery in all cases reported, even in cases of failed joint injection. If treatment is delayed, resulting in chronic denervation, then tendon transfers are an option.

Suprascapular nerve entrapment is an uncommon but often under-recognized entity caused by a variety of mechanisms and injuries to the shoulder area. The case presented is of a patient with neuropathy after a bilateral hernia repair. This is a previously undocumented association not closely adhering to the usually proposed mechanisms of injury. These mechanisms and the diagnosis and treatment of suprascapular nerve compression are reviewed.

Marfan's syndrome is a hereditary disorder involving a deficit in connective tissue collagen. Physical findings include musculoskeletal, ocular, and cardiovascular abnormalities. A 29-year-old man with a history of Marfan's syndrome was admitted to the hospital with back and chest pain secondary to a dissecting aortic aneurysm. He later underwent surgical aortic bypass graft surgery. Postoperatively, he was paraplegic. Our impression was anterior spinal artery syndrome due to prolonged cross-clamping of the aorta during surgical repair. This paper shows the risk of paralysis resulting from surgical repair of an aortic aneurysm as a poorly documented complication of Marfan's syndrome.

Evidence is mounting that susceptibility to pressure ulcers in the spinal cord injured is due to the interactive effects of prolonged immobilization and injury-related autonomic dysfunction associated with reduced tissue perfusion. To determine whether tissue oxygenation at the sacrum is reduced in spinal cord injury, we compared transcutaneous oxygen tension (PtcO2) levels in 21 subjects with spinal cord injury and 11 able-bodied controls lying prone and supine on egg-crate mattresses. Spinal cord injured subjects above and below the median supine PtcO2 value were also compared in terms of the presence or absence of pressure ulcers. The PtcO2 level of the spinal cord injured (mean +/- SD) was lower than that of the controls in the prone position (65.3 +/- 16mmHg vs 76.4 +/- 13mmHg; F = 3.9, df = 1, p = .053), and markedly lower in the supine position (49.1 +/- 26mmHg versus 74.2 +/- 10mmHg; F = 9.7, df = 1, p = .004). Examination of mean PtcO2 levels over time showed that those of the controls fell slightly following supination but returned to the previous level within 15 minutes. In contrast, those of the spinal cord injured fell rapidly by 18mmHg and stabilized after 15 minutes at a level 27mmHg below that of the controls. Five of the 10 (50%) spinal cord injured subjects with PtcO2 levels below the median supine PtcO2 level had a pressure ulcer compared to one among the 11 (9%) spinal cord injured subjects with PtcO2 levels above the median (p = .055, by Fisher's exact test). These results suggest the need for further studies on the role of reduced tissue oxygenation in the etiology of pressure ulcers.

Evidence is mounting that spinal cord injured (SCI) persons may be at increased risk of pressure ulcers due to prolonged immobilization together with the injury-induced loss of sympathetic tone and decreased vascular resistance. With a view to developing a new method of preventing pressure ulcers, the objective of this study was to determine whether high voltage pulsed galvanic stimulation (HVPGS) could increase sacral transcutaneous oxygen tension (PtcO2) in SCI persons lying prone and supine. In experiment 1, HVPGS applied to the back at spinal level T6 led to a sustained, dose-related increase in sacral PtcO2 in 3 subjects lying prone. In experiment 2, carried out on 29 subjects lying supine on egg-crate mattresses, HVPGS (75 volts, 10 Hz) produced a 35% increase in sacral PtcO2, from a baseline level (Mean +/- SD) of 49 +/- 21 mmHg to 66 +/- 18 mmHg after 30 minutes of stimulation (F = 39.4, p < .00001). In experiment 3, simulated HVPGS was found to have no effect on sacral PtcO2 in 5 subjects lying supine. In experiment 4, HVPGS was repeated on 10 subjects and its effects found to be highly reproducible. It is hypothesized that HVPGS restores sympathetic tone and vascular resistance below the level of the spinal cord lesion, thereby increasing the perfusion pressure gradient in the capillary beds. Randomized controlled trials are now indicated to determine the efficacy of HVPGS for preventing pressure ulcers.

Pressure ulcers are notoriously common in spinal-cord-injured patients, in patients with other neurological deficits, in malnourished and severely debilitated patients, and in the frail elderly. Prolonged localized external pressure, coupled with insensitivity to ischemia resulting from neurologic injury, has long been considered the major causal factor. Preventive efforts have focused on the relief of pressure via frequent repositioning and the use of pressure-relieving devices. However, consensus is growing that host factors also play a role in the development of pressure ulcers, the most important in spinal-cord-injured patients being the injury-induced loss of vasomotor control below the level of the lesion, resulting in hypoxemia. Accordingly, pressure ulcers may be prevented not only by reducing external pressure but also by increasing the patient's resistance to pressure, that is, by directly influencing tissue oxygenation. Review of the literature suggests that electrical stimulation increases cutaneous blood flow and promotes the healing of pressure ulcers. Moreover, high-voltage pulsed galvanic stimulation (75 V, 10 Hz) applied to the back at spinal level T6 in spinal-cord-injured persons lying supine on egg-crate mattresses can raise sacral transcutaneous oxygen tension levels into the normal ranges (A. R. Mawson, F. H. Siddiqui, B. J. Connolly, C. J. Sharp, W. R. Summer, and J. J. Biundo, Jr., Paraplegia in press). Randomized controlled trials are needed to determine the efficacy of high-voltage pulsed galvanic stimulation for preventing pressure ulcers in spinal-cord-injured persons and other groups at high risk.

A 56-year-old man developed left shoulder pain three weeks after starting a cardiac rehabilitation program, which consisted of submaximal aerobic and progressive resistive exercises. Pain in the left shoulder intensified and weakness developed one week later. He sought medical attention ten weeks after the onset. Physical examination showed only weakness of left shoulder abduction and external rotation with mild atrophy of the left supraspinatus and infraspinatus muscles. Electrodiagnostic study showed fibrillation potentials and positive sharp waves in the left supraspinatus and infraspinatus muscles with delayed conduction to the supraspinatus. The left suprascapular notch was injected with local steroid. Within one week, improvement occurred, and one month later the patient was pain free and stronger. The motor latency returned to normal, and no fibrillations nor positive waves were seen. The patient returned to his previous functional level. Suprascapular neuropathy should be considered as a cause of shoulder pain and weakness in a person involved in any strengthening exercise program. A steroid injection of the suprascapular notch performed early may avoid the need for surgery.

A retrospective chart review was carried out on all spinal cord injured patients admitted to the Louisiana Rehabilitation Institute, Charity Hospital, between 1965 and 1984. In addition, former patients who could be contacted and who gave their informal consent were interviewed by telephone about the circumstances of their injury. The patients were most commonly male (86%) and black (53%); the average age at injury was 29, the most common diagnosis was complete paraplegia (44%); and the leading cause of injury was gunshot (or other penetrating) wounds (41%) followed by motor vehicle crashes (36%). These findings mirror the pattern of serious injury in Orleans Parish as a whole and point to firearms as a major health hazard in this community.

We carried out a prospective study to determine the association between immobilization in the immediate postinjury period and the development of pressure ulcers in spinal cord-injured patients following their admission to Charity Hospital, New Orleans. Of 39 patients consecutively admitted to the hospital, 23 (59%) developed a grade one ulcer within 30 days, mostly in the sacral region (57%), the peak time of onset being day 4 postinjury (6/23 cases). In partial support of an earlier retrospective study (Linares HA, Mawson AR, Suarez E, Biundo JJ Jr: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-573), duration of unrelieved pressure prior to ward admission was significantly associated with ulcers developing within the first eight days of injury (P = 0.04), but not with ulcers developing during the entire 30-day observation period (P = 0.09). Time on the spinal board was also significantly associated with ulcers developing within 8 days (P = 0.01), but not with ulcers developing within 30 days (P = 0.09). An unexpected finding was the significant inverse association between systolic blood pressure and the development of ulcers both within 8 days (P = 0.03) and within 30 days (P = 0.02), suggesting that reduced tissue perfusion increases the spinal cord-injured patient's susceptibility to pressure ulcers.

The technique of counterimmunoelectrophoresis (CIE) has been adapted for detection of serum precipitins to calf thymus (CT) DNA in patients with SLE, discoid LE, miscellaneous connective tissue and infectious diseases, and control populations. Of seventy-eight LE patients, 58% demonstrated anti-ss DNA precipitins, and 20% exhibited anti-ds DNA precipitins. Good correlation was noted between the presence of ss DNA precipitins and ss DNA binding values determined by the more sensitive ammonium sulphate precipitation assay. Depressed total serum haemolytic complement activity in CH50 mu/ml was noted in 64% of sera exhibiting ss DNA precipitins and 38% of those with negative ss DNA precipitins. There was a strong association, however, between ds DNA precipitins and depressed serum complement levels. Although less sensitive than primary binding assays, CIE can be used as a rapid and simple screening test for detection of circulating anti-native and denatured CT DNA precipitins. CT DNA serum precipitins are present in a significantly higher percentage of SLE patients when compared with other disease states and normal control populations.

Randomly selected sera from 88 patients with systemic lupus erythematosus (SLE) were studied for the frequency of antibodies to SS-A, SS-B, RANA, RNP, Sm, Sc-1, and dsDNA. Results were in agreement with previous reports except for an increased incidence of anti-SS-A antibody (33%). Nine of 14 patients with anti-SS-A antibody on whom serial studies were performed had fluctuating titers. Titer changes often correlated with disease activity and dsDNA antibody levels.

The role of avidity in the pathogenicity of double-stranded DNA/anti-double-stranded DNA immune complexes in systemic lupus erythematosus (SLE) has been controversial. We used polyethylene glycol to identify low avidity antibodies and the standard Farr assay to detect high avidity antibodies against double-stranded DNA in a longitudinal study of sera from 19 patients with SLE. We found that high and low avidity antibodies to double-stranded DNA did not move independently, but instead, rose and fell in a parallel and relatively fixed manner in these patients. The mechanisms responsible for the changes in titer of anti-double-stranded DNA antibody appeared nondiscriminatory in regard to avidity. In addition, the humoral immune response in SLE depicted by these antibody measurements appeared atypical, lacking maturational features.

Evidence is presented that Felty's syndrome (FS) is rare among black patients with rheumatoid arthritis (RA). All of 12 patients with FS seen at Parkland Memorial Hospital, Dallas, Texas betwen 1964 and 1978 were white. During this period 52% of patients admitted to the Parkland medical service were black and 31% of patients dischargd with a diagnosis of RA were black. The number of expected black cases of FS on the basis of the racial distribution of hospitalized patients with RA was 3.7 (P is less than 0.02 when the zero incidence in blacks was compared with the expected incidence). All 7 cases of FS observed at Charity Hospital, New Orleans, Louisiana between 1968 and 1978 were also white. During this period, 65% of patients discharged with a diagnosis of RA were black, and the number of expected black cases of FS was 4.5 (P is less than 0.001). These findings suggest a genetic basis for the development of leukopenia and splenomegaly in RA patients.

Two patients, one a 14-year-old girl and the other a 20-year-old man, with typical manifestations of juvenile rheumatoid arthritis had leukopenia and thrombocytopenia, two heretofore unreported findings. The presence of leukopenia should not be used to exclude a diagnosis of Still's disease.

To study the association between actual and claimed belt usage, to determine drivers' attitudes toward seatbelts, and to identify some of the factors associated with the use and nonuse of seatbelts, we administered a one-page questionnaire to 1,103 drivers attending their annual brake tag inspection in New Orleans, Louisiana. Actual belt use was unobtrusively recorded at the same time. Fifty-one per cent of drivers stated that they wore seatbelts always or most of the time, 52% agreed that seatbelts should be worn, and 28% favored mandatory seatbelt use. Yet only 5.4% of drivers were actually observed wearing seatbelts. Drivers who had experienced a previous auto injury that required a doctor's visit were 1.7 times as likely to be wearing seatbelts as those without prior injury, yet only 8% of the injured were wearing them. The results of the survey are discussed in relation to the discrepancy between attitudes towards seatbelts and observed seatbelt use.

A retrospective case-control study was carried out to determine whether sensation-seeking preferences were associated with spinal cord injury (SCI). One hundred forty male SCI patients were individually matched by age, race, gender, educational attainment at the time of SCI, and current zip code with 140 current Louisiana driver's license holders. Participants were interviewed by telephone. Sensation-seeking was assessed by the Disinhibition (Dis) and Boredom Susceptibility (BS) subscales of Zuckerman's Sensation-Seeking Scale (SSS, Form V). Although an earlier study found no difference on the SSS between a group of SCI patients and published norms, modest but statistically significant differences were found between SCI subjects and control subjects with respect to both subscales and the combined SSS score. The mean difference on the latter was 1.6 units on a scale of 0-20 (t = 4.11, p = .0001). Compared to patients scoring below the tenth percentile on the SSS, those scoring above the 90th percentile were significantly younger at the time of SCI, more likely to report an arrest before their SCI, and more likely to be using drugs or alcohol at the time of SCI.

In the management of rheumatic diseases, the use of corticosteroids should be reserved for active arthritis. Phenylbutazone (Butazolidin) is probably the drug of choice for acute gout and is also effective in ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. Indomethacin (Indocin) also is useful in these conditions. Ibuprofen (Motrin) is only slightly more efficacious than aspirin. Aspirin is still the preferred treatment for rheumatoid arthritis and should be tried before ibuprofen. Osteoarthritis of the cervical or lumbar spine calls for a full program of physical therapy. Experimental procedures for total replacement of joints other than hip and knee show promise.

In a case of rheumatic disease, the patient's history and a careful physical examination should yield most of the information needed to identify the specific disorder present. A convenient classification is based on four differentiating features: number of joints affected, acuteness or chronicity of disease, absence of joint involvement, and anatomic distribution.

Alpha 1-antitrypsin is a glycoprotein that functions as the major protease inhibitor in human serum. Many genetic variants of alpha 1-antitrypsin can be detected by electrophoretic techniques. We used isoelectric focusing on ultrathin gels to determine the common M subtypes as well as other variants of alpha 1-antitrypsin in 62 white patients with rheumatoid arthritis (RA) and 51 white patients with systemic sclerosis (SSc). We found no increased prevalence of variant phenotypes in either disease group as a whole. In RA, however, the association between pulmonary interstitial fibrosis and alpha 1-antitrypsin variants was striking. Interstitial fibrosis was seen on chest roentgenogram in only 1 of 30 subjects apparently homozygous for M1 (the "wild type" or "normal" phenotype), compared with 13 of 32 patients with variant phenotypes. Seven of 15 patients with M1M2 (the most common variant phenotype) had pulmonary fibrosis. In contrast, there was no apparent association of variant phenotypes with pulmonary involvement in SSc. Our findings suggest a possible role of alpha 1-antitrypsin in the pathogenesis of interstitial fibrosis in patients with RA. The absence of such an association in SSc suggests that pulmonary involvement in these 2 rheumatic diseases may have different pathogeneses.

Two black male patients with aortic insufficiency were later found to have mild, asymptomatic ankylosing spondylitis, evident from roentgenograms and from the presence of HLA-B27 antigen. The two cases emphasize the even "subclinical" ankylosing spondylitis may have aortic insufficiency, and that the uncommon occurrence of ankylosing spondylitis in black patients may also be associated with this extra-articular manifestation.

The characteristics of 100 patients with anti-SSA(Ro) antibody were studied. By accepted criteria 34 patients had systemic lupus erythematosus, 25 had other known connective tissue diseases (CTD) and 9 had no significant evidence of a CTD. Thirty-two patients had an unclassified CTD characterized in most instances by arthritis, dermatitis, and a positive fluorescent antinuclear antibody test. The results support the concept of a continuous spectrum of autoimmune disease in which anti-SSA(Ro) antibody may be a marker and in which a variety of disorders may be found that cannot be classified by accepted criteria.