Therapeutic uses of humor

This paper examines psychological aspects of humor, leading into a review of the role of humor in psychotherapy. Constructive and destructive aspects of humor in psychotherapy are listed and brief clinical examples from a case given.     

Mortality and complications of the locked-in syndrome

The locked-in syndrome is a severe disability consisting of quadriplegia and anarthria with preserved consciousness. No large series of cases have been reported and very few cases of long-term survival have been described. We present a follow-up of 27 patients "locked-in" for more than one year. Twenty-four were still alive up to 12.5 years after onset, with a mean survival of 4.9 years. Significant recovery was noted in only a few patients. Seventeen patients lived at home at the time of study. Eight were never hospitalized after the initial event. Gastrostomy and tracheostomy tubes and indwelling catheters were eventually removed from many patients. Electronic devices were used by ten patients to facilitate communication. We conclude that rehabilitation and medical care must be planned carefully, given the length of survival shown in this group.     

The accuracy of needle placement in lower-limb muscles: a blinded study

OBJECTIVE: To assess the accuracy of common anatomic guides for electromyographic needle placement in muscles. DESIGN: Blinded study. The dissector identified different needle placements by a random number attached to a wire in the insertion site. SETTING: A university anatomy laboratory. CADAVERS: Ten cadaver lower limbs. INTERVENTIONS: By using techniques published in texts by Gieringer and Delagi and Perotto, clinical electromyographers palpated and measured appropriate locations for needle placement. A thin wire was inserted through the needle into 36 different muscles in 10 cadavers, resulting in 263 targeted muscles. An anatomist blinded to intended location dissected and recorded muscles and other tissues that the wire pierced or passed near. MAIN OUTCOME MEASURES: Targeted muscle penetration, final resting place of the wire tip, and proximity to vital structures. RESULTS: Fifty-seven percent of insertions penetrated the intended muscle. The wire tip was in the intended muscle 45% of the time. Seventeen percent of insertions penetrated or passed within 5mm of an important structure, including nerve (9.1%), tendon (3.0%), named artery (2.7%), vein (2.7%), or joint (0.8%). Specific muscle accuracy was highly variable, from 0% for 12 tries in various deep hip muscles to 100% of 10 tries in the vastus medialis. CONCLUSION: The accuracy of blind needle placement varied according to muscle. With the blind insertion technique, more accurate and safe needle placement strategies can be developed.     

Comparing pain severity and functional status of older adults without spinal symptoms, with lumbar spinal stenosis, and with axial low back pain

BACKGROUND: Functional status has been quantified in the adult low back pain (LBP) population, but has not been characterized for older adults with spinal symptoms. OBJECTIVES: To compare pain severity and functional status of older adults with and without spinal symptoms, and to determine what factors are associated with quality of life in the spinal stenosis and axial LBP groups. METHODS: In 24 subjects greater than 55-years old with lumbar spinal stenosis, 12 with LBP, and 12 without spinal symptoms, obtain the following: pain severity with 10-cm visual analog scale (VAS), 15-minute walk test, 7-day walking distance, Quebec Back Pain Disability Scale (QBPDS), and Pain Disability Index (PDI). RESULTS: The mean scores were worst for the stenosis group, were intermediate for the LBP group, and were the best for the asymptomatic group. Analysis of variance showed that the pain VAS (p < 0.001), 15-minute walk test (p = 0.01), 7-day walk (p = 0.02), QBPDS (p < 0.001), and PDI (p < 0.001) were different between at least two groups. All the variables in the stenosis group were worse than in the asymptomatic group, but only the pain VAS, QBPDS, and PDI in the LBP group were worse than in the asymptomatic group. In both the stenosis and LBP group the QBPDS and PDI were only related to pain VAS. CONCLUSION: Seniors with spinal stenosis and LBP have more disability than asymptomatic seniors. The 15-minute walking test with the stenosis group was slower than with the asymptomatic seniors. However, they compensate so that their 7-day walking distance is not as significantly decreased.     

Orchestrating development and function: retrograde BMP signaling in the Drosophila nervous system

Recent work has shown that bone morphogenetic protein (BMP) growth factors regulate development of the larval neuromuscular junction (NMJ) of Drosophila. Intriguingly, the same BMP growth factors also influence the expression of circulating hormones that modulate the physiological properties of NMJs. Together, the results suggest that retrograde growth factor signaling by BMPs integrates neuromuscular development and function at both local and global levels in the animal.     

The value of electrodiagnostic consultation for patients with upper extremity nerve complaints: a prospective comparison with the history and physical examination.

OBJECTIVES: To determine whether electrodiagnostic testing changes diagnostic certainty compared with a detailed history and physical examination, and whether interactions between medical information, the extent of testing, and diagnostic certainty imply a need for advanced medical knowledge on the part of the tester. DESIGN: Prospective observation. SETTING: University orthopedic department and small community hospital electrodiagnostic laboratories. PATIENTS: Two hundred fifty-five consecutive referrals for upper extremity nerve complaints. OUTCOME MEASURES: Diagnosis, diagnostic confidence, and severity of neurologic lesion were coded after standardized history and physical and after electrodiagnostic testing. RESULTS: Electrodiagnostic testing substantially altered 42% of diagnoses, confirmed 37%, and did not clarify 21%. The extent of testing correlated with the size of the differential diagnosis, the number of previous hospitalizations, and the number of other medical problems. Confidence in final diagnoses correlated positively with severity of the lesion, but negatively with the size of the differential diagnosis and the number of painful body areas. Hospitalizations and medical problems also tended towards negative correlations. CONCLUSIONS: This study, in which all electrodiagnostics, histories, and physical examinations were performed by a single physician, suggests that electrodiagnosis substantially alters clinical impressions in a large percentage of patients. The complex relationship between clinical information, the extent of testing, and final diagnostic certainty suggests that specialized medical knowledge is required for accurate electrodiagnosis.     

Multidisciplinary team evaluation of upper extremity injuries in a single visit: the UPPER Program.

Musculoskeletal disorders are the leading cause of disability among people between 18 and 64 years of age. Patients with musculoskeletal injuries of the upper extremities are usually evaluated and treated by an individual physician and therapist. However, for patients who have problems, especially after being treated by a hand surgeon and a certified hand therapist, there are few other management options. A multidisciplinary assessment program for patients with chronic upper limb pain has not been described in the literature. As part of The University of Michigan RERC (Rehabilitation Engineering Research Center), the UPPER Program (UPper extremity Protocol Evaluation in Rehabilitation) was developed to evaluate patients who have disabling upper limb musculoskeletal disorders. At the center of the program is a multidisciplinary team composed of a physiatrist (physical medicine and rehabilitation specialist), occupational therapist, physical therapist, exercise physiologist, vocational counselor and pain psychologist. The UPPER Program elements include a pre-evaluation questionnaire, individual team member assessments and a team meeting. It is followed by a patient appointment with the team physician to review the results and recommendations. The essential details of the program are presented in this article so it can be reproduced elsewhere.