Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for the polytrauma rehabilitation.

Problem: Chronic pain conditions are common sequelae of traumatic brain injury (TBI). Unfortunately, the incidence of TBI among personnel deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) is significant, and there is growing evidence that ongoing pain, particularly headaches, will be a primary concern for these individuals. Objective: This article synthesizes empirical data from civilian and veteran populations and clinical experience with OEF/OIF personnel with polytrauma to provide recommendations for the assessment and treatment of chronic pain among those with TBI. Conclusions: The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions. A proposed model of treatment is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Head injury rehabilitation: Psychological issues and roles for the rehabilitation psychologist.

Points out that rehabilitation psychologists are critical members of the health care team in the provision of diagnostic, remediational, and consultative services to the victims of head injury, family members, and relevant social welfare and 3rd-party payers. The present authors consider the roles of the rehabilitation psychologist when the head-injured are involved in the legal process, including consulting with attorneys, serving as an expert witness, and acting as an advocate for clients. Case illustrations are provided of additional psycholegal issues, such as the use of psychological data as evidence, eligibility criteria for various programs, and the need for the psychologist to act as a liaison with educational and vocational systems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of nerve recovery from minimal-duration crush injury

The recovery of damaged peripheral nerves has been the subject of multiple studies. The effects of an inadvertent clamping of a nerve has not been well examined. An experiment was performed to evaluate the effects of a minimal-duration crush injury on the rat sciatic nerve and to determine if walking track analysis was useful in evaluating the short-term functional deficit. Ten Sprague-Dawley rats underwent high-pressure, short-duration crush injuries. Walking track analysis was done regularly for 3 weeks. Histological specimens for light and electron microscopy were taken at postoperative days 3, 7, 14, 21, and 42 from similar animals. There was significant decrease in function by the second week, which then improved to control levels after week 3. Toluidine blue and electron microscopic findings confirmed the clinical course, while routine histological findings tended to lag behind the return of function. Walking track analysis appears to be an effective method of evaluating the short-duration nerve crush injury.     

Evaluation of nutritional status in persons with spinal cord injury: a prerequisite for successful rehabilitation

A minority of patients with acute pulmonary embolism (PE) show failure of resolution when assessed by serial ventilation/perfusion (V/Q) radionuclide lung imaging. The fibrinolytic systems were studied in six such patients (group I), and in 11 patients in whom PE had resolved (group II), together with 17 healthy control subjects. Assays of the fibrinolytic system included euglobulin clot lysis times (ECLT), tissue plasminogen activator (tPA), and plasminogen activator inhibitor-1 (PAI-1). Euglobulin clot lysis times were not prolonged in the unresolved PE group, but were significantly longer in patients in group II when compared to control subjects (P < 0.03). This could not be explained either on the basis of tPA levels, which were higher in group II when compared to group I (P < 0.05) and control subjects (P < 0.02), or on the basis of PAI-1 levels which did not differ significantly between the three groups. Our inability to demonstrate derangements of fibrinolysis in the patients with unresolved PE makes defective fibrinolysis an unlikely aetiological factor in the persistence of thrombosis in these patients.     

Cognitive aspects of pain and pain control

The cognitive and cognitive-behavioral approaches have been shown to be very effective in controlling pain and its sequelae both in the laboratory and in the clinical setting. As used in most research and treatment, cognitive approaches are concerned with the way the person perceives, interprets, and relates to his or her pain rather than with the elimination of the pain per se. This article reviews some of the origins of cognitive theory and pain theory, as well as examples of the techniques used and the research support for the approach. Special emphasis is given to self-efficacy, perceived control, and stress inoculation therapy. There is also discussion of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.     

周围性面神经断裂伤的外科治疗

目的:评估周围性面神经断裂损伤患者手术治疗后的效果,分析影响预后的相关因素.方法:自1999年至2009年因周围性面神经断裂在我院接受手术修复的患者104例,男75例,女29例,年龄2～77岁,中位年龄30岁.单纯面神经吻合术72例,随访至最终恢复的65例(90.2%).自体神经移植术32例,随访至最终恢复的24例(75.0%).面神经功能评价采用了整体及分区House-Brackmann(HB)评价方法,以卡方检验或Fisher确切概率法进行统计分析.结果:单纯面神经吻合术后总体恢复程度为HB Ⅰ级者37例(56.9%),Ⅱ级者11例(16.9%),Ⅲ级者15例(23.1%),Ⅳ级者2例(3.1%);各分区恢复至HB Ⅰ、Ⅱ级的比例分别为:眼部97.6%、面中部97.9%、口角78.6%、额部27.3%(P<0.001).自体神经移植术后总体恢复程度为HB Ⅰ级者4例(16.7%),Ⅱ级者5例(20.8%),Ⅲ级者7例(29.2%),Ⅳ级者8例(33.3%);各分区恢复程度达HB Ⅰ、Ⅱ级的分别为:眼部73.7%、面中部72.7%、口角44.4%、额部37.5%.神经吻合术后面神经功能恢复程度优于自体神经移植术(P=0.002).结论:面神经吻合术和自体神经移植是修复周嗣性面神经断裂损伤的有效方法;面神经受损分支、损伤范围、手术修复距离损伤的时间和患者年龄均对手术预后有所影响.     

Psychological services in rehabilitation medicine: Clinical aspects of rehabilitation psychology.

Reviews the role of the psychologist in a rehabilitation medicine setting, with emphasis on the application of traditional clinical and counseling skills to psychological problems encountered by the physically disabled. Briefly reviewed are the rehabilitation perspective, issues of adaptation and personality, psychodiagnostic and psychotherapeutic consultation, and behavioral principles. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of stress inoculation training on athletes' postsurgical pain and rehabilitation after orthopedic injury.

The efficacy of a cognitive-behavioral intervention ( stress inoculation training; SIT ) for postsurgical anxiety, pain, and physical rehabilitation in injured athletes was tested. Sixty male athletes who underwent arthroscopic surgery for miniscus injury in 1 knee were randomly assigned to either treatment (SIT and physical therapy) or control (physical therapy only) conditions. Results showed that participants in the treatment group demonstrated significantly less postsurgical pain and anxiety during the rehabilitation process, compared with controls. Additionally, treated participants required fewer days to return to criterion physical functioning, compared with nontreated participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of iatrogenic accessory nerve injury in forensic medical practice

The authors give a survey of the clinical and medical-legal characteristics of the accessory nerve injury. In the past two decades the conception of the successfulness of the surgical treatment of the accessory nerve injury became prevailing. About the medical-legal aspects of the iatrogenic injury of the nerve reported in connection of the reconstructive surgery chiefly also departments of neurosurgery, orthopedics and traumatology. In the case of the authors a 70 year old patient suffered 10 years ago a iatrogenic accessory nerve injury. The mild trapezius palsy recovered spontaneously practically with cosmetic disadvantage. In connection with the development of extreme dorso-lumbal scoliosis associated with torsion the trapezius atrophy worsened. Physical therapy was partly successful. But the patient became unfit for manual work. Their observations sustain the data of authors who established that in the case of accessory nerve injury not only the surgical but also conservative treatment is usually successful. In opposite to certain data of the literature the authors establish that the iatrogenic injuries of the accessory nerve may lead to significant lifelong disability. The diagnosis is not always made in time with consequent delay in repair. This may be regarded as an unfavorable issue during medical-legal discussions. The authors recommend in interest to prevent nerve injury in the posterior triangle of the neck to perform operation in special department.     

Tourniquet pain: anatomic-physiological notes and clinical aspects

OBJECTIVES: The mechanism of tourniquet pain is quite complex. This paper, supported by the previous literature on this topic, tries to explain why the anaesthetic blockade of a limb, even when thechnically successful, not always prevents the occurrence of this pain. DATA SOURCES: Papers published between 1990 and 1995, listed on Index Medicus, with pertinent references. STUDY SELECTION: Reports dealing with physiological basis of tourniquet pain. CONCLUSIONS: Tourniquet pain is nociceptive, generated not only by activation of peripheral nociceptors, but also by direct axonal stimulation of nervous trunks. Is is hardly to tolerated by patients since ischemia and mechanical compression induce an activation of C fibres, resistent to ischemia. A beta fibres are involved as well, due to the activation of low-threshold mechanoceptors.     

Neuropsychological aspects of the rehabilitation of patients with paralysis from a spinal injury who also have a brain injury

In order to examine the rehabilitation process of patients suffering from a severe spinal cord injury and who also have a cerebral injury, 322 patients with paralysis from a spinal injury were subjected to neuro-psychiatric and neuro-psychological examinations. On average 20.2% of these patients showed an associated cerebral lesion. The psychological results of such cerebral lesions are summarized under the concept of the co-called organic psychic syndrome (OPS). In 27.7% of these patients no organic psychic syndrome resulted, and in these patients a conventional paralysis rehabilitation could be carried out. 41.6% showed very minor to moderate injuries, with 30.7% being severely disabled from the cerebral injury. Rehabilitation for these patients was modified, using new therapeutic approaches, and also traditional therapeutic methods adapted to the abilities and needs of this patient group. In 25.5% of the patients there was no substantial improvement during the treatment period of initial rehabilitation (x = 12.5 weeks for the treatment of cerebral injury); but in 36.2% of the patients there was substantial improvement and in 38.3% full remission of organic psychic disorders occurred. Improvements in this sphere have a direct bearing on the rehabilitation capacity of this patient group.     

Electrical stimulation of the trigeminal nerve root for the treatment of chronic facial pain

BACKGROUND: Alterations of the p53 gene are involved in the development of diverse human malignancies, but their incidence and clinicopathologic features are still not well characterized for endometrial carcinoma. METHODS: To investigate the clinicopathologic significance of p53, mutations and loss of heterozygosity (LOH) in endometrial carcinoma in 92 patients with this disease were examined. RESULTS: Mutations of p53 were detected in 20 (22%) of the 92 patients with carcinoma, and LOH was detected in 23 (32%) of the 72 patients in whom heterozygosity of the gene was available. There was a significant correlation between the occurrence of mutation and LOH. Mutations and LOH were more frequent in patients with Grade 3 tumors than in those with Grades 1 and 2 tumors (P = 0.0498, P = 0.0051, respectively). Patients with LOH had a poorer postoperative survival than those without LOH (P = 0.0022, log-rank test), and patients with both LOH and mutation showed the worst prognosis (P < 0.0001, log rank test). Loss of heterozygosity of the p53 gene showed a significant relation to prognosis that was independent of tumor stage, histologic grade, and muscular invasion. CONCLUSIONS: Mutation and LOH of the p53 gene are prognostic indicators in patients with endometrial carcinoma, suggesting that alterations of p53 may play an important role in the development of this cancer.     

The facial nerve. Current trends in diagnosis, treatment, and rehabilitation

Facial paralysis is a potentially devastating disorder with numerous implications. Multiple entities must be considered in its etiology, and recent advances in microbiology, radiographic imaging, electrodiagnostic testing, and microsurgery have provided great insight into the pathophysiology, diagnosis, treatment, and rehabilitation of the facial nerve. Recent DNA PCR testing has shed new insight into the potential cause for Bell's palsy. This article focuses on the evaluation, differential diagnosis, medical treatment, and rehabilitation of facial nerve pathology with primary emphasis on facial paralysis. Surgical management is also discussed, including reanimation of the paralyzed face.