Migraine headache is now emerging as a previously under-recognized side effect of interferon-beta, the most commonly used therapy for relapsing multiple sclerosis (MS). We describe an MS patient who developed migraine headaches, which followed a specific pattern coincident with interferon-beta administration. The frequency and severity of these migraines escalated and seemed to culminate in an MS exacerbation. Since initiation of migraine prophylaxis with daily amitriptyline, our patient reported a significant decrease in the frequency and severity of her migraines on interferon. It has been postulated that migraine headaches may trigger MS relapse. If so, migraine prophylaxis in MS patients, especially those treated with interferon-beta, is of paramount importance. Migraine headaches can be a significant source of disability. Identifying and treating migraines in MS patients serves to enhance their function and reduce disability.

Objectives: To study and quantify the effects of rear-end collision on the lumbar spine.Design: The lumbar spine of a cadaver was instrumented with rosette strain gauges applied on the lateral and anterior surfaces of T12, L2, and L4. Biaxial accelerometers were mounted on L1, L3, and L5. The cadaver was seated, restrained, and subjected to rear impacts of 5g and 8g.Results: The anterior shear strains had a biphasic shape. Spinal strains peaked at the T12 at approximately 120 and 370 msec, whereas in the L4 vertebra, it peaked at 200 and 380 msec. The anterior strain pattern of the L4 and T12 vertebrae were in diametrically opposite directions. In the second set of tests (8g experiment), the acceleration forces and strains pattern were similar to the 5g test but of higher magnitude. The principal anterior strain was 480 mum/m for 5g and 530 mum/m for 8g; the lateral shear strain was 680 mum/m and 1500 mum/m in the 5g and 8g experiments, respectively.Conclusions: Forces generated during simulated whiplash collision induce biphasic lumbar spinal motions (increased-decreased lordosis) of insufficient magnitude to cause bony injuries, but they may be sufficient to cause soft-tissue injuries.

Walking backwards has been used in therapy to improve balance and gait. There has not been any systematic investigation into the effectiveness or safety of walking backwards. We present two cases in which walking backwards during physical therapy resulted in a fall and considerable morbidity. The only clear indication for treatment by walking backwards should be a task-specific need to do so, and only then if adequate safety can be assured.

The objective of this study was to determine the effect of two types of restraining belts (lap belt and a four-point belt) on an instrumented dummy during three situations: wheelchair hitting straight into curb (SIC); wheelchair falling straight off a curb (SOC); wheelchair falling diagonally off a curb (DOC). A fully instrumented (50th percentile Hybrid III) dummy was seated in a standard wheelchair and restrained with one of the belts. The wheelchair rolled down a ramp reaching a platform at 2.4 miles per hour (comfortable walking speed). Three types of experiments were performed: SIC, SOC, DOC. Each experiment was repeated at least three times. Forces, moments, and acceleration were monitored and recorded via 48 sensors placed at the head, spine, and limbs. All experiments were videotaped and photographed. The data were averaged and compared with standards that have been previously established in car crash testing and with data recently obtained in a similar study using a nonrestrained dummy. Our results showed that in the SIC experiments, low magnitude forces, moments, and acceleration of no clinical significance were recorded with both types of belts. The wheelchair remained upright and the dummy safely seated. In the SOC experiments, the two belts prevented the dummy's ejection from the chair and, thus, have been effective in lowering the forces, moments, and acceleration and preventing significant injuries to the head and neck regions. In the DOC experiments, the lap belt proved to be somewhat more effective than the four-point belt in lowering the extension forces at the upper neck and the moments at the lower neck below injury levels. It also kept the head injury criteria well below injury level. We postulate that the four-point belt was less effective because of its more extensive body fixation, which leads to concentration of moments and forces at the head and lower neck regions. The results of this study show that restraining systems can enhance the safety of wheelchair occupants in certain incidents. It has been demonstrated that the lap belt is as effective as the four-point belt system in SIC and SOC incidents. In DOC falls, neither belt could prevent falls and trauma to the head and neck region. The lap belt, however, was somewhat superior. We recommend that wheelchairs be equipped with a lap belt and patients be encouraged to buckle-up while using the wheelchair outdoors.

To determine the magnitude and distribution of the forces, moments, and accelerations acting on an individual sitting in a wheelchair during three possible accidents occurring while negotiating a sidewalk curb, experimental trials were performed in a bioengineering laboratory using a 50th percentile Hybrid III dummy seated in a standard wheelchair. A ramp was designed with an adjustable incline to allow the wheelchair to reach the edge of a sidewalk height platform at the desired forward speed of 2.5 miles per hour (comfortable walking speed). The wheelchair velocity was monitored via an optical pickup. Three types of accidents were simulated: (1) a wheelchair hitting straight into a curb; (2) a wheelchair falling forward straight off a curb; (3) a wheelchair falling diagonally off a curb. Each experiment was repeated three times. Each run was photographed using high-speed cameras and videotaped from three perspectives: frontal, lateral, and overhead. The results were averaged and compared with published Injury Assessment Values (IAV) and Head Injury Criteria (HIC). Of significance were the following results. In the straight into a curb experiments, the wheelchair remained upright and the dummy seated. Low magnitude forces (23-73 N), moments (1-12 Nm), and accelerations (0.2-1 G) were recorded at the neck and head. The HIC was low at 0.3. These results were of no clinical significance. In the straight off a curb experiments, properly attached footrests prevented the wheelchair from toppling over but did not prevent the dummy from falling off the wheelchair, Forces (187-4,176 N), moments (3-178 Nm), and accelerations (131-206 G) of great magnitude were recorded at the head and neck when the dummy fell off the wheelchair. These values were above IAV. The HIC was 960. In the diagonally off a curb experiments, both the wheelchair and the dummy fell sideways. High-magnitude forces (274-2,313 N), moments (4-110 Nm), and acceleration (140-236 G) were recorded in the head and neck regions. The HIC was 975. These values were close to IAV and may signify potential serious injuries.

Study Design. Case presentation and review of pertinent literature.Objectives. To present an unusual case and alert other physicians to possible missed diagnoses.Summary of Background Data. An unusual case is presented of a young man with severe psoriatic spondyloarthropathy and fusion of C2-C7 [Type II cervical psoriatic ankylosing disease] who fell at home, sustaining an unrecognized fracture of the odontoid process leading to subluxation of C1-C2 and transitory tetraplegia. The patient presented with torticollis, and the fracture was unrecognized for a long period of time.Methods. Case presentation.Results. This patient became independent in all activities of daily living after surgery and rehabilitation despite persistence of torticollis.Conclusions. A patient who presents clinically with traumatic torticollis after minor trauma and who also has psoriasis and ankylosis of the cervical spine should be suspected of having a fracture-subluxation until definitely proven otherwise. In the present case, the late diagnosis delayed surgical stabilization.

1From the Department of Rehabilitation Medicine (S.F.W.), Montefiore Medical Center (A.F.), Albert Einstein College of Medicine, Bronx, New York. 2 All correspondence and requests for reprints should be addressed to: Montefiore Medical Center, Department of Rehabilitation Medicine, 111 E. 210th Street, Bronx, New York 10467.

Studies documenting the forces that are transmitted through a walker's frame are still scant. The purpose of this study was to evaluate the pattern and magnitude of forces that are transmitted through the frame of a walker during ambulation. A standard aluminum walker was instrumented. Gauges, which were mounted on all four legs, recorded axial, frontal, and sagittally oriented forces. A custom made computerized system registered the forces during 30 seconds of data acquisition. Twelve patients with ambulation dysfunction were tested with this system. Two different usage patterns emerged from the study. One usage pattern was observed in patients who were using the walker as a mean to reduce the amount of weight transmitted through the lower extremity. The second pattern was observed in patients with severe balance problems. These patients used the walker to enhance their balance and stability. The system described allows walker usage pattern analysis. Better understanding of force distribution and usage patterns may lead to improved or new walker design.

Total knee arthroplasty in Parkinson's disease (PD) has been reported only twice in the literature. Parkinson's disease is considered a contra-indication for total knee replacement by some authors. We report on a 77-year-old man with PD who underwent total knee arthroplasty for severe degenerative joint disease. The patient had a somewhat prolonged but successful rehabilitation as an inpatient and continued to make gains following discharge. Currently he is an independent functional ambulator. Based on our experience with this patient, we recommend that patients with PD who maintain ambulatory function prior to surgery and are cognitively able to integrate new knowledge and follow commands should be considered candidates for total knee replacement if it is indicated. Our patient demonstrates, however, that even in patients suffering from mild PD the rehabilitation process may be significantly prolonged and more difficult than in patients without PD. Objective studies evaluating the role of pre-surgical rehabilitation are needed.

Three patients with diabetic radiculopathy (DR) are presented. The clinical aspects of DR, its management, and differential diagnosis are reviewed. Diabetic radiculopathy commonly presents with severe unilateral pain of sudden onset that is usually located in the lower extremity, frequently in the proximal segments. Occasionally, bilateral asymmetric pain may be observed. The pain is severe and may require narcotic medications. Sphincteric involvement is rare. Weakness of hip or thigh muscles, decreased sensation and hypo- or areflexia are commonly observed. The clinical picture can resemble that of high lumbar disc herniation. Electrodiagnostic and radiological studies may help differentiate between the two conditions.

Twelve women in their third trimester of pregnancy and 10 age-matched nonpregnant controls underwent complete polysomnography for one night in the laboratory. Seven of the original women returned for a second study 3-5 months postpartum. During late pregnancy, women showed increased wake after sleep onset (WASO) and a lower sleep efficiency in comparison with the control group. The percentage of rapid eye movement (REM) sleep was significantly decreased and the percentage of stage 1 significantly increased compared to the nonpregnant group. At 3-5 months postpartum, a significant reduction in WASO and increased sleep efficiency were noted. However, only a slight increase was noted in REM sleep during the postpartum period compared to the prepartum period. The most frequent sleep complaints in the pregnant group were restless sleep, low back pain, leg cramps and frightening dreams. In summary, in accordance with their complaints, women in their third trimester demonstrated polysomnographic patterns of sleep maintenance insomnia.

ABSTRACT: Thirteen women in late stages of pregnancy underwent a polysomnographic study. Eight women (61%) complained of mild nocturnal back pain or back discomfort. Five women (39%) did not complain of nocturnal back pain. The two groups did not differ in total bed time, total sleep time, sleep latency, and wake after sleep onset (WASO). A significant decrease in rapid eye movement (REM) sleep and an increase in stage 2 were observed in the pain group. The same group had a statistically significant decrease in the basal O2 saturation level. The pain group also spent a longer time sleeping in the supine position. We hypothesize that a prolonged stay in the supine position leads to obstruction of the vena cava. In the presence of inadequate collateral circulation, increased pressure and venostasis in combination with a decrease in basal oxygen saturation may lead to hypoxemia, compromise the metabolic supply of the neural structures, and result in pain. It appears, therefore, that the vascular system plays an important role in the pathogenesis of pain. The role played by the disturbed sleep architecture in the production of pain remains to be established. It is possible that the changes observed in sleep architecture result from pain rather than contribute to pain production;.

The effect of surface cooling on intra-articular temperature was examined in dogs' knees. Four treatment protocols were examined: local ice compress application for 5, 15 and 30 min and local ice bath immersion for 15 min. Intra-articular temperatures were recorded using a needle microprobe inserted into the knee and continuous temperature recordings were made before, during and after the treatment. Rectal temperatures were also simultaneously recorded. Intra-articular temperatures rapidly dropped during icing. Five minutes of ice compress application resulted in a 2.2 +/- 1.2 degrees C intra-articular temperature drop with no change in rectal temperature. After 15 min of ice compress application, the joint temperature fell 4.1 +/- 1.3 degrees C with no change in rectal temperature. Thirty minutes of local ice compress application dropped the knee temperature 6.5 +/- 4.0 degrees C with a slight 0.5 +/- 0.3 degrees C drop in rectal temperature. Fifteen minutes of ice water immersion caused a much greater drop in intra-articular temperatures (20.2 +/- 8.4 degrees C) than could be achieved with ice compress. Rectal temperatures fell slightly during immersion (1.6 +/- 0.3 degrees C). After the removal of any type of cryotherapy, intra-articular temperatures continued to drop for several minutes and then a prolonged rewarming period commenced. The mean time required to return to baseline intra-articular temperature varied from 22-60 min, depending on the type and duration of cryotherapy. We conclude that brief periods of topical cold application to a dog's knee can induce significant and long lasting depression of intra-articular temperatures and that this is a local effect not dependent on core temperature cooling.

An attempt was made to determine the effect of pregnancy on the abdominal muscles and to correlate changes in abdominal muscles strength with low-back pain during pregnancy. The study included 328 women. Group A consisted of 164 pregnant women; group B consisted of 164 non-pregnant women. The race, age, height, weight, parity, profession, time devoted to physical fitness per week, abdominal length, and relation between the abdominal length to height were recorded. A detailed history relating to backache prior to and during pregnancy was obtained. Each woman was asked to perform a single sit-up. The results of the study indicate that about 10% of pregnant women develop severe low-back pain that interferes with daily life activities. About 49% of the non-pregnant women complained of LBP. The pain did not interfere with activities of daily living. During pregnancy, due to overstretching of the abdominal muscles, the ability to perform a sit-up is significantly decreased. Whereas all non-pregnant women could perform a sit-up, 16.6% of pregnant women could not perform a single sit-up. There was no statistically significant correlation between the sit-up performance and backache. It may be concluded that during pregnancy the abdominal muscles become insufficient.

Complete dislocation of the knee joint is a severe injury that is commonly the result of high-velocity injuries and often associated with disruption of the popliteal artery. We report two cases in which obesity appeared to be the principal cause of knee dislocation with vascular compromise. Preventive measures in extremely obese patients are recommended.

A 52-year-old woman complained of numbness affecting the thumb, index, and middle fingers of both hands. The patient was managed with night splints with partial relief of symptoms. As a house cleaner, the patient was routinely exposed to water and detergents. About a year later, the patient developed contact dermatitis in the fingertips innervated by the median nerves. Electromyographic studies confirmed the presence of bilateral carpal tunnel syndrome. The temperature of all the fingertips was measured. The median innervated fingertips were warmer than those innervated by the ulnar nerves. The median sympathetic fibers may be compromized by compression in the carpal tunnel. This caused vasodilation, increased finger temperature, and lack of sweating in the median innervated fingers. Due to regular exposure to water and detergents, the susceptible dry fingertips developed contact dermatitis. The patient was managed conservatively, and the rash and numbness disappeared.

Low back pain and sciatica may be caused by pathology remote from disc and lumbosacral vertebral segments. We report on a 59-year-old patient with systemic lupus erythematosis whose history illustrates this point. The patient was evaluated and diagnosed to have a septic arthritis of the wrist and lumbar spinal stenosis, for which she was treated. The patient's failure to respond to therapy led to further evaluation. A massive gluteal abscess was identified and drained, and with appropriate antibiotic therapy, the patient recovered. Patients with lupus have increased likelihood of infection, and their evaluation should include a search to discover unusual locations in cases that are unresponsive to standard and seemingly appropriate therapy.