HISTORY A 30-year-old professional women's football player presented to the emergency room with altered mental status, headaches, nausea, and vomiting two hours after completing a scheduled morning game. The game time temperature was 92 degrees Fahrenheit with 62 percent humidity. Immediately after the game the patient complained of headaches and “not feeling right”. She denied sustaining a head injury or physical injury during the game. Believing that she was dehydrated after the game, the patient recalls drinking abundant amounts of water in an attempt to “re-hydrate”. The patient reports drinking 30 – 40 ounces of water the night before the game, and 30 – 40 ounces during the game. Medications taken the morning of the game included ibuprofen, glucosamine, and a multivitamin. Her menstrual cycle had begun the day before. While in the emergency room the patient developed sinus bradycardia, became unresponsive, and went into respiratory distress requiring intubation. PHYSICAL EXAMINATION Pre-game wt 71 kg, ht 173 cm. Brief training room exam. Vitals not recorded. No clinical orthostasis. Gen: Alert and oriented. Tolerating oral intake. HEENT: Normal, no photophobia. Moist mucous membranes. Pulm/CV: Normal. Neuro/Musc: Normal mental status. Normal strength and tone. DIFFERENTIAL DIAGNOSIS Heat stroke/dehydration Electrolyte imbalance – hyponatremia, hypoglycemia, hypercalcemia Occult head injury Drug or alcohol intoxication Pneumothorax or Pulmonary embolism TESTS AND RESULTS Abnormal serum labs only: Na 117 meq/l (normal 135 – 145 meq/l), K 3.3 meq/l, Cl 87 meq/l, CO2 19 meq/l, Gl 169 mg/dl, Ca 8.0 mg/dl, WBC 154,000 units, Hgb 11.9 g/dl. Urine toxicology – negative. Urine HCG – negative. CT scan of the head was normal. Chest X-ray prior to intubation was without infiltrates or evidence of pulmonary edema. Upon correction of the patient's hyponatremia, the patient became increasingly responsive and was extubated three days later. The patient was without neurological sequelae following extubation and without evidence of permanent metabolic abnormalities. FINAL/WORKING DIAGNOSIS Acute severe hyponatremia – exercise associated TREATMENT AND OUTCOMES The patient received intravenous fluids of 0.9 percent normal saline, 3 percent normal saline, and lasix in order to correct her hyponatremia. ICU admission for four days. Extubated on third day. Repeat laboratory values two weeks after discharge were within normal limits. Returned to training one month after discharge. Returned to play in Women's Professional Football League (WPFL) playoffs. Education on appropriate fluid replacement practices.

This self-directed learning module highlights the underlying anatomy and biomechanics of the cervical spine and shoulder as a basis for developing a differential diagnosis of contributing pathology in an industrial injury. This includes components of the history, examination, and appropriate diagnostic testing that are necessary to develop an optimal rehabilitation plan, Treatment options are reviewed and include medications, therapy, selective injections, and return-to-work programs in the industrial setting.Overall Article Objectives: (a) To be able to identify neck and shoulder pathology, (b) to effectively evaluate cervical spine and shoulder injuries, and (c) to rehabilitate acute cervical spine and shoulder injuries in the industrial setting.

This self-directed learning module highlights the evaluation and management of the injured worker with low back pain (LBP). This chapter reviews the importance of recognizing the physiologic implications of a lifting injury and evaluating its structural etiology in a worker with LBP. A review of the steps required to make an accurate diagnosis is included. Justifying restrictions and prescribing therapeutic intervention is summarized.Overall Article Objective: To be able to provide a step-by-step plan for evaluating, treating, and safely returning to work the injured worker with LBP.

This self-directed learning module highlights work-related injuries in specific patient populations that the physiatrist may encounter. This chapter focuses on evaluating work-related injuries in the aging and disabled population. Specific problems encountered in pregnant working women and the dental profession are also summarized. Specific biologic and/or environmental factors as they relate to workers in the specific populations are reviewed. Strategies for evaluation, rehabilitation, and health care management of these workers are discussed.

UNLABELLED:This self-directed learning module highlights the importance of recognizing the relationships between multiple, concurrent joint injuries in the lower extremity of an injured worker. This chapter focuses on evaluating the lower extremity and devising a rehabilitation program that incorporates the entire kinetic chain. Further recommendations for return to work are discussed.OVERALL ARTICLE OBJECTIVES:(a) To accurately recognize and diagnose coexisting injuries in the lower extremity and (b) to devise an evaluation and treatment program enabling the worker to return to work.

UNLABELLED:This self-directed learning module highlights the physician's role in treating industrial injuries, from the initial causality determination to the eventual case closure. It is part of the chapter on industrial medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The article reviews important factors in determining whether an injury is work-related, particularly in the presence of preexisting, underlying conditions. The article addresses the roles of functional capacity examinations and work-hardening programs in facilitating successful return to work. Interactions are outlined between work return and nonwork activities of daily living, as well as financial and psychologic barriers that may impede work return. Legal issues regarding independent medical examinations and depositions are reviewed. Guidance is offered for identifying those relatively few injured workers who may require referral for surgical or other consultations.OVERALL ARTICLE OBJECTIVES:(a) To review the important medical, administrative, and legal challenges involved in treating injured workers and to describe strategies that physiatrists use to overcome effectively these challenges.

A retrospective case-controlled study was conducted on marathon runners admitted to the major medical tent of the 2000 Houston Marathon. Twenty-one cases of hyponatremia were detected in runners finishing the marathon on an unseasonably warm (25C) and humid (93%) day. PURPOSE: To identify risk factors and clinical signs of acute hyponatremia in marathon runners. METHODS: Questionnaires were sent to those runners treated in the medical tent. Questions asked about the amount and type of race fluid intake, training preparation, symptomatology, and NSAID use. Responders were divided into 2 groups: those with [Na] < 135 (Group 1) and those with [Na] > 135 (Group 2). Significant differences between the groups were determined using non-paired t-tests. ANOVA studies were also conducted within Group 1: [Na] 135–130mmol/L (1A); 129–120mmol/L (1B); and < 120mmol/L (1C). RESULTS: 17 hyponatremic (8 male, 9 female) and 22 non-hyponatremic (12 male, 10 female) runners responded to the questionnaire. Mean ages were 36 and 40 years old, respectively. The amount of water (p < .01) electrolyte/carbohydrate solution (p < .01), and total amount of fluid ingested (p < .001) were statistically significant between Groups 1 and 2. Group 1 runners consumed more fluid along the course in a linear fashion, with the lowest serum sodium levels reporting the highest amount of fluid intake. ANOVA studies between Groups 1A, 1B, and 1C documented this dose dependent relationship. Although not significant, there was a trend towards the least experienced runners developing low sodium levels. The only symptom that proved significant was vomiting (p < .05) with a higher incidence in Group 1. There were no differences between the groups in the use of NSAIDs. CONCLUSION: Marathon runners developing hyponatremia consumed significantly more fluid along the course than nonhyponatremic runners. Vomiting was the only clinical sign defining hyponatremia from other conditions that are associated with exercise associated collapse.

This self-directed learning module highlights various cumulative trauma disorders of the upper limb that may be seen in computer users. The biomechanics and ergonomics of computer users are addressed in relationship to specific neurologic and musculoskeletal conditions within the neck and upper limbs. In addition to a general overview of these conditions, a case presentation is used to show the evaluation and treatment of a computer user who has carpal tunnel syndrome and concomitant de Quervain tenosynovitis.

312 Little is known regarding motivations for beginning a marathon training program. Motivation for training may effect not only training success, but injury rate as well. The purpose of this study was to evaluate self-reported motivations for beginning a formal marathon training program and to evaluate differences by gender and running experience. Women (n=585;mean age 34.6 yrs.)& men (n=338;mean age 37.9 yrs.) participants in an organized marathon training program completed baseline surveys on running history, training experience and injury history. They also were asked to rate on a Likert scale from 1(not a reason), to 4 (most important reason) how important each of 10 statements were as individual goals for marathon training. One-third (29.3%) never trained for, or completed a marathon (IN); the remainder had experience training for a marathon, or had completed a marathon (EX). This value was similar among men & women (p=0.76). The level of importance rating for several training goals significantly differed between IN & EXP runners, while few differences existed between genders. The goal for IN rated as most important was health/fitness (68 vs.57% for EXP, p=0.036), while EXP rated the ability to finish (53 vs.33%,p<0.001) as most important. Training goals rated as not a reason for training by the IN which were significantly different from the EXP were: "to be a marathoner" (57 vs. 38%,p<0.001); to finish in a specific time (48 vs. 26%, p<0.001); the ability to finish (33 vs. 53%,p<0.001); and social interaction (27 vs. 15%, p=0.008). Female EXP runners rated "to feel good about myself" as a most important goal for marathon training, which differed significantly from IN females (64 vs.52%,p=0.023). This difference was not present between male EXP & IN runners. This study indicates that goals for training significantly differ between experienced and inexperienced runners. This study suggests that experience and gender not only effect training program design, but motivation for training as well.

Physicians who treat musculoskeletal and neurologic disorders often treat patients who have paresthesias or weakness of a single extremity. Although the diagnosis is often straightforward, cases that are atypical in nature may pose a diagnostic dilemma. This report describes the case of a middle-aged man with symptoms indicative of, though not classic for, a cervical radiculopathy. An extensive investigation was unremarkable and only the eventual rapid progression of symptoms led to the diagnosis of a glioblastoma multiforme. Although this is a deadly form of brain cancer, early recognition provides the best chance for a prolonged and greater quality of life.