Student Publications
Author: Jahad El Jojo
Title: Physical medicine and Rehabilitation

Area:
Country: United States
Program:
Avialable for Download: Yes

Content                                                                        

Introduction

Physiatry – also called physical medicine and rehabilitation is a branch of medicine that specializes in diagnosis, treatment and management of disease primarily using "physical" means (such as physical therapy and medications). Essentially, physiatrists specialize in a wide variety of conservative treatments for the musculoskeletal system (the muscles and bones) cardiovascular and pulmonary systems that may produce temporary or permanent impairment. Physical Medicine and Rehabilitation is one of the 24 medical specialties certified by the American Board of Medical Specialties. Physiatry provides integrated care in the treatment of all neurological and musculoskeletal disabilities from traumatic brain injury to lower back pain and do not perform surgery.

The specialty of physiatry is approximately 50 years old. Today, there are over 6,000 physicians practicing physical medicine and rehabilitation.

 The physiatrist's role in treatment

A physiatrist may treat patients directly, lead an interdisciplinary team, or act as a consultant. Here are some scenarios that illustrate the varied roles of a physiatrist:

Goals of physiatry treatment

Physiatrists strive to treat the whole patient not just the specific injury or condition which improves overall recovery and prevents recurrence. The goal of treatment is always to restore normal function and improve quality of life for patients from a physical, emotional, psychosocial and vocational perspective.
Since physiatrists focus on restoring patients to maximum function, the difference they make can be dramatic. In the case of the herniated disc, the physiatrist not only takes care of the acute problem, but also treats the patient until he or she returns to optimal functioning, usually without surgery. The physiatrist also teaches the patient how to prevent the injury in the future.

A broken hip in an elderly patient is another example. Physiatrists can provide aggressive rehabilitation so patients can walk and even exercise again. And because the physiatrist is concerned with all areas of rehabilitation – social, vocational, and medical – the quality of life is significantly increased for patients.

The following is a list of some conditions commonly treated by physiatrists:

Philosophy

The major concern of the field is the ability of the person to function optimally within the limitations placed upon them by a disease process for which there is no cure. The general emphasis is not on the full restoration to the premorbid condition, but rather the optimization of the quality of life for those who may not achieve full restoration. Team approaches to chronic conditions are emphasized, using multidisciplinary team meetings to coordinate care of the patients.

Rehabilitation begins with identification of preserved strengths and capabilities of the patient. Residual strengths are enhanced to maximize function of the person who has been subject to disease-related impairment. This involves a holistic approach to the nature of human function. Areas of motivation and capabilities of the performer as well as the environmental contingencies are explored. Examples of environmental contingencies include opportunities afforded by the presence of other individuals (eg. caregivers, attendants) who are able to provide physical, supervisory and emotional assistance to the affected person.

The History of Physiatry

Physical means of healing have been practiced since prehistoric times, but Physiatry did not become recognized as a separate medical specialty until 1947. Most widely known as the field of Physical Medicine and Rehabilitation, the medical specialty of modern-day Physiatry comprises the related disciplines of Physical Medicine, Rehabilitation Medicine and Electromyography. The term Physiatry derives from the Greek words physikos (physical) and iatreia (art of healing). A Physiatrist is a physician who creatively employs physical agents as well as other medical therapeutics to help in the healing and rehabilitation of a patient. Treatment involves the whole person and addresses the physical, emotional and social needs that must be satisfied to successfully restore the patient's quality of life to its maximum potential. Since the beginning of time, people have used physical means for treatment of illness and injury. Such physical agents for healing have included water, heat, cold, massage, light, exercise and electricity. Throughout history, water has functioned as a primary means of physical healing. Written ccounts of physical techniques for healing can be traced as far back as the writings of Hippocrates in 400 B.C.

Rehabilitation involves the restoration of a diseased or disabled person to optimal physical, psychological and social functioning.
During and after World War I, empirical trials indicated that various physical methods were useful to augment medical care and convalescence of patients. Physicians began practicing "physiotherapy" in "reconstruction hospitals" to rehabilitate injured and disabled soldiers. Therapeutic tools and methods were developed or improved to apply heat, massage, exercise, electrical timulation, heliotherapy and diathermy. Physicians pioneered new medical applications of electrotherapeutics and x-rays. Functional activities of occupational therapy to provide exercise, retraining of coordination and reassurance that useful
performance could be regained, were extensively practiced in Army Hospitals. Beginning in the 1920's, medical organizations such as the AMA Council on Physical Therapy and the American Society of Physical Therapy Physicians were formed. These organizations later were changed and renamed a number of times to reflect the evolving specialties of physical medicine, hysical therapy, electrotherapeutics, radiology, and rehabilitation. The major organizations for physicians in the field of physiatry today include the American Academy of Physical Medicine and Rehabilitation (AAPM&R), the Association of Academic hysiatrists (AAP),

the American Board of Physical Medicine and Rehabilitation (ABRM&R), the International Rehabilitation Medicine Association (IRMA), and the American Congress of Rehabilitation Medicine (ACRM). These organizations represent seven decades of development of the field of physiatry. Two major medical journals have evolved to publish research in the field of Physiatry. The Archives of Physical Medicine and Rehabilitation is published by the AAPM&R and the ACRM, and the American Journal of Physical Medicine and Rehabilitation is published by the AAP.

Formal education for Physiatry had its beginning in 1926 when, after service in the U.S. Army during World War I, Dr. John Stanley Coulter joined the faculty of Northwestern University Medical School as the first full-time academic physician in physical medicine. He became the leader of the educational development of the practice of physical medicine over the next two decades. He initiated the first continuing teaching program in physical medicine, consisting of short courses of three to six month's duration, later extended to one year for physicians in practice. Prior to that time, training in Physical Medicine had been by short preceptor ship with a practitioner of some aspect of physical medicine. During that period, Dr. Coulter gained recognition as the leader of the developing organizations for physical medicine physicians. The decade of the 1930's brought further organization and purpose to the field of rehabilitation. Only a few training programs for physical therapy tecnicians
existed, but these were standardized by the formation of The American Registry of Physical Therapists. Likewise additional opportunities for training physicians began to develop, and groups began to form to represent specific interests within Physical Medicine and Rehabilitation. Frank Krusen, MD, established the Physical Medicine Program at the Mayo Clinic in 1936 and nitiated the first three-year residency in Physical Medicine. Drs. Coulter and Krusen led the organization of the American Academy of Physical Medicine in 1938, and Dr. Coulter is credited with being its Organizational President. In that year, Dr. rusen coined the word "Physiatrist" to describe the small group of physicians who were dedicated to the approach of adding physical medicine to medical therapeutics to treat neurological and musculoskeletal disorders. Krusen wrote the first widely used textbook on Physical Medicine in 1941. He is recognized as the "Father of Physical Medicine." In 1946, the AMA Council on Physical Medicine voted to sponsor the term "physiatrist" () and physiatry () with the accent on the third syllable. This is how the pronunciation appears in most American dictionaries.

It was not until after World War II, however, that society began to understand the necessity for more advanced treatment and rehabilitation for the disabled. The public became more aware of the rehabilitation effort due to the substantial
numbers of debilitating war injuries plus the thousands of individuals disabled by a poliomyelitis epidemic that sent fear into every American home. The influence of radio, movie newsreels, and later television brought home the reality of polio in the person of President Franklin D. Roosevelt, who had regained his capacity to return to public life after physical therapy at Georgia Warm Springs. These events created an increased demand for physicians trained in a comprehensive approach to rehabilitation, including the physical, mental, emotional, vocational and social aspects. With the cases of polio reaching nearly 58,000 in 1952, physiatrists were called upon to treat the "whole patient" and direct the restoration of the disabled and their return to functional roles in their communities. From quite a different origin, as a result of his experience in the Army Air Corps Convalescent and Rehabilitation Services at Jefferson Barracks in World War II, Howard A. Rusk, MD, an internist, saw and recognized that passive, inactive, non-physical convalescence resulted in both physical and emotional deterioration of soldiers recovering from accident or illness. As a result, these soldiers were often classified as unfit to return to duty. Although Rusk faced passive resistance from medical officialdom, he was able to set up a controlled experiment in one barracks in which active rehabilitation was carried out while a control barracks continued the passive program of convalescence. The dramatic demonstration of the more rapid recovery of strength and endurance and the much more rapid return to active duty due to the benefits of planned aggressive rehabilitation were so remarkable that the Army Air Corps extended the program to all of its
hospitals, and shortly thereafter, it was extended throughout the military services. The Medical War Manpower Board ecognized the great value of active rehabilitation and introduced it into civilian medical practice.


After the war, Rusk left his medical practice in Missouri and went to New York's Bellevue Hospital where he began his 30-year campaign to train physicians and establish rehabilitation programs to treat the whole patient. During those years, Rusk had a profound influence on present-day physiatry. He established the Institute of Rehabilitation Medicine at the New York University Medical Center and helped to found The World Rehabilitation Fund, which has trained hundreds of rehabilitation specialists and physicians representing dozens of countries.

Rusk advocated the aggressive approach to rehabilitation medicine, which he had begun in the Army Hospitals and which is practiced widely today. He insisted that patients should not remain inactive during convalescence but should be involved in early ambulation, aggressive physical therapy, recreational and sports activities of progressive intensity and programs involving emotional and psychological support. Rusk's endeavors earned him recognition as "the Father of Rehabilitation Medicine."
The Veterans Administration, through its experience in caring for thousands of injured and disabled soldiers over many decades, has been a primary influence in the development of Physical Medicine and Rehabilitation. After World War II, under the directorship of A.B.C. Knudson, MD, the modern-day Physical Medicine and Rehabilitation Service was established. Since that time, the VA has become an important partner to university PM&R residency programs in providing training facilities, faculty and patients. Physical Medicine and Rehabilitation is currently practiced in each of the 171 VA Medical Centers throughout the United States and Puerto Rico.

Another group of great importance to Physiatry was the Baruch Committee, which

left a lasting legacy for the development of university research and training programs in the field of physiatry. The committee, which served from 1943-52, was appointed by philanthropist Bernard Baruch in memory of his father, Dr. Simon Baruch, who was a leading proponent of hydrotherapy as a faculty member at Columbia University's College of Physicians and Surgeons. The committee awarded grants to hospitals and medical schools to establish PM&R teaching and research programs. By 1946, medical residencies or fellowships in PM&R had been established at 25 hospitals as a result of funding from the Baruch Committee. Although the grants provided the basis for the expansion of training and research, the propelling influence for the expansion of the field of physiatry was the recognition by the public that rehabilitation worked. Hundreds of wounded soldiers and injured civilians were being rehabilitated and returned to be productive, tax-paying members of society. This was the testimony before Congress and to the public at large that ensured the future of the field physiatry. In January 1947, the Advisory Board of Medical Specialties (now the American Board of Medical Specialties) formally recognized the American Board of Physical Medicine. Two years later, at the urging of Dr. Rusk, the name was changed to include "Rehabilitation." For the first time, the specialty of physical medicine and the specialty of rehabilitation medicine were under one governing board. At that time, university hospitals were offering a total of 85 positions for residents or fellows in Physical Medicine and Rehabilitation. In the 1950's, a major collaborator with Howard Rusk, Mary Switzer, director of the Office of Vocational Rehabilitation (OVR) brought about the economic opportunity for the great expansion of Physical Medicine and Rehabilitation. Mary Switzer was totally committed to the improvement of the quality of life for people with disabilities. She became convinced by Howard Rusk that physical medicine and rehabilitation under the direction of physiatrists could provide the greatest benefits for people with disabilities. Her effectiveness as an administrator and advocate for the disabled before Congress resulted in greatly increased budgets not only to provide rehabilitation services, but also to support physiatric training programs, physiatric fellowships, and support for research in medical rehabilitation. During her administration, the concept of regional
rehabilitation research and training centers was adopted and funded by Congress. These centers remained the major resources available to physiatrists for rehabilitation research and research training until 1990, when the National Center for Medical Rehabilitation Research was established at the National Institutes of Health. The 1950's brought an increase in the numbers of rehabilitation professionals and a more cohesive union between the fields of Physical Medicine, Rehabilitation Medicine, and Electromyography. Electromyography (EMG) was introduced into Physiatry
as a profoundly important electro diagnostic method for the evaluation of problems of the neuromuscular system, which constitutes a major part of the work of the physiatrist. Through EMG, it is possible to localize and evaluate significant pathology of both the muscular and sensory components of the nervous system. The general acceptance of this diagnostic tool created a significant niche for the growing specialty of PM&R.

On the therapeutic side, many rehabilitation centers were born because the value of medical rehabilitation was recognized by the general public, who demanded that these services be made available in every large community.
Along with the expansion of education and training opportunities in physical medicine and rehabilitation, interest in physiatric research multiplied during the 1960's. The Association of Academic Physiatrists (AAP) was formed in 1967 by a small group of dedicated physiatric educators with Ernest W. Johnson, MD, considered the "founding father". The AAP is the only major PM&R organization that at the present uses "physiatrist" in its name. The primary purpose of the AAP is to promote methods of undergraduate and graduate teaching of the art and science of PM&R. From 1968 to 1992, the AAP grew to more than 1,000 members. The AAP mission is concerned with issues such as support for academic departments, improving the quality of teaching programs and encouraging the development of physiatric research. Although many new physicians graduated from PM&R residency programs in the 1970's, the increase in the number of new physiatrists was far slower than the increased demand for physiatric services. In 1974, the Commission on Rehabilitation Medicine, a group with representatives from the American Board of Physical Medicine and Rehabilitation, the American Academy of Physical Medicine and Rehabilitation and the Association of Academic Physiatrists, published a bulletin: Physical Medicine, Need, Supply and Demand, 1972-1987. These estimates predicted that only with significantly increased productivity of new physiatrists would the supply reach the lower limit of demand for 4000 physiatrists in 1990. The upper limit of demand could not be predicted because it was recognized that as physiatry became more available, there would be an increased demand for the rehabilitation of persons with disabilities who were "out of the circuit" and living in passive dependency. In the 1980's, the recognition by the American public that medical rehabilitation decreased dependency and increased the quality of life for handicapped persons resulted in the development of many community rehabilitation centers and created a demand for many more physiatrists to direct these medical programs, which was in accord with the projections made by the Commission on PM&R in 1974.

A severe shortage of physiatrists developed, and American medical students began to discover the field as a promising career. By 1982, the number of residents climbed to 500 and the positions were more competitive. The rate of training of young physiatrists did increase, but not up to the rate predicted as necessary to meet the lower limit of demand in 1990.

In 1994, the American Board of PM&R reported 1313 residency positions were offered and 1277 (97 percent) of those positions were filled. American medical school graduates account for 84 percent of those residents. The Seventh Edition of the Residency Training Program Directory published in 1995 by the Association of Academic Physiatrists listed 79 accredited residency training programs. As of 1994, the total number of Board Certified Physiatrists grew to 4642, with 2561 of those certified between 1984-94. The current decade promises continued
growth in the number of physiatrists. As a result of so many newly graduated physiatrists entering the field, the average age of a physiatrist is now under 40 and still decreasing. Some areas of the country have an adequate supply of physiatrists, while other areas continue to have a shortage of rehabilitation services and/or physiatrists. As is true for other medical specialties, there is a geographic misdistribution of physiatrists and in certain geographic areas, no physiatric services are available. The greatest unmet need in physiatry, however, is the need to increase the number of academic physiatrists trained for research and teaching. PM&R Residency Programs continue to experience a shortage of academic talent to fill chairperson and faculty positions. The next century promises much medical advancement and with them new challenges to maintain a high level of medical ethics and a high standard of medical care with the resources and services that are available. Advancements in medical technology will save more lives and therefore multiply the number of persons needing rehabilitation services. Society will continue to grapple with controversies and conflicts of policy and practice stemming from medical, social and economic issues that match selfishness, convenience and conspicuous consumption for some against the presence or absence of the quality of life available for others. The ensuing struggle promises to shake the foundations of the Hippocratic Oath.
Quality of life throughout the time of survival, and the cost of each medical service in relation to the benefit to the quality and duration of life which it provides will be a central issue. Physiatrists will be challenged to stand firm in the battle to add quality of life to years and duration of years to that quality of life for all patients.

Neuropsychological evaluation (NPE) is used to examine brain function and impairment. The various test, such as the Luria-Nebraska and Halstead-Reitan test batteries, are commonly used and help to assess brain impairment. By using such measures, neuropsychologists can determine and localize organic brain impairment and can develop rehabilitation programs for cognitively impaired patients. A neuropsychologic evaluation is more sensitive to the functional manifestations of brain impairment than an MRI or CT scan. However, neuropsychological tests are of limited utility by themselves and must be interpreted in conjunction with other clinical, imaging, physical examination, and laboratory information.
These tests are not always appropriate for all patients with cognitive deficits. Variability in the training and experience of neuropsychologists also may affect the validity and reliability of findings. Nevertheless, a carefully conducted examination can characterize cognitive and behavioral disturbances and may be helpful to the clinician in the course of diagnostic assessment and treatment planning.

The neuropsychological evaluation serves as an extension of the basic mental status examination, and it employs standardized measures to quantify a performance at a given time. These tests use a variety of normative databases to evaluate performance relative to the entire population or to specialized subpopulations. The distributions of test scores obtained from samples of neurologically intact persons, grouped by sex, age, education, or other relevant criteria, provide a reference for interpreting the test performance of specific patients. The analysis of test scores allows for qualitative interpretation of problem solving strategies and cognitive processing deficits.

Whom to refer for an NPE

Neuropsychological testing provides diagnostic clarification and grading of the clinical severity of impairment for patients with sub clinical or obvious cognitive deficits. Often these patients include the following:

When to refer a patient for an NPE

Obviously, not all patients who exhibit cognitive or behavioral difficulties should be referred for an NPE. The threshold for each clinician to request an NPE depends on a variety of factors. Data obtained from the NPE are most useful for the following purposes:

INFORMATION OBTAINED FROM A NEUROPSYCHOLOGICAL REPORT
Neuropsychological tests are a series of measures that identify cognitive impairment and functioning in individuals. They provide quantifiable data about the following aspects of cognition:

Planning, synthesizing, and organizing abilities

ESTABLISHED APPLICATIONS OF NEUROPSYCHOLOGICAL EVALUATION

Applications of NPE include the following:

Developmental disorders (eg, specific learning disabilities) require detailed assessment of cognition, academic achievement, and psychosocial adjustment for proper identification and as a guide to management. Academic placement in special education and resource classroom may be needed.
NPE is of limited value in the following cases:

TECHNICAL ISSUES IN NEUROPSYCHOLOGICAL EVALUATION

Results of an NPE must be considered in the context of the patient's age, education, sex, and cultural background. These factors can affect test performance and limit the conclusions that can be drawn from evaluation. In addition, issues such as reliability, validity, sensitivity, and specificity need to be considered.
Large population-based norms are available for relatively few measures. Those measures that do boast such norms, such as major intellectual and academic instruments, are of limited usefulness within a neuropsychological test battery. Ideally, patients should be compared with population-based norms, as well as local norms and subgroup norms (ie, specific patient populations) to examine strengths and weaknesses. Significant gaps can be found in the normative data for all age, educational, and intellectual ranges, not to mention major deficiencies in development of appropriate measures and norms for minority populations.

TEST SELECTION: RELIABILITY, VALIDITY, SENSITIVITY, AND SPECIFICITY

Reliability refers to the consistency with which the same information is obtained by the test or set of tests. In the absence of intervening variables (eg, illness, injury, new learning), scores should remain stable even in the event of variables such as the following:

Validity refers to how well the test measures what it purports to measure. Does the test do what the examiner reports? Other specific types of validity that may be questioned include the following:

Generally, findings suggest that performance on tests of motor functioning, speed of cognitive processing, cognitive flexibility, complex attention, and memory are related positively to real-world success. The amount of variance accounted for by cognitive factors alone, however, is typically quite small. Exceptions occur when comparisons are made between results of formal NPE and real-world criteria are limited to very simple, very circumscribed, and/or very well-defined functions. Consequently, situational assessment is seen as a critical adjunct to neuropsychological assessment, especially at higher levels of cognitive functioning. Neuropsychological tests, with very few exceptions, were not developed with an eye toward ecological validity. They were developed as indicators of brain function or dysfunction and generally were validated against neurosurgical, neurologic, and neuroradiologic data. Nevertheless, many tests have proven to be good predictors of future behavior and, therefore, have demonstrated ecological validity.

A qualitative process approach may improve the ecological validity of the neuropsychological test battery. For example, testing the limits with measures of memory and executive functioning allows the examiner to understand better what a person can do under relatively ideal circumstances (not “what” but “how”). The test itself may have little demonstrable ecological validity, but an accurate analysis and insightful interpretation of findings can be highly valid from an ecological perspective.

Sensitivity and specificity

The deficit assessment paradigm and virtually all existing NPE tests were developed before the advent of noninvasive technologies that have allowed the most precise analysis of brain-behavior relationships. Many commonly used instruments were constructed without the specific intention of their use as instruments to assess brain function and detect brain disorders, but extensive experience with these measures has provided a basis for interpreting the tests in neurologic terms in the following cases:

Generally speaking, there is a trade-off between the ability of a test to detect a minimum of CNS dysfunction (sensitivity) and the ability of a test to detect specific CNS pathologies. Measures of rapid speed of cognitive and/or motor processing tend to be very sensitive to diffuse or multifocal cerebral dysfunction and subtle changes in performance attributable to recovery or decline. Such tests, however, tend to be of little help in specifying or describing specific pathologies. Untimed measures tend to be less sensitive to diffuse pathology, but they may be very useful in identifying focal brain lesions.

MAJOR DOMAINS OF NEUROPSYCHOLOGICAL FUNCTIONING

NPE is useful in measuring many categories of functioning, including the following:

EXAMPLES OF COMMONLY USED NEUROPSYCHOLOGICAL TESTS

Examples of commonly used neuropsychological tests, including the domain and the corresponding neuropsychological tests, are as follows:

Intellectual functioning

Academic achievement

Language processing

Visuospatial processing

Attention/concentration

Verbal learning and memory

Visual learning and memory

Executive functions

Speed of processing

Sensory-perceptual functions - Halstead-Reitan Neuropsychological

Motor speed and strength

Motivation

Personality assessment

Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function. The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and the extent of injury based on a systematic motor and sensory examination of neurologic function. The following terminology has developed around classification of SCI:

SCI can be sustained through different mechanisms with the following 3 common abnormalities leading to tissue damage:

Edema could ensue subsequent to any of these types of damage. The different clinical presentations of the above causes of tissue damage are explained further below.

Spinal shock

Spinal shock is a state of transient physiological (rather than anatomical) reflex depression of cord function below the level of injury with associated loss of all sensorimotor functions. An initial increase in blood pressure is noted due to the release of catecholamines, followed by hypotension. Flaccid paralysis, including of the bowel and bladder, is observed, and sometimes sustained priapism develops. These symptoms tend to last several hours to days until the reflex arcs below the level of the injury begin to function again (eg, bulbocavernosus reflex, muscle stretch reflex [MSR]).

Neurogenic shock

Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia. Shock tends to occur more commonly in injuries above T6, secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone, leading to decrease in vascular resistance with associated vascular dilatation. Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. Hypovolemic shock tends to be associated with tachycardia.

Motor strengths and sensory testing

The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification), using the following categories:

Perform rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing.
Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing.

Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers with the sacral fibers located more at the periphery of the cord. Indication of the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. This finding tends to be repeated and better defined after the period of spinal shock.
With the ASIA classification system, the terms paraparesis and quadriparesis now have become obsolete. The ASIA classification using the description of the neurologic level of injury is used in defining the type of SCI (eg, C8 ASIA A with zone of partial preservation of pinprick to T2).
Other classifications of SCI include the following:

Muscle strengths are graded using the following Medical Research Council (MRC) scale of 0-5:

Muscle strength always should be graded according to maximum strength attained, no matter how briefly that strength is maintained during the examination. The muscles are tested with the patient supine.

The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated:

Sensory testing is performed at the following levels:

Sensory scoring is for light touch and pinprick, as follows:

A score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge.
Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5)
Motor index scoring - Using the 0-5 scoring of each key muscle with total points being 25/extremity and a total possible score of 100
Sensory level - Most caudal dermatome with a normal score of 2/2 for both pinprick and light touch
Sensory index scoring - Total score from adding each dermatomal score with possible total score (= 112 each for pinprick and light touch)
Neurologic level of injury - Most caudal level at which both motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2
Zone of partial preservation - This index is used only when the injury is complete. All segments below the neurologic level of injury with preservation of motor or sensory findings
Skeletal level of injury - Level of greatest vertebral damage on radiograph
Lower extremities motor score (LEMS) - Uses the ASIA key muscles in both lower extremities with a total possible score of 50 (ie, maximum score of 5 for each key muscle L2, L3, L4, L5, and S1 per extremity). A LEMS score of 20 or less indicates patients are likely to be limited ambulators. A LEMS of 30 or more suggests that patients are likely to be community ambulators.
EPIDEMIOLOGY
SCI due to trauma is not a common condition, but it has a major effect on the injured person's functional, medical, financial, and psychosocial well-being.
The most common causes of SCI include the following:

Other causes of SCI include the following:

The incidence of traumatic SCI in the United States is 30-60 new cases per million population, or 10,000 cases per year in the United States. Some sources cite 8 cases per 10,000 population per year.
Figures on estimated prevalence vary from approximately 183,000 to 230,000 cases in the United States, the equivalent of 700-900 cases per million population.
Race
Incidence among whites is higher than among African Americans, which is higher than among Hispanics in the United States. Current studies indicate whites at 66.4%, African Americans at 21.1%, Hispanics at 8.8%, Asians at 1.6%, Native Americans at 1.1%, and others at 1%.
Sex
The male-to-female ratio of individuals with SCI in the United States is 4:1, ie, males constituting about 80%.
Age
More than 50% of all cases of SCI occur in persons aged 16-30 years. The median age is 26.4 years, while the mean age is 31.8 years and the mode age at injury is 19 years. Traumatic SCI is more common in persons younger than 40 years, while nontraumatic SCI is more common in persons older than 40 years. Greater mortality is reported in the older patients with SCI.
Associated injuries
Other injuries are often associated with traumatic SCI, and these include bone fractures (29.3%), loss of consciousness (17.8%), and traumatic brain injury affecting emotional/cognitive functioning (11.5%).

Marital status

Single persons sustain SCI more commonly than married persons. Approximately one third of patients with SCI sustained at least 15 years before remain single 20 years after injury. The marriage rate after SCI is about 59% below that of the general population of comparable gender, age, and marital status annually. The divorce rate annually among individuals with SCI within the first 3 years following injury is approximately 2.5 times that of the general population, while that of marriages contracted after the injury is about 1.7 times that of the general population. Marriage is more likely if the patient is a college graduate, previously divorced, paraplegic (not tetraplegic), ambulatory, living in a private residence, and independent in performance of ADL.
The divorce rate among those married at the time of injury is higher if the patient is younger, female, African American, without children, nonambulatory, and previously divorced. The divorce rate among those who were married after the SCI is higher if the individual is male, has less than a college education, has a thoracic level injury, and has been divorced previously.

Educational status

At the time of injury, educational status figures are less than high school graduate at 39.8%, high school graduate at 49.9%, associate degree at 1.6%, bachelors degree at 5.9%, masters or doctorate degree at 2.1%, and other degrees at 0.7%.

Level and type of injury

The most common levels of injury on admission are C4, C5 (the most common), and C6, while the level for paraplegia is the thoracolumbar junction (T12). The most common type of injury on admission is ASIA level A.

Season

SCIs occur most frequently in the month of July and least commonly in February. The most common day when SCIs occur is Saturday. SCIs occur more frequently in the daylight hours, which may be due to the increased frequency of vehicular, diving, and other recreational sports accidents.

Substance abuse

The rate of alcohol intoxication among individuals who sustain SCI is 17-49%.

Injuries by ASIA classification

The most common neurologic level of injury is C5. In paraplegia, T12 is the most common level.

Employment

Patients with SCI classified as ASIA D are more likely to be employed than individuals with ASIA A, B, and C. Persons employed tend to work full-time. Individuals who return to work within a year of injury tend to return to the same job. Those individuals who return to work after a year of injury tend to work for a different employer at a different job requiring retraining. The likelihood of employment after injury is greater in patients who are younger, male, and white and who have more formal education, higher reported intelligence quotient (IQ), greater functional capacity, and less severe injury. Patients with greater functional capacity, less severe injury, history of employment at the time of injury, greater motivation to return to work, nonviolent injury, and ability to drive are more likely to return to work, especially after more elapsed time following injury.

Life expectancy

Approximately 10-20% of patients who have sustained SCI do not survive to reach acute hospitalization, with approximately 3% of patients dying during acute hospitalization. Patients aged 20 years at the time of sustaining SCI have life expectancies of approximately 33 years as tetraplegics, 39 years as low tetraplegics, and 44 years as paraplegics. Individuals aged 60 years at the time of injury have a life expectancy of approximately 7 years as tetraplegics, 9 years as low tetraplegics, and 13 years as paraplegics. The annual death rate for patients with acute SCI is 750-1000 deaths per year in the United States.

Leading cause of death

The leading cause of death in patients following SCI is pneumonia and other respiratory conditions, followed by heart disease, subsequent trauma, and septicemia. Among patients with incomplete paraplegia, the leading causes of death among incomplete paraplegics are cancer and suicide (1:1 ratio); among complete paraplegic patients, the leading cause of death is suicide, followed by heart disease. Suicide and alcohol-related deaths are also major causes of death in patients with SCI. The suicide rate is higher among the SCI population who are younger than 25 years. No statistical/epidemiological data have been compiled for nontraumatic SCI, but cancer alone may account for more SCI than trauma. Spondylosis is also a common cause of SCI. Trauma is more common in those younger than 40 years, while nontraumatic injury is more common in persons older than 40 years.

• Spina Bifida

(Synonyms: myelomeningocele, meningocele, leptomyelolipoma, open neural tube defect, closed neural tube defect, spina bifida occulta)
Spina bifida affects 1,500 to 2,000 babies (about 1 in every 2,000 births) in the United States each year and is a serious birth defect.
Fortunately, with the proper medical care, children with spina bifida can lead active and productive lives. Most are successful in school and many are actively involved in modified sports activities despite their physical challenges. Twenty-year follow-up studies of children with spina bifida show they enter college in the same proportion as the general population, and many are actively employed. With recent advancements in care for these children, their prognosis continues to improve.

Description

Spina bifida occurs when the spinal cord does not close properly. This condition can cause a portion of the spinal cord and the surrounding structures to develop outside, instead of inside, the body. Spina bifida can be mild to severe depending on the type of defect, how big it is, where it is and if there are other problems.
A baby's spinal cord forms a few weeks after conception. The spinal cord, and any associated problems, arises from a baby's neural tube -- the structure that eventually develops into the baby's brain, the spinal cord and the tissues that enclose them. Consequently, spina bifida is often referred to as a neural tube disorder (NTD).
Many words are used to describe these defects: myelomeningocele, meningocele, open neural tube defect and closed neural tube defect.

Forms of Spina Bifida

Spina bifida occurs in three forms, each varying in severity:

A closed neural tube defect is often called spina bifida occulta. The spinal cord is not exposed through the skin. This abnormality is often associated with an abnormality in the spine or vertebrae. An open neural tube defect is often called a myelomeningocele. A myelomeningocele is a protrusion of the spinal cord and its coverings through an open defect in the skin of the back.

Treatments for Spina Bifida

Many different parts of the body and nervous system can be affected when a child has spina bifida. A child may need to see numerous physicians and therapists for follow-up. In addition to surgery, physical therapy and early intervention, a child with spina bifida may need treatment for incontinence (inability to control urine and bowel movements) as well as bracing for the legs or spine. In many areas of the country these services are provided through spina bifida clinics.

Goal of Treatment

The primary goal of managing spina bifida is to prevent infection and prevent any further injury to the exposed spinal cord and nerves, not to return neurological function, which was not present at birth.
Specific management of spina bifida will be determined by the child's treatment team based on:

Treatment Options
Surgery

An infant born with a myelomeningocele (a protrusion of the spinal cord and its coverings through an open defect in the skin of the back) will require surgery soon after birth to close this abnormality. Often an infant born with a myelomeningocele will also have associated hydrocephalus (an enlargement of the head due to pressure from trapped cerebral spinal fluid). This condition may require the placement of a shunt to drain the excess cerebral spinal fluid. During the procedure, a neurosurgeon places the spinal cord and exposed tissue inside the body and covers them with muscle and skin. A plastic surgeon is occasionally needed if there is a large area that may be difficult to close. Many babies with myelomeningocele have spinal cords that are less able to properly grow in length as the child grows. This progressive "tethering" can cause loss of muscle function to the legs, bowel or bladder. Surgery on the spinal cord may allow the child to regain a normal level of functioning. Women who know that they are carrying a baby with spina bifida may require a cesarean section (C-section). At Mayo Clinic, this decision is made jointly by the patient and physician. Women may also choose to deliver their child in a large medical center rather than a small community hospital.

Physical therapy

In babies who have myelomeningocele, irreparable nerve damage has already occurred. As soon after surgery as possible, a physical therapist teaches parents how to exercise their baby's legs and feet to prepare for walking with leg braces and crutches. These help prevent damage to the joints and help the child walk.

Urology services

Children who have spina bifida are usually seen by a urologist to evaluate the bladder. The child will usually be tested for bladder function and, if there are problems, a catheterization (insertion of a small tube into the bladder to drain urine) schedule may be started and the parents taught how perform the procedure.

• Cerebral Palsy

Cerebral palsy is a group of disorders characterized by loss of movement or nerve functions. Cerebral refers to brain and palsy to weakness or poor control of muscles. Cerebral palsy is caused by abnormal brain development during fetal development or by injuries to the brain from birth through the first three years of life.
A person with cerebral palsy can have mild to severe physical disabilities. Some people have only a slight limp or an uncoordinated walk. Others have little or no control over their arms and legs or other body part.

Diagnosis

Doctors diagnose cerebral palsy by examining a child's physical and behavioral signs. Additional tests to rule out other disorders that can cause movement problems may also be performed. Mayo Clinic doctors have the expertise and tools to make an accurate diagnosis.

Diagnosis of Cerebral Palsy
Doctors diagnose cerebral palsy by examining a child's physical and behavioral signs. Additional tests to rule out other disorders
that can cause movement problems may also be performed. Mayo Clinic doctors have the expertise and many tools to make an accurate diagnosis.
Other diagnostic procedures that may be included:

Cerebral palsy is generally diagnosed in the first year or two after birth, but it's often difficult to diagnose in the first six months. Each year, about 5,000 American babies and infants are diagnosed with cerebral palsy.
Treatment Options for Cerebral Palsy
Cerebral palsy, although not curable, does worsen over time. However, complications may arise related to abnormal muscle tone and other issues. Treatment aims to improve quality of life, enhance participation socially and academically in school, increase strength, facilitate personal hygiene, reduce disabilities, and prevent complications, such as slowed growth and joint problems. The plan of care depends on the needs and condition of each child and may include:
Physical therapy:
This is one of the most important therapies for people with cerebral palsy. Muscle training and exercises may improve strength, balance and mobility and lead to greater independence. Stretching is one component of a program that may help slow the formation of contractures (limitation of joint range of motion). Physical therapy may begin as soon as a muscle tone abnormality or developmental delay is detected and may continue for years. Specialists assist with recommendations regarding wheelchairs and other mobility devices when needed.

Medications:
Medications may relax tight muscles and reduce tremors and muscle spasms. Injectable medications such as Botox or phenol may be used to reduce areas of muscle spasticity. People who have seizures also may need antiseizure (anticonvulsant) medications. If other medical conditions are present, additional medications may be necessary.
Orthotic devices:
For children with cerebral palsy, muscles do not grow fast enough to keep pace with lengthening bones. The resulting contracture can disrupt balance and trigger loss of abilities. Special braces (orthotic devices) combined with physical therapy and other interventions may prevent this complication by stretching spastic muscles.
Surgery:
Surgery may help loosen tight or stiff muscles or correct problems such as curvature of the spine or uneven leg growth. To decrease spasticity, a surgeon can implant a pump to deliver medications to the spinal cord or sever nerve roots (rhizotomy) that contribute to increased muscle tone.
A child may need surgery on muscles, tendons, nerves or joints to place his or her arms and legs in their correct positions. Surgery can help facilitate sitting or walking, improving a child's ability to use the hands, decreasing pain, easing care issues for families and avoiding future surgeries.
Surgery may also be used to place feeding tubes and to control gastroesophageal reflux. Recently, botulinum toxin injections have been used to reduce or delay the need for surgery.
Occupational therapy:
This therapy often focuses on developing a child's hand function, hand skills and self-care skills. Feeding and swallowing problems may be addressed. Occupational therapists also have expertise regarding special equipment that can benefit a child in daily living, school and mobility.
Speech therapy:
Speech therapists can help children improve their speech and language skills or use of alternative means of communication.
Hearing aid:
Children and adults can benefit from hearing aids.
Eyeglasses or eye surgery:
If glasses are not sufficient to correct a child's vision problems, surgery may be used to correct cross-eye or inability of the eyes to focus together properly (strabismus).

Background:
 Osteoarthritis (OA) is a chronic disease process affecting synovial joints, particularly large weight-bearing joints. OA is particularly common in older patients but can occur in younger patients either through a genetic mechanism or, more commonly, because of previous joint trauma.
Pathophysiology:
Joints can be classified as synovial, fibrous, or combination joints, based on the presence or absence of a synovial membrane and the amount of motion that occurs in the joint. Normal synovial joints allow a significant amount of motion along their extremely smooth articular surface. These joints are comprised of a synovial membrane, articular or hyaline cartilage, subchondral bone, synovial fluid, and a joint capsule. Although traditional teaching prescribes that OA affects primarily the articular cartilage of synovial joints, pathophysiologic changes also occur in the synovial fluid, as well as in the underlying (subchondral) bone and overlying joint capsule.
The affected cartilage initially develops small tears known as fibrillations, followed by larger tears, and eventually it fragments off into joints. The cartilage-forming cells (ie, chondrocytes) replicate in an attempt to keep up with the cartilage loss; however, they eventually are unable to do so, and the underlying bone becomes exposed because of gross areas of bone denuded of cartilage. Bone along the periphery of the joint replicates to form osteophytes, while the subchondral bone along the mid portion of the joint becomes sclerotic, and areas within it eventually may undergo cystic degeneration.
Synovial fluid is formed through an ultrafiltration process of serum by cells termed synoviocytes, which form the synovial membrane. Synovial cells also manufacture the major protein component of synovial fluid, hyaluronic acid, also termed hyaluronate. Synovial fluid acts to provide nutrients to the avascular articular cartilage and to provide viscosity for shock absorption with slow movements and elasticity for shock absorption with rapid movements. The osteoarthritic joint is characterized by decreased concentration of hyaluronic acid because of reduced production by synoviocytes and increased water content as a result of inflammation, particularly during later stages of the disease.
Pain is usually of insidious onset and generally is described as aching or throbbing. Most often, the pain is worse with activity involving the affected joint and initially is relieved with rest, but eventually pain occurs even at rest. Since cartilage itself is aneural, the pain is presumed to be from a combination of mechanisms, including (1) osteophytic periosteal elevation, (2) vascular congestion of subchondral bone leading to increased intraosseous pressure, (3) synovitis with activation of synovial membrane nociceptors, (4) fatigue of muscles that cross the joint, and (5) overall joint contracture.
In addition to the underlying pathophysiologic changes described above, the joint overall may undergo mechanical deformation with resultant malalignment and instability. Alternatively, the joint can ankylose.
History:
Patients with OA generally complain of insidious throbbing arthralgias with activity. Initially, resting relieves the pain. Eventually, the pain occurs even at rest. Intermittent joint swelling and give-way weakness in the knees (ie, quadriceps pain inhibition) are noted.
Physical:
Early in the disease process, physical examination findings include the following:

Later in the disease process, physical examination findings include the following:

Causes:
Primary OA is idiopathic, except in rare cases where a defective gene has been found to cause a familial form of OA.
Secondary OA can be caused by the following:

Rehabilitation Program:
Physical Therapy:
A program of physical therapy should emphasize the importance of strengthening all muscles that cross the given joint affected by OA. Most research focuses on quadriceps strengthening in knee OA. Stress the importance of aerobic conditioning, particularly low-impact exercises if OA affects weight-bearing joints. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Use of assistive devices may be indicated. A cane can be used in the opposite hand for OA of the hip, or a cane in the hand of comfort may be helpful for OA of the knee. Teach the patient joint protection techniques.
Occupational Therapy:
Evaluation of performance of activities of daily living and retraining can be assisted by the occupational therapist. Emphasize joint protection techniques. Hand splinting, especially of the first carpometacarpal joint, may be indicated.
Recreational Therapy:
A home exercise program that incorporates all of the above treatment principles could be designed and implemented to help the patient retain mobility.
Medical Issues/Complications:
Osteophyte formation in the spine can lead to radiculopathy and/or myelopathy. Osteophyte formation in the cervical spine near the vertebral arteries can lead to vertebral artery compression.
Surgical Intervention:
Surgical intervention may be indicated. Types of procedures vary according to the site and the degree of involvement. Various surgical interventions include the following:
Surgical interventions for OA of the knee

Surgical interventions for OA of the hip

Consultations:
Consultation with an orthopedic surgeon sometimes may be needed. Rheumatology consultation is indicated if an alternative diagnosis (eg, rheumatoid arthritis) is suggested.
Other Treatment (injection, manipulation, etc.):
Viscosupplementation, in the form of a series of intra-articular injections of hyaluronate, may be needed. The rationale is that decreased synovial fluid hyaluronate concentration plays a role in pathogenesis in OA of the knee. The US Food and Drug Administration (FDA) has approved hyaluronate only for use in the knee. Currently, 2 products, sodium hyaluronate (Hyalgan) and Hylan GF-50 (Synvisc), are available. They are classified as medical devices, rather than medications. The exact mechanism or mechanisms of action are unknown. This treatment increases synovial fluid viscoelasticity. Viscosity serves to protect joints during slow movements, while elasticity blunts deforming forces during rapid motions. The treatment also appears to convey some anti-inflammatory effect.
Other benefits of the treatment include the following:

Background:
In 1990, nearly 15 million office visits took place for mechanical low back pain (LBP), ranking this problem as the second most common symptom-related reason for seeing a physician. Surveys suggest that the lifetime incidence of LBP ranges from 60-90% with a 5% annual incidence. For persons younger than 45 years, mechanical LBP represents the most common cause of disability, and it is the third most common cause of disability in persons aged older than 45 years. No consensus exists among physicians, physical therapists, or chiropractors concerning the most appropriate treatment and management of mechanical LBP. The physiatrist, however, may possess the best functional understanding of all specialists in applying physical medicine and rehabilitation principles to the treatment and management of mechanical LBP.
History:
Patients generally present with a history of an inciting event that produced immediate LBP. The most commonly reported histories include the following:

Psychosocial factors (eg, depression, hypochondriasis, heavy alcohol consumption, tobacco use, low pay, menial work, poor job satisfaction, stressors at home or work) may accompany histories involving a work-related injury.
Establishing a rapport with the patient is essential to detect serious conditions and to provide insights into the patient's concerns, expectations, and likely response to treatment.
In addition to the history of the present illness, past medical history should be obtained to rule out infections (eg, septic arthritis), congenital abnormalities (eg, dysplasias, juvenile rheumatoid arthritis), metabolic disorders (eg, Paget disease), or previous traumatic causes (eg, athletic participation, military service), history of headache, peptic ulcer disease, prior cancer, or unexplained weight loss.
The review of systems is helpful for relating the current symptoms to any other body parts or systems. Interruption in bowel or bladder function should be a reminder to consider more serious causes of back pain such as a tumor, infection, or fracture. Review of systems also should include a thorough medical history (including history of cancer, arthritis, infection, systemic disease that could increase susceptibility to infection, nocturnal pain, fever, drug use, depression, and symptoms suggestive of metabolic or metastatic disease). Look also for x-ray evidence of herniated nucleus pulposus, spinal stenosis, or other conditions associated with back pain.
Use open-ended questions to ascertain the maximum information about the patient's history.
Commence the history by asking for the patient's age, hand dominance, and occupation. Also ask about the patient's current work status, goals, and perceptions (often wrong). If the back pain is the result of a work-related injury, ask the name of employer and inquire how long the patient has worked for this particular employer. Sample questions are as follows:

Physical:
The single most important part of the physical examination is the general observation of the patient. The patient presents with pain in the low back region and generally places his or her whole hand against the skin to indicate a regional presence, rather than indicating one location.
Realize that much of the physical examination is subjective since a patient-generated response or interpretation to the examiner's questions is required. A directed examination, consistently performed, yields the most objective information that can stand up to rigorous scrutiny by any involved third parties (eg, insurance company, attorney, worker's compensation judge).
Equipment often required for the examination includes a stethoscope, goniometer, inclinometer, pinwheel or safety pin, tape measure, and reflex hammer.

Supine straight leg raising (SLR) test: Reproduction of pain caused by elevation of the contralateral limb raises the probability of a disc herniation to 98%. Remember that the SLR test can be negative in persons with spinal stenosis.
Sitting straight leg raising (knee extension) test (for lower roots): The patient should sit on the table edge with both hips and knees flexed at 90° and extend the knee slowly. This maneuver stretches the nerve roots as much as a moderate degree of supine SLR. The straight leg raising test, if positive, reproduces symptoms of sciatica with pain that radiates below the knee.
The prone SLR test (also called the reverse SLR test or the femoral nerve stretch test) assesses the upper lumbar roots, a less common site of radiculopathy worth remembering.
Nonphysiological testing (Waddell signs): The presence of 3 or more positive findings out of the 5 types may be clinically significant in terms of psychosocial issues or poor surgical outcome. Isolated positive signs are of limited value.
Nonorganic tenderness consists of the following:

Simulation tests give the patient the impression that a particular examination is being conducted, including the following:

Regional disturbances that do not correlate with anatomy include the following:

Causes:
Causes of mechanical LBP generally are attributed to an acute traumatic event but also may include cumulative trauma. The severity of an acute traumatic event ranges widely from twisting one's back to being involved in a motor vehicle collision. Mechanical LBP due to cumulative trauma tends to occur more commonly in the workplace. Observational studies have found a strong correlation between low social support and low job satisfaction and a high incidence of LBP in the workplace.
Rehabilitation Program:
Physical Therapy:
The treatment program for mechanical LBP must have specific functional goals and can be outlined in the following 6 steps:
Control of pain and the inflammatory process
Pain treatment should be initiated early and efficiently to gain control. Ice, transcutaneous electrical nerve stimulation (TENS), and relative rest may help with controlling the pain and the inflammatory process. Excessive bedrest, however, may be detrimental by leading to lumbar segment motion, loss of muscle strength, and general deconditioning with blunting of motivation.
Restoration of joint ROM and soft-tissue extensibility
Extension exercises may reduce neural tension. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia. The use of ultrasound may improve collagen extensibility.
Improvement of muscular strength and endurance
Exercise training can begin after the patient has passed successfully through the pain control phase. The key is to attain adequate musculoligamentous control of lumbar spine forces to minimize the risk of repetitive injury to the intervertebral discs, facet joints, and surrounding structures. Start with isometrics, then progress to isotonic exercises with effort directed at concentric strengthening.
Coordination retraining
Dynamic exercise in a structured training program maximizes coordinated muscle group activities that lead to postural control and the fusion of muscle control with spine stability.
Improvement of general cardiovascular condition
Patients are encouraged to remain active and initiate brisk walking programs, aquatic activities, or use of stationary bicycles/stair steppers. These activities can increase endorphin levels, promoting a sense of well-being, and allow the patient to perform at a higher level of function before perceiving pain.
Maintenance exercise programs
A home program is developed within the tolerance and ability of the patient in order to encourage continued exercise after discharge from physical therapy.
The main goal of physical therapy in acute back pain is not to increase strength, but to achieve adequate pain control. No benefit has been demonstrated for strengthening exercises in acute back pain. Exercise should begin with extension exercises in the prone position after lateral trunk shifts and then progress, as tolerated, to prone lying with support. Flexion exercises can be performed only if no acute dural tension exists.
The spine should be stabilized using strengthening of segmental muscles followed by the prime movers of the spine (latissimus dorsi, abdominals, erector spinae). Muscle groups should be strengthened in a neutral position to decrease tension on ligaments and joints; this position allows balanced segmental forces between the discs and the zygapophyseal joints and maximizes functional stability with axial loading.
Physical therapy programs also should include positioning the patient to maximize comfort. Loosening of the hamstrings, glutei, gastrocnemius/soleus group, tensor fascia latae, quadriceps group, and hip flexors also contributes to reduction of LBP and effective conditioning.
Medical Issues/Complications:
Mechanical LBP is not a life-threatening illness. Unfortunately, it does have a far-reaching impact on medical care expenditures for injured workers. An in-depth examination of the impact of mechanical LBP on the US workers' compensation system, which varies from state to state, is beyond the subject of this article. Many interesting perceptions about mechanical LBP have been noted.
In studies where subjects had to answer self-assessment instruments, patients with insurance referrals had poorer self-assessment scores regardless of functional status.
Among different health care providers, patients rated care and communication, followed by competence, over efficacy of treatment.
Chiropractors often have been favored over internists and orthopedic surgeons on the basis of their "high touch" approach to treatment.
Orthopedic surgeons were found to be less restrictive with activities compared to family practitioners.
In a Dutch study, factors such as better health, better job satisfaction, being the bread winner, lower age, and reporting of less pain, were favorable prognosticators of return to work in individuals who had not been working for more than 3 months. The authors of the study believed that more focus was necessary on the psychosocial aspects of health behavior and job satisfaction.
Exercise was found to be more effective than usual primary care management.
Surgical Intervention:
Surgical interventions for mechanical LBP are the last choice for treatment. Discectomies are performed in the US at a rate proportional to the number of spine surgeons in the community. The US rate of surgeries is twice that of Europe, Canada, and Australia, and 5 times the rate in the UK. Better results occur with open excisions, compared with percutaneous discectomies. Results were best when there was no workers' compensation or litigation involved.
Other Treatment (injection, manipulation, etc.):

Deep brain stimulation suppresses tremor by delivering mild electrical stimulation to block brain signals that cause the uncontrollable shaking.
A thin, insulated wire lead with four electrodes at the tip is surgically implanted into the thalamus area of the brain. A wire runs under the skin to a battery-operated pulse generator implanted near the collarbone. The generator is programmed by a movement disorders clinician to send continuous electrical pulses to the brain. It can be turned on or off by the patient swiping a special magnet over the generator. (Patients typically turn off the device at night, because tremors stop during sleep.)
To implant the electrodes, a neurosurgeon uses a stereotactic head frame and imaging (such as an MRI or CT scan) to map the brain and pinpoint the thalamus. The patient's scalp is anesthetized before the procedure, but the patient is awake while the electrodes are placed to report side effects, and by holding a cup or moving an arm, show how well the tremor is being suppressed. This allows the lead to be placed for maximum effectiveness and minimum side effects. The patient will receive sedation or general anesthesia before the wire lead and the pulse generator are implanted.
Deep brain stimulation can be done on one or both sides of the brain, depending on the disorder and the patient's problems.
Side effects are generally mild and reversible. The most common are a temporary tingling in the limbs, slight paralysis, slurred speech and loss of balance.
Battery life varies with usage and settings. Generally, the battery should last about five years with 16 hours of use a day. When the battery needs to be replaced, the pulse generator is replaced, usually under local anesthesia in an outpatient procedure.
The procedure is expensive. It uses both sophisticated surgical and implanted equipment. This does not include the cost of surgery or hospitalization. Fortunately, Medicare and many insurance plans cover most costs associated with thalamic deep brain stimulation. Other uses of deep brain stimulation will likely be covered in the future.
Deep brain stimulation has dramatically changed the lives of many patients with uncontrollable tremors. Patients often can resume normal activities, such as feeding and dressing themselves, and can have active and fulfilling lives. The need for anti-tremor medications is often reduced or eliminated.