Physical Medicine and Rehabilitation
Urinary tract infections (UTIs) in catheterized patients are considered “complicated UTIs”. However, this term can be misleading and prompt clinicians to over treat infections in this population. It is generally recommended that persons with spinal cord injury (SCI) be treated for bacteriuria only if they have symptoms. Specifically, the 2006 Consortium for Spinal Cord Medicine Guidelines for Healthcare Providers require that the following three criteria be met before an individual with SCI is diagnosed with a UTI: (1) significant bacteriuria, (2) pyuria, and (3) signs and symptoms of a UTI.
Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. J Spinal Cord Med. 2006; 29(5): 527–573. PMID: 17274492.
Hsieh J, et al. Spinal Cord Injury Rehabilitation Evidence: Bladder Management Following Spinal Cord Injury, version 5.0 [Internet]. 2014 [cited 2016 Sep 26].
Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Bed rest is often used to treat a variety of medical conditions. Prolonged bed rest causes major cardiovascular, respiratory, musculoskeletal and neuropsychological changes. Negative effects include thromboembolism, pneumonia, muscle wasting and physical deconditioning. Many of the negative effects begin within days of confinement, but consequences can last much longer. Specifically, in acute DVT/PE, bed rest has no impact on the risk of developing new PE. Furthermore, in acute low back pain, advice to stay active compared to rest in bed showed benefits in pain relief and functional improvement. Therefore, it is important to limit bed rest as much as possible.
Adler J, et al. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012 Mar;23(1):5-13. PMID: 22807649.
Aissaoui N, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009 Sep 11;137(1):37-41. PMID: 18691773.
Castelino T, et al. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Surgery. 2016 Apr;159(4):991-1003. PMID: 26804821.
Dahm KT, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612. PMID: 20556780.
Stuempfle K, et al. The physiological consequences of bed rest. Journal of Exercise Physiology. 2007;10(3):32-41.
Patient Pamphlets: Treating Lower Back Pain: How much bed rest is too much?
Prescription pain medications have been shown to be effective for pain relief. However, a number of adverse events have been established. While pain reduction is an important outcome measure for patients, they also highly value improved function and quality of life. The addition of prescription pain medications does not always improve functional outcomes, or even pain. There is also a significant risk of long-term addiction. It is imperative that providers work with patients to establish treatment goals, regularly reassess pain and function, and taper or discontinue medications as able or if patients experience harm.
Chapman JR, et al. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S54-68. PMID: 21952190.
Chou R, et al. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14. PMID: 17909211.
Friedman BW, et al. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015 Oct 20;314(15):1572-80. PMID: 26501533.
Harned M, et al. Safety concerns with long-term opioid use. Expert Opin Drug Saf. 2016 Jul;15(7):955-62. PMID: 27070052.
Houry D, et al. Announcing the CDC guideline for prescribing opioids for chronic pain. J Safety Res. 2016 Jun;57:83-4. PMID: 27178083.
Low back pain is one of the leading causes of disability, with a lifetime prevalence of 40%. Routine imaging for low back pain in the absence of red flag symptoms does not change clinical outcomes including pain, function, quality of life and mental health. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. In comparing early versus late imaging for non-specific low back pain, there is no difference between groups in terms of overall treatment plan. Imaging can result in “labeling” of patients, exposure to radiation, and unnecessary invasive procedure.
Chou R, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918.
Gilbert FJ, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome–multicenter randomized trial. Radiology. 2004 May;231(2):343-51. PMID: 15031430.
Jarvik JG, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar 17;313(11):1143-53. PMID: 25781443.
Srinivas SV, et al. Application of “less is more” to low back pain. Arch Intern Med. 2012 Jul 9;172(13):1016-20. PMID: 22664775.
Patient Pamphlets: Imaging Tests for Lower Back Pain: When you need them and when you don’t
After initial stabilization and when intracranial pressure is controlled, the use of benzodiazepines in the acute phase of traumatic brain injury should be limited to specific medical indications, such as alcohol withdrawal. In animal models of acute TBI, benzodiazepines have been associated with slowed or halted recovery. Moreover, benzodiazepines have adverse effects on cognition, and can cause respiratory depression, paradoxical agitation, and anterograde amnesia. Non-pharmacologic interventions are essential components of the management of agitation after TBI. Beta blockers, such as propranolol, are first line pharmacotherapeutic agents, and anticonvulsants can also be used to decrease agitated behaviours.
Goldstein LB. Prescribing of potentially harmful drugs to patients admitted to hospital after head injury. J Neurol Neurosurg Psychiatry. 1995 Jun;58(6):753-5. PMID: 7608684.
Lombard LA, et al. Agitation after traumatic brain injury: considerations and treatment options. Am J Phys Med Rehabil. 2005 Oct;84(10):797-812. PMID: 16205436.
Rao V, et al. Aggression after traumatic brain injury: prevalence and correlates. J Neuropsychiatry Clin Neurosci. 2009 Fall;21(4):420-9. PMID: 19996251.
Schallert T, et al. Recovery of function after brain damage: severe and chronic disruption by diazepam. Brain Res. 1986 Jul 30;379(1):104-11. PMID: 3742206.
Zafonte RD. Treatment of agitation in the acute care setting. J Head Trauma Rehab. 1997;12(2):78-81.
Carpal tunnel release is a highly effective treatment for Carpal Tunnel Syndrome. Clinicians considering referral for surgical management should be aware that good surgical outcome is best correlated with a combination of positive clinical and positive electrodiagnostic studies (EDX). Clinical tests together with EDX have a better association with surgical outcome than either alone. Pre-op nerve conduction study severity can also better predict time to resolution and degree of resolution of symptoms.
Basiri K, et al. Practical approach to electrodiagnosis of the carpal tunnel syndrome: A review. Adv Biomed Res. 2015 Feb 17;4:50. PMID: 25802819.
Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40. PMID: 11410921.
Fowler JR, et al. Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release. J Hand Surg Eur Vol. 2016 Feb;41(2):137-42. PMID: 25770901.
Keith MW, et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009 Jun;17(6):389-96. PMID: 19474448.
Ono S, et al. Optimal management of carpal tunnel syndrome. Int J Gen Med. 2010 Aug 30;3:255-61. PMID: 20830201.