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Biomedical subjects

N E Walsh

Publications and source records attributed to N E Walsh.

At least 19 recordsLinked to original sources
PubMed1996

Physical medicine and rehabilitation workforce study: the supply of and demand for physiatrists.

OBJECTIVE: Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN: A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS: Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS: Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.

Forecasting↗
PubMed1990

A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain.

A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.

Back Pain↗
PubMed1990

Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain.

Therapeutic trials often attempt to "blind" patient and investigator to the true nature of treatments received, reducing the influences of conscious or subconscious prejudices. In drug trials, this is accomplished with placebo tablets, but blinding in trials of physical treatments is more problematic. This issue arose in a clinical trial of transcutaneous electrical nerve stimulation (TENS) for patients with chronic low back pain. Several study design features were incorporated to promote blinding: use of sham TENS units visually identical with real units, exclusion of potential subjects with previous TENS experience, avoidance of a crossover design and use of identical visit frequency, instructions and modifications in electrode placement. Subjects were asked not to discuss treatments with the clinicians who performed outcome assessments. Both patients and clinicians were asked to guess actual treatment assignments at the trial's end. Every patient in the true TENS group believed the unit was functioning properly, but the degree of certainty varied. In the sham TENS group, 84% also believed they had functioning units, but their certainty was significantly less than in the active treatment group. Differences in patient perceptions did not affect compliance, as the two groups had similar dropout rates, appointment compliance, days of TENS use and daily duration of TENS use. Clinicians guessed treatments correctly 61% of the time (as opposed to 50% expected by chance), again suggesting partial success in blinding. These efforts at blinding may partly explain the negative trial results for TENS efficacy. We conclude that complete blinding is difficult to achieve because of sensory difference in treatment and unintended communication between patient and examiner.(ABSTRACT TRUNCATED AT 250 WORDS)

Back Pain↗
PubMed1990

The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace.

This study was designed to determine the effect of multimodal intervention and the prevention of back injury, and to evaluate the adverse side effects of using a lumbosacral corset in the workplace. Subjects were 90 male warehouse workers randomly selected from over 800 employees at a grocery distribution center. Subjects were assigned to three groups: true controls, no back school, no brace orthoses; back school only; and back school plus wearing a custom molded lumbosacral orthosis. Comparisons of pre-testing and 6-month follow-up post-testing for abdominal strength, cognitive data, work injury incidence and productivity and use of health care services were evaluated. Controls and training-only group showed no changes in strength productivity or lost time. Orthoses and training-group showed no changes in strength productivity or accident rate; however, they showed substantially less lost time. This study supports the concept of using education and prophylactic bracing to prevent back injury and reduce time loss. It appears that the use of intermittent prophylactic bracing has no adverse affects on abdominal muscle strength and may contribute to decreased lost time from work injuries.

Abdomen↗
PubMed1989

Evaluation of neurolytic blocks using phenol and cryogenic block in the management of chronic pain.

This study compared the use of phenol and cryogenic blocks for neurolysis in 28 patients. Patients were assigned randomly to receive peripheral nerve blocks with either phenol or cryoanalgesia. Significantly more patients in the phenol group received 20% or greater relief at 2, 12, and 24 wk than patients in the cryogenic group. Only 27% of patients received significant relief, however, indicating that neurolytic blocks were not particularly effective even though local anesthetic blocks produced significant but temporary pain relief.

Adult↗
PubMed1989

Normative model for cold pressor test.

The cold pressor test elicits an emotional/motivational pain experience from the immersion of a limb in cold water. It has been widely used to evaluate (experimental and chronic) pain. However, normative models for quantification and comparison for pain tolerance have not previously been established. This study developed a normative mathematical model for pain tolerance using the cold pressor test with over 600 subjects. Norms for age, sex, and ethnic group were calculated. In addition, chronic pain patients were compared with pain-free patients to determine normative differences in response. The results indicate that at any given age Anglo-Saxon males have the longest tolerance time followed by non-Anglo-Saxon males, Anglo-Saxon females, and finally non-Anglo-Saxon females. There is a consistent decrease in tolerance time as the male age increases and minimal change in tolerance time as the female age increases. Chronic pain patients exhibited the same type of pain response pattern as healthy volunteers when corrected for age, sex, and ethnocultural subgroup.

Adolescent↗
PubMed1989

Diagnostic epidural opioid technique.

Diagnostic epidural blocks were performed on 27 chronic pain patients sequentially using saline, fentanyl, and lidocaine solution. The patients were divided into one of four groups based on their response to the epidural solutions: placebo response group--pain relief with placebo solutions; fentanyl response group--pain relief with epidural fentanyl; lidocaine response group (LRG)--pain relief with lidocaine but not fentanyl; and no response group--no pain relief with any of the solutions used. The four groups were compared on the basis of age, sex, site of pain, duration of pain, narcotic use, pain assessment index, and workmen's compensation claims. The comparisons resulted in the conclusion that LRG patients had a much longer average duration of pain than the other groups. On the basis of the information gathered, it was theorized that, despite their response to epidural lidocaine, LRG patients may actually be a group of operant pain patients. Their failure to receive analgesia from epidural fentanyl may be a learned response such that they associate any sensory input from the affected area as painful. If follow-up studies support these findings, then the diagnostic opioid technique may be a more sensitive tool in diagnosing chronic pain.

Adult↗
PubMed1989

Studies of the Modified Somatic Perceptions Questionnaire (MSPQ) in patients with back pain. Psychometric and predictive properties.

The Modified Somatic Perceptions Questionnaire (MSPQ) was designed to measure heightened somatic awareness among patients with chronic pain. It was hoped that this questionnaire would help predict therapeutic responses for back pain patients. The reliability, validity, and predictive characteristics of this scale were tested among 97 patients with chronic low-back pain enrolled in a clinical trial of transcutaneous nerve stimulation and stretching exercises. Internal consistency was good (alpha = 0.78), and correlations with the Zung depression scale and certain MMPI scales were significant. Correlations with a baseline functional scale (the Sickness Impact Profile) were stronger than those with the MMPI. Unfortunately, the MSPQ did not correlate with functional outcomes, and was only weakly associated with pain outcomes. Thus, the MSPQ appears to be reliable and valid, but the somatic perceptions it measures may have little relation to patient outcomes.

Awareness↗
PubMed1989

The premotor potential.

A small waveform precedes the compound muscle action potential evoked from the thenar eminence with median nerve stimulation with high amplifier gains. This potential is believed to emanate from fibers destined to innervate the volar aspect of the first digit. It has been suggested recently that the source of the premotor potential is the palmar cutaneous branch of the median nerve. In this study, the palmar cutaneous branch of the median nerve was blocked at the wrist. A localized zone of anesthesia was observed over the proximal midpalm, not the thenar eminence, and the premotor response remained unchanged as did a midpalmar potential. The median nerve was then blocked at the base of the thenar eminence; only then did the premotor potential disappear. The palmar cutaneous branch of the median nerve innervates only a small portion of the medial aspect of the thenar eminence and does not produce the thenar premotor potential. Additionally, because of the close proximity of the main median nerve to its palmar cutaneous branch, volume conduction of stimuli and responses precludes an electrophysiologic technique which exclusively localizes the palmar cutaneous branch of the median nerve.

Action Potentials↗
PubMed1988

Practical instrumentation and common sources of error.

A thorough comprehension of electrodiagnostic equipment is essential to consistently obtain accurate and reproducible data. Unreliable waveform latencies or morphologies may result from inappropriate filter settings, sensitivity comparisons, sweep speeds, interelectrode separation, cathode/anode reversals and stimulus artifact. A low frequency filter with too high a frequency limit may decrease amplitude, shorten peak latency, decrease the negative spike duration, add a phase and increase total waveform duration. A high frequency filter with too low a cut-off may decrease amplitude and prolong onset and peak latencies. Increasing the amplifier's sensitivity may shorten the onset latency of a response. Sweep speeds that are too slow may omit phases, turns or entire potentials when using digital equipment. If the interelectrode separation is inadequate, waveform morphology and amplitude can be altered. Reversing cathode and anode placement affects latency and velocity determinations. Stimulus artifact may obscure a response and its reduction must be understood. Comparing latencies and amplitudes at different instrument settings is never appropriate and can lead to serious errors and misdiagnoses. A naive approach to instrumentation, therefore, is indefensible.

Electrodiagnosis↗
PubMed1988

Electrophysiologic evaluation of the facial nerve in Bell's palsy. A review.

Facial nerve paralysis is the most common mononeuropathy and idiopathic facial paralysis (Bell's palsy) the most common seventh nerve disease electromyographers may be asked to evaluate. The electrophysiologic method of choice to assess the facial nerve is side-to-side evoked amplitude comparison with the affected side expressed as a percentage of the nonaffected side. This examination should be performed on days 3, 5, 7, 9, 11 and 13 after onset of paralysis. If the percentage of surviving axons falls below 10% within the first 14 days, an incomplete recovery is suggested. Electromyography may assist in prognosticating a functional return, determining neural conduction across the site of injury and following reinervation in the recovery period. The persistence or early return of an absent R1 component of the blink reflex may qualitatively suggest a satisfactory functional outcome in facial paralysis. Supramaximally exciting the facial nerve at the stylomastoid foramen and comparing the clinical response on the affected and nonaffected side, maximum stimulation test, can also predict eventual seventh nerve return. Observing a minimal twitch, utilizing the nerve excitability test or measuring the facial nerve latency have yielded poor correlations with functional return and are of limited usefulness in the prognostication of acute facial palsies. Trigeminal somatosensory evoked potentials can be employed to evaluate the status of the trigeminal nerve as approximately 50% of patients with Bell's palsy also have lesions involving the fifth nerve. Side-to-side amplitude comparison and electromyography are the two most valuable electrophysiologic methods of assessing facial nerve functioning.

Action Potentials↗
PubMed1988

Prognostic variability among chronic pain patients: implications for study design, interpretation, and reporting.

Chronic pain patients share many characteristics, but there is important prognostic variability among them. By selecting for certain characteristics, different recruitment methods and entry criteria for clinical or research programs may influence the likelihood of success regardless of treatment efficacy. This was demonstrated when subjects (n = 55) were recruited through lay publicity for a clinical trial of therapy for chronic back pain. In comparison to routine pain clinic patients (n=61), subjects in the clinical trial were better educated, were more often employed, had more favorable personality profiles, and were less likely to have had surgery or narcotic use (all p less than 0.004). Pain relief was significantly better for clinical trial subjects, apparently due to baseline prognostic differences rather than uniquely efficacious therapy. We conclude that chronic pain patients vary in prognostically important ways; that recruitment methods and criteria strongly influence these characteristics; and that greater attention to these details is needed when interpreting and reporting clinical research.

Adult↗
PubMed1987

Brachial neuritis involving the bilateral phrenic nerves.

Brachial neuritis with bilateral hemidiaphragmatic paralysis has been reported in two previous cases in the literature. We report a patient who experienced severe right shoulder discomfort three weeks prior to hospital admission which evolved to include both shoulders. Two weeks prior to admission he noticed the onset of discomfort in breathing in the supine position and shortness of breath with minor exertion. The admitting diagnoses were myocardial infarction due to significant ECG changes and idiopathic elevated bilateral hemidiaphragms. The patient had findings significant for tachypnea, dyspnea, decreased breath sounds at the bases bilaterally, impaired motion of the bilateral lung bases on inspiration and paradoxical respirations. Comprehensive medical testing and evaluation revealed bilateral elevated hemidiaphragms and vital capacity 40% of normal. Weakness of the proximal shoulder girdle and bicep musculature bilaterally was noted. Electromyography was significant for reduced recruitment pattern in the bilateral shoulder girdle musculature. Nerve conduction studies suggested bilateral phrenic neuropathy. This case is an unusual presentation of brachial neuritis affecting the bilateral shoulder girdle with phrenic nerve involvement. The differential diagnosis of acute shoulder pain associated with respiratory symptomatology should therefore include brachial neuritis.

Brachial Plexus↗
PubMed1986

Analgesic effectiveness of D-phenylalanine in chronic pain patients.

Enkephalins are a biochemical pathway for endogenous analgesia. A number of compounds inhibit degradation of enkephalins within the body. One of these compounds, D-phenylalanine (DPA), has been shown to increase the pain threshold in animals. It is hypothesized that this naloxone reversible analgesia is induced by DPA blockage of enkephalin degradation by the enzyme carboxypeptidase A. Preliminary studies of chronic pain patients have shown a response rate to DPA from 32% to 75%. This study was a double-blind crossover evaluation of a randomized parallel design to determine the efficacy of DPA in 30 subjects with chronic pain from varied etiology which was unrelieved by multiple therapeutic interventions. Each patient received a stabilized therapeutic regimen during this study consisting of four weeks of either DPA 250 mg or lactose (placebo) orally four times a day. After four weeks the DPA and placebo groups were crossed over for an additional four weeks of treatment. Pain was quantified using a visual analog pain scale and a cold pressor test. Data from the pain questionnaires revealed more pain relief on DPA reported by 25% of the patients, more pain relief on placebo reported by 22% of the patients, and no difference in pain relief reported by 53% of the patients. Lowest pain level of the visual analog scale was reported by 47% of the patients on DPA and 53% on placebo. There appears to be no significant analgesic effect from D-phenylalanine in chronic pain patients when compared to placebo.

Animals↗
PubMed1983

An epidemiologic study of the risks associated with peripheral intravenous catheters.

As part of a standardized, multi-hospital prospective surveillance system for nosocomial infections in Rhode Island, an analysis was undertaken in March 1980-February 1982 to determine the interplay of factors that contribute to the risk of phlebitis in peripheral, non-steel, non-butterfly intravenous catheters. The authors studied 3094 patients with 5161 total episodes of peripheral intravenous catheters from day of admission until day of discharge. The overall rate of phlebitis was 2.3% (118 episodes), and the rate of intravenous catheter-associated bacteremia was 0.08% (1 definite episode, 3 possible episodes). Factors significantly associated with the occurrence of phlebitis were: underlying risk for any nosocomial infection, duration of the catheter episode, chronological order of the episode and an interaction between the latter two variables. Analysis of day-specific risk of phlebitis indicated that, for patients with low risk diagnoses, initial peripheral intravenous catheters might be left in place with relative safety for up to 96 hours. Over this time period, the day-specific risk for such patients ranged between 0.8% and 1.4%, exclusive of the first day. In all other circumstances, the current recommendation of 48-72 hours seems appropriate.

Adult↗