EPITOMES-PHYSICAL MEDICINE AND REHABILITATION
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All team members can provide a supportive and educational role. Defining the family's goals for the patient (and themselves) should be initiated early during the rehabilitation course, when the team's plans and goals for treatment are established. The therapists can instruct the family how to assist the patient in various activities of daily living, transfers, ambulation, and communication. Medication regimens, bowel and bladder management, and skin care can be taught by the nursing staff. It is important for the rehabilitation team to incorporate the family into the care of the stroke patient and the careful planning for the return home for a smoother, less stressful transition and readjustment. The role of a comprehensive rehabilitation program becomes evident to this end. The better adjusted the family is to the consequences of the stroke, the better the physical and emotional recovery the patient will likely make and maintain after discharge. JEFFREY TERAOKA, MD RENEE BURGARD, LCSW Stanford, California REFERENCES Berk SN, Schall RR: Psychosocial factors in stroke rehabilitation, In Goldberg G (Ed): Physical Medicine and Rehabilitation Clinics-Vol 2. Philadelphia, PA, WB Saunders, 1991, pp 547-562 Evans RL, Bishop DS, Matlock A, Stranahan S, Halar EM, Noonan WC: Prestroke family interaction as a predictor of stroke outcome. Arch Phys Med Rehabil 1987; 68:508-512 Evans RL, Bishop DS, Matlock A, Stranahan S, Smith GG, Halar EM: Family interaction and treatment adherence after stroke. Arch Phys Med Rehabil 1987; 68:513-5 17 Malec JF, Richardson JW, Sinaki M, O'Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil 1990; 71:279-284
Focal Dystonia in Musicians DYSTONIA IS A SPECIFIC type of involuntary movement characterized by sustained muscle contractions, often causing twisting and repetitive movements. Although dystonic movements can be seen secondarily in a number of conditions, including inherited disorders, Wilson's disease, drug and heavy metal toxicity, and stroke, adult-onset dystonia is usually idiopathic and often starts and remains localized to a circumscribed body part. Well-known examples of focal dystonia are writer's cramp and blepharospasm, but similar dysfunctions occur in musicians' hands and facial muscles. The incidence of writer's cramp has been estimated to be 3 per 1 million person-years. The incidence of focal dystonia in musicians is not known, but about 10% of musicians seen in arts medicine centers have motor control problems. For the better part of this century, the dystonias were thought of as functional, psychiatric syndromes. This view no longer predominates because objective findings have been shown. Although the diagnosis remains one of exclusion, in musicians symptoms may include weakness, a loss of control, the drooping of fingers, involuntary flexing and extending, difficulty relaxing, difficulty moving fingers off keys, and difficulty with rapid alternating, ascending, or descending patterns. Facial involvement manifests as difficulty with embouchure. Pain is not common. The abnormal movement is usually task specific and requires examining the patients as they play their instruments. Men are affected by a ratio of 2 to 1. A family history of movement disorders such as essential tremor and Parkinson's disease may raise the index of suspicion. There does not appear to be an association between handedness or number of years playing. A history of some earlier injury to the affected area, such as transient
overuse from excessive practicing, is common. The yield is low from workup for an underlying disease, but any suggestion of nerve entrapment should be fully evaluated electrodiagnostically because there have been occasional reports of dystonia resolving following a surgical release. In general, only 5% of cases of dystonia resolve spontaneously. The basal ganglia are thought to be the site ofthe disorder, but no identifiable lesions have been shown on imaging studies-computed tomography, magnetic resonance imaging-in musicians. Recently abnormalities in the normal pattern of reciprocal inhibition between agonist and antagonist muscles have been observed electrophysiologically. Instead of the normal, smoothly coordinated pattern of antagonist relaxation with agonist contraction, a defect in presynaptic inhibition occurs at the spinal level (possibly due to a disruption of descending control from the subcortical areas), resulting in an abnormal cocontraction seen clinically as a cramp or involuntary movement. These findings are not unique to dystonia but do provide objective evidence of central, neurophysiologic disturbance. No single treatment has been consistently successful. Electromyographic biofeedback, manipulative and movement therapies (such as the Alexander technique), stretching and strengthening exercises, relaxation techniques, and laborious retraining of musical technique have been of some benefit in a few cases. Anticholinergics (trihexyphenidyl hydrochloride) have been the most effective medications. Administering botulinum toxin to the abnormally contracting muscle has been effective in reducing the involuntary contraction in several types of dystonia, most notably blepharospasm, torticollis, and spasmodic dysphonia. Results in instrumental musicians have been mixed because of unavoidable weakness and the need for repeated administrations. The success of treatment in musicians depends largely on the playing requirements of each person. A better result can be expected for a section player than a concert soloist. Unfortunately, substantial compromises often must be made in repertoire, tempo, and overall performing availability. Patients should be encouraged to consider other outlets such as teaching, conducting, and composing. The best approach at this time combines physical, pharmacologic, and pedagogic measures.
SCOTT E. BROWN, MD
Loma Linda, California
REFERENCES Brin MF, Fahn S, Moskowitz C, et al: Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Adv Neurol 1988; 50:599-608 Lederman RJ: Focal dystonia in instrumentalists: Clinical features. Med Problems Perforn Art 1991; 6: 132-136 Panizza ME, Hallett M, Nilsson J: Reciprocal inhibition in patients with hand cramps. Neurology 1989; 39:85-89
Venous Thromboembolism in Stroke THE INCIDENCE OF deep venous thrombosis is greatly increased in patients who have survived a stroke. Its risk is higher in patients with the most severe leg weakness, and, in patients at highest risk who do not receive thrombotic prophylaxis, the incidence may be as high as 75%. Although most thrombi have been detected within the first week following a stroke, the risk of deep venous thrombosis continues after the acute phase. Almost a third of patients admitted to a rehabilitation hospital after a recent stroke have deep venous thrombosis that can be detected by impedance plethysmography, despite being unsuspected clinically. Stud-
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All team members can provide a supportive and educational role. Defining the family's goals for the patient (and themselves) should be initiated early during the rehabilitation course, when the team's plans and goals for treatment are established. The therapists can instruct the family how to assist the patient in various activities of daily living, transfers, ambulation, and communication. Medication regimens, bowel and bladder management, and skin care can be taught by the nursing staff. It is important for the rehabilitation team to incorporate the family into the care of the stroke patient and the careful planning for the return home for a smoother, less stressful transition and readjustment. The role of a comprehensive rehabilitation program becomes evident to this end. The better adjusted the family is to the consequences of the stroke, the better the physical and emotional recovery the patient will likely make and maintain after discharge. JEFFREY TERAOKA, MD RENEE BURGARD, LCSW Stanford, California REFERENCES Berk SN, Schall RR: Psychosocial factors in stroke rehabilitation, In Goldberg G (Ed): Physical Medicine and Rehabilitation Clinics-Vol 2. Philadelphia, PA, WB Saunders, 1991, pp 547-562 Evans RL, Bishop DS, Matlock A, Stranahan S, Halar EM, Noonan WC: Prestroke family interaction as a predictor of stroke outcome. Arch Phys Med Rehabil 1987; 68:508-512 Evans RL, Bishop DS, Matlock A, Stranahan S, Smith GG, Halar EM: Family interaction and treatment adherence after stroke. Arch Phys Med Rehabil 1987; 68:513-5 17 Malec JF, Richardson JW, Sinaki M, O'Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil 1990; 71:279-284
Focal Dystonia in Musicians DYSTONIA IS A SPECIFIC type of involuntary movement characterized by sustained muscle contractions, often causing twisting and repetitive movements. Although dystonic movements can be seen secondarily in a number of conditions, including inherited disorders, Wilson's disease, drug and heavy metal toxicity, and stroke, adult-onset dystonia is usually idiopathic and often starts and remains localized to a circumscribed body part. Well-known examples of focal dystonia are writer's cramp and blepharospasm, but similar dysfunctions occur in musicians' hands and facial muscles. The incidence of writer's cramp has been estimated to be 3 per 1 million person-years. The incidence of focal dystonia in musicians is not known, but about 10% of musicians seen in arts medicine centers have motor control problems. For the better part of this century, the dystonias were thought of as functional, psychiatric syndromes. This view no longer predominates because objective findings have been shown. Although the diagnosis remains one of exclusion, in musicians symptoms may include weakness, a loss of control, the drooping of fingers, involuntary flexing and extending, difficulty relaxing, difficulty moving fingers off keys, and difficulty with rapid alternating, ascending, or descending patterns. Facial involvement manifests as difficulty with embouchure. Pain is not common. The abnormal movement is usually task specific and requires examining the patients as they play their instruments. Men are affected by a ratio of 2 to 1. A family history of movement disorders such as essential tremor and Parkinson's disease may raise the index of suspicion. There does not appear to be an association between handedness or number of years playing. A history of some earlier injury to the affected area, such as transient
overuse from excessive practicing, is common. The yield is low from workup for an underlying disease, but any suggestion of nerve entrapment should be fully evaluated electrodiagnostically because there have been occasional reports of dystonia resolving following a surgical release. In general, only 5% of cases of dystonia resolve spontaneously. The basal ganglia are thought to be the site ofthe disorder, but no identifiable lesions have been shown on imaging studies-computed tomography, magnetic resonance imaging-in musicians. Recently abnormalities in the normal pattern of reciprocal inhibition between agonist and antagonist muscles have been observed electrophysiologically. Instead of the normal, smoothly coordinated pattern of antagonist relaxation with agonist contraction, a defect in presynaptic inhibition occurs at the spinal level (possibly due to a disruption of descending control from the subcortical areas), resulting in an abnormal cocontraction seen clinically as a cramp or involuntary movement. These findings are not unique to dystonia but do provide objective evidence of central, neurophysiologic disturbance. No single treatment has been consistently successful. Electromyographic biofeedback, manipulative and movement therapies (such as the Alexander technique), stretching and strengthening exercises, relaxation techniques, and laborious retraining of musical technique have been of some benefit in a few cases. Anticholinergics (trihexyphenidyl hydrochloride) have been the most effective medications. Administering botulinum toxin to the abnormally contracting muscle has been effective in reducing the involuntary contraction in several types of dystonia, most notably blepharospasm, torticollis, and spasmodic dysphonia. Results in instrumental musicians have been mixed because of unavoidable weakness and the need for repeated administrations. The success of treatment in musicians depends largely on the playing requirements of each person. A better result can be expected for a section player than a concert soloist. Unfortunately, substantial compromises often must be made in repertoire, tempo, and overall performing availability. Patients should be encouraged to consider other outlets such as teaching, conducting, and composing. The best approach at this time combines physical, pharmacologic, and pedagogic measures.
SCOTT E. BROWN, MD
Loma Linda, California
REFERENCES Brin MF, Fahn S, Moskowitz C, et al: Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Adv Neurol 1988; 50:599-608 Lederman RJ: Focal dystonia in instrumentalists: Clinical features. Med Problems Perforn Art 1991; 6: 132-136 Panizza ME, Hallett M, Nilsson J: Reciprocal inhibition in patients with hand cramps. Neurology 1989; 39:85-89
Venous Thromboembolism in Stroke THE INCIDENCE OF deep venous thrombosis is greatly increased in patients who have survived a stroke. Its risk is higher in patients with the most severe leg weakness, and, in patients at highest risk who do not receive thrombotic prophylaxis, the incidence may be as high as 75%. Although most thrombi have been detected within the first week following a stroke, the risk of deep venous thrombosis continues after the acute phase. Almost a third of patients admitted to a rehabilitation hospital after a recent stroke have deep venous thrombosis that can be detected by impedance plethysmography, despite being unsuspected clinically. Stud-
