Critical Pathways in Therapeutic Intervention: Upper Extremities.

Saidoff DC, McDonough AL. St Louis, MO, 63146, Mosby-Year Book Inc, 1997, hardback, $37.95.

This book was written to provide insight into the decision-making process that occurs during the evaluation and treatment of a variety of upper-extremity conditions commonly seen in physical therapy. Unlike many books that review the anatomy, biomechanics, pathophysiology, and evaluation and treatment of common conditions, this text uses a case format, answers the questions surrounding the case, and presents information concerning the condition's typical presentation. The case format, however, does not limit the information regarding the diagnosis, because all perspectives are presented.

Twenty-five cases are presented, encompassing most of the problems typically seen in patients receiving physical therapy for upper-extrmity disorders. The cases also cover the life span, from neonates to the geriatric population.

"Critical pathways" refers to the analysis and decision-making process that must be thought through as we decide how to manage the patient's care. Each chapter contains a brief summary of the case, starting with history and subjective information. Next, supporting clinical data, such as range of motion, strength, results of special tests, and palpation, are presented. These data are followed by a series of questions on the condition and a detailed review of the answers. The cases are well-referenced and also provide a list of additional recommended readings.

Part 1 "The Hand and Wrist," covers disorders such as carpal tunnel syndrome, Colles' fracture, Raynaud's phenomenon, Dupuytren's contracture, and de Quervain's disease. It does not, however, address common fractures of the hand or laceration injuries, which would make this section a more complete reference.

Part 2, "The Elbow and Forearm," covers the difficult topic of reflex sympathetic dystrophy syndrome in a very clear manner, providing an excellent summary. Tennis elbow and golfer's elbow are also covered well in this section. Part 3 discusses 10 common conditions seen in the shoulder: adhesive capsulitis, rotator cuff rupture, supraspinatus impingement, bicipital tendinitis, calcific supraspinatus tendinitis, acromioclavicular joint sprain, subacromial bursitis, clavicle fracture, shoulder separation, and shoulder dislocation. The coverage of these conditions is comprehensive, and the cases are well-chosen to reinforce each other in the decision-making process.

Part 4 does a thorough job of covering a variety of topics, including thoracic outlet syndrome, Erb's palsy, myofascial pain syndrome, primary fibromyalgia syndrome, and congenital muscular torticollis. The book concludes with a section on nerve and muscle lesions, including Bell's palsy.

This book was written primarily for physical therapy practitioners, although other health care professionals such as athletic trainers, occupational therapists, and others who treat upper-extremity disorders will find it useful. The authors provide a well-written and clinically useful text that may be used as a reference in both academic and clinical settings. This book is effectively bridges the gap between theory and practice, by providing the fundamental information needed and the answers to many common clinical questions. It is also a book that will be useful to practitioners of varying ability, from the student to the experienced clinician. Students or practitioners in the early stages of their career will find this text to be a comprehensive guide to treatment, whereas experienced practitioners will also gain from the insightful approach and challenging questions the cases pose.

One strength of this book is the consistency of the writing style, as all chapters are written in the same format. It is generally clear, given the sometimes multifarious subject matter, and it is organized well. Another strength is the excellent illustrations throughout, many from classic articles and books on the topic. This book would certainly be useful as a resource for physical therapy practitioners, and it is comprehensive enough to be used as a textbook in physical therapy curricula.

One limitation of this book is that it periodically lists possible treatments for conditions without discussing rationale, which may present a problem for the inexperienced practitioner. Although joint mobilization is mentioned as a potential treatment for several conditions, it is not well described. In the treatment of patients with adhesive capsulitis, for example, grade I and II mobilizations are mentioned for stretching, which is inconsistent with the traditional terminology for joint mobilization. Many commonly used mobilizations are also omitted; for example, dorsal or ventral glides of the radiocarpal joint to facilitate wrist flexion and extension in patients with Colles' fracture. These criticisms, however, do not detract from the overall quality of this book, which is refreshingly new to the market and commendable.

David Levine, PhD, PT The University of Tennessee at Chattanooga Chattanooga, Tenn

Dr Levine is a UC Foundation Assistant Professor in the Department of Physical Therapy. His teaching, research, and clinical practice are in the areas of orthopedics and sports medicine.