Essentials of Physical Medicine and Rehabilitation
Musculoskeletal Disorders, Pain, and Rehabilitation
Walter R. Frontera, MD, PhD, MA (Hon.), FRCP
Professor
Physical Medicine, Rehabilitation, and Sports Medicine
Physiology and Biophysics
University of Puerto Rico School of Medicine
San Juan Puerto Rico
Julie K. Silver, MD
Associate Professor and Associate Chair
Department of Physical Medicine and Rehabilitation
Harvard Medical School
Attending Physician, Spaulding Rehabilitation Hospital
Clinical Associate, Massachusetts General Hospital
Associate in Physiatry, Brigham and Women’s Hospital Boston, Massachusetts
Thomas D. Rizzo, Jr., MD
Consultant
Physical Medicine and Rehabilitation
Mayo Clinic
Jacksonville, Florida
Assistant Professor
College of Medicine
Mayo Clinic
Rochester, Minnesota Fourth
1600 John F. Kennedy Blvd.
Ste 1800 Philadelphia, PA 19103-2899
ESSENTIALS OF PHYSICAL MEDICINE AND REHABILITATION: MUSCULOSKELETAL DISORDERS, PAIN, AND REHABILITATION, FOURTH EDITION
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ISBN: 978-0-323-54947-9
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Previous editions copyrighted 2015, 2008, and 2002.
Library of Congress Control Number: 2018944804
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We dedicate this book to our mentors, teachers, colleagues, and students, who have encouraged us to pursue academic careers with their enthusiasm for knowledge and learning; to our patients, who often are our greatest teachers; and to our families, who support us and provide the foundation for our pursuits.
Walter R. Frontera, MD, PhD, MA (Hon.), FRCP
Julie K. Silver, MD
Thomas D. Rizzo, Jr., MD
Contributors
TAYYABA AHMED, DO
Physical Medicine and Rehabilitation, Lenox Hill Hospital, New York, New York
Pelvic Pain
VENU AKUTHOTA, MD
Professor and Chair, Physical Medicine and Rehabilitation, University of Colorado, Denver, Colorado
Collateral Ligament Sprain
Iliotibial Band Syndrome
Meniscal Injuries
JOSEPH T. ALLEVA, MD, MBA
Division Head, Division of Physical Medicine and Rehabilitation; Clinical Assistant Professor, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
Cervical Sprain or Strain
Patellar Tendinopathy (Jumper’s Knee)
Patellofemoral Syndrome
Piriformis Syndrome
ERIC L. ALTSCHULER, MD, PhD
Associate Chief, Residency Program Director, Department of Physical Medicine and Rehabilitation, Metropolitan Hospital Center, New York, New York
Complex Regional Pain Syndrome
Central Post-Stroke Pain (Thalamic Pain Syndrome)
JOAO E.D. AMADERA, MD, PhD
Assistant Professor at the Orthopedic and Traumatology Institute, University of São Spine Center, São Paulo, Brazil
Low Back Strain or Sprain Baker Cyst
EDUARDO AMY, MD
Assistant Professor, Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
Anterior Cruciate Ligament Sprain
OGOCHUKWU AZUH, MD
Clinical Lecturer, Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
Lumbar Degenerative Disease
Temporomandibular Joint Pain
JOHN R. BACH, MD
Professor, Department of Physical Medicine and Rehabilitation and Neurology, Rutgers University New Jersey Medical School, Newark, New Jersey
Rehabilitation of the Patient with Respiratory Dysfunction
Respiratory Management of Neuromuscular Disorders
PATRICK J. BACHOURA, MD
Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
LUIS BAERGA-VARELA, MD
Assistant Professor, Physical Medicine, Rehabilitation and Sports Medicine, University of Puerto Rico, Rio Piedras, Puerto Rico
Knee Bursopathy
LESLIE BAGAY, MD
Clinical Assistant Professor, Residency Assistant Program Director, Department of Physical Medicine and Rehabilitation, Rutgers-Robert Wood Johnson Medical School, JFK Johnson Rehabilitation Institute, Edison, New Jersey Lymphedema
MOON SUK BANG, MD, PhD
Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea Cervical Dystonia Phantom Limb Pain
MATTHEW N. BARTELS, MD, MPH
Professor and Chairman, Department of Rehabilitation Medicine, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, New York Rehabilitation of the Patient with Respiratory Dysfunction
GERASIMOS BASTAS, MD, PhD
Director of Limb Loss Rehabilitation, Assistant Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee Lower Limb Amputations
KEITH A. BENGTSON, MD
Director of Hand Rehabilitation, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota Trigger Finger
TOMMIE BERRY, JR., MD
Schwab Rehabilitation Hospital, University of Chicago, Chicago, Illinois Patellar Tendinopathy (Jumper’s Knee)
SAURABHA BHATNAGAR, MD
Associate Residency Program Director, Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Boston, Massachusetts
Lumbar Degenerative Disease
Temporomandibular Joint Pain
DAVID M. BLAUSTEIN, MD
Director of Inpatient Rehabilitation Unit and Amputee Program at the Boston VA Healthcare System, Physical Medicine and Rehabilitation, VA Boston Healthcare System, West Roxbury, Massachusetts
Knee Osteoarthritis
Osteoarthritis
BRENNAN J. BOETTCHER, DO
Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota Hip Labral Tears
KATH BOGIE, DPhil
Associate Professor, Department of Orthopaedics, Case Western Reserve University; Senior Research Scientist, Advanced Platform Technology Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio Pressure Ulcers
KRISTIAN BORG, MD, PhD
Professor and Chair, Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden Myopathies
JOANNE BORG-STEIN, MD
Associate Professor and Associate Chair, Chief, Division of Sports and Musculoskeletal Rehabilitation; Associate Director, Harvard/Spaulding Sports Medicine Fellowship, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Cervicogenic Vertigo
Fibromyalgia
HAYLEE E. BORGSTROM, MD, MS
Resident Physician, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, Massachusetts Fibromyalgia
GLENDALIZ BOSQUES, MD
Associate Professor, Physical Medicine and Rehabilitation, University of Texas - Health Science Center at Houston; Chief, Pediatric Rehabilitation Medicine, TIRR Memorial Hermann, Houston, Texas Neural Tube Defects
MICHELLE E. BRASSIL, MD
Resident Physician, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, Massachusetts
Cervicogenic Vertigo
Sacroiliac Joint Dysfunction
Fibromyalgia
Burns
JEFFREY S. BRAULT, DO
Consultant, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
Extensor Tendon Injuries
Flexor Tendon Injuries
DIANE W. BRAZA, MD
Professor and Chair, Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin
Upper Limb Amputations
Diabetic Foot and Peripheral Arterial Disease
DAVID P. BROWN, DO
Clinical Professor of Medicine, Department of Rehabilitation Medicine, Johnson Rehabilitation Institute, Edison, New Jersey
Hand Osteoarthritis
DAVID T. BURKE, MD, MA
Professor and Chairman, Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia
Median Neuropathy (Carpal Tunnel Syndrome)
Traumatic Brain Injury
RONALD ROLF BUTENDIECK, MD
Department of Internal Medicine, Division of Rheumatology, Mayo Clinic Florida, Jacksonville, Florida
Ankylosing Spondylitis
AARON W. BUTLER, MD
Resident Physician, Rehabilitation Medicine, University of Washington, Seattle, Washington
Ankle Sprain
KEVIN BYRAM, MD
Assistant Professor of Medicine, Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Rheumatoid Arthritis
Systemic Lupus Erythematosus
ALISON L. CABRERA, MD
Tennessee Orthopaedic Alliance, Clarksville, Tennessee
Knee Chondral Injuries
MELANIE E. CAMPBELL, MS, ATC, FNP-C
Orthopedic Nurse Practitioner, Maine Medical Center, Maine Medical Partners Orthopedics and Sports Medicine, Portland, Maine
Ankle Arthritis
Bunion and Bunionette
Hallux Rigidus
Posterior Tibial Tendon Dysfunction
T. MARK CAMPBELL, MD, MSC, FRCPC
Clinician Investigator, Physical Medicine and Rehabilitation, Elisabeth Bruyère, Ottawa, Ontario, Canada
Joint Contractures
ALEXIOS G. CARAYANNOPOULOS, DO, MPH
Assistant Professor of Neurosurgery, Brown University, Medical Director Comprehensive Spine Center, Division Director Pain and Rehabilitation Medicine, Department of Neurosurgery, Rhode Island Hospital and Newport Hospital, Providence, Rhode Island Thoracic Sprain or Strain
GREGORY T. CARTER, MD, MS
Chief Medical Officer, Physiatry, St. Luke’s Rehabilitation Institute; Clinical Professor, Biomedical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington; Clinical Faculty, MEDEX, University of Washington School of Medicine, Seattle, Washington Motor Neuron Disease
ISABEL CHAN, MD
Assistant Clinical Professor, Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, Texas Pelvic Pain
SOPHIA CHAN, DPT
Medical Student, MS-IV, University of New England College of Osteopathic Medicine, Biddeford, Maine
Coccydynia
Postherpetic Neuralgia
ERIC T. CHEN, MD, MS
Physician, Rehabilitation Medicine, University of Washington, Seattle, Washington Adhesive Capsulitis
AMANDA CHEUNG, BSC, MBT
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada Pressure Ulcers
ANDREA CHEVILLE, MD, MSCE
Professor, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota Cancer-Related Fatigue
KELVIN CHEW, MBBCH, MSPMED
Senior Consultant, Sports Medicine Department, Changi General Hospital, Singapore Greater Trochanteric Pain Syndrome
SALLAYA CHINRATANALAB, MD
Assistant Professor of Medicine, Division of Rheumatology and Immunology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Rheumatoid Arthritis
Systemic Lupus Erythematosus
ELLIA CIAMMAICHELLA, DO, JD
Resident Physician, Physical Medicine and Rehabilitation, McGovern Medical School at UT Health in Houston, Houston, Texas
Neural Tube Defects
JOHN CIANCA, MD
Adjunct Associate Professor, Physical Medicine and Rehabilitation, Baylor College of Medicine; Adjunct Associate Professor, Physical Medicine and Rehabilitation, University of Texas Medical Branch, Houston, Texas
Hamstring Strain
DANIEL MICHAEL CLINCHOT, MD
Vice Dean for Education, Chair, Biomedical Education and Anatomy, The Ohio State University, Columbus, Ohio
Femoral Neuropathy
Lateral Femoral Cutaneous Neuropathy
RICARDO E. COLBERG, MD, RMSK
Sports Medicine Physician, Physical Medicine and Rehabilitation, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama
Hip Adductor Strain
EARL J. CRAIG, MD
Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation; Clinical Assistant Professor, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
Femoral Neuropathy
Lateral Femoral Cutaneous Neuropathy
LISANNE C. CRUZ, MD, MSC
Rehabilitation Medicine, Icahn SOM at Mount Sinai, New York, New York
Compartment Syndrome of the Leg
SARA CUCCURULLO, MD
Clinical Professor and Chairman, Residency Program Director, Department of Physical Medicine and Rehabilitation, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey; Vice President and Medical Director, JFK Johnson Rehabilitation Institute, Edison, New Jersey
Abdominal Wall Pain
CHRISTIAN M. CUSTODIO, MD
Associate Attending Physiatrist, Rehabilitation Medicine Service, Memorial Sloan Kettering Cancer Center; Associate Clinical Professor, Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York
Chemotherapy-Induced Peripheral Neuropathy
ALAN M. DAVIS, MD, PhD
Associate Professor, Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
Cardiac Rehabilitation
DAVID R. DEL TORO, MD
Professor, Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin
Fibular (Peroneal) Neuropathy
Tibial Neuropathy (Tarsal Tunnel Syndrome)
LAURENT DELAVAUX, BS, MS, MD
Fellow, Physical Medicine and Rehabilitation, JFK Johnson
Rehabilitation Institute, Edison, New Jersey
Abdominal Wall Pain
FRANCESCA DI FELICE, MD
Italian Scientific Spine Institute, Milan, Italy
Scoliosis and Kyphosis
JAYNE DONOVAN, MD
Clinical Assistant Professor, Rutgers New Jersey Medical School; Clinical Chief of Outpatient Spinal Cord Injury Services, Kessler Institute for Rehabilitation, Newark, New Jersey
Olecranon Bursitis
SABRINA DONZELLI, MD
Italian Scientific Spine Institute, Milan, Italy
Scoliosis and Kyphosis
SUSAN J. DREYER, MD
Associate Professor, Orthopaedic Surgery; Associate Professor, Physical Medicine and Rehabilitation, Emory University School of Medicine, Atlanta, Georgia
Intercostal Neuralgia
NANCY DUDEK, MD, MED
Professor, Medicine, Division of Physical Medicine and Rehabilitation, University of Ottawa, Ottawa, Ontario, Canada
Joint Contractures
ISRAEL DUDKIEWICZ, PROFESSOR
Chairman, Department of Rehabilitation Medicine, Tel Aviv Medical Center, Tel Aviv, Israel
Cervical Spondylotic Myelopathy
Cervical Degenerative Disease
SHEILA A. DUGAN, MD
Professor, Physical Medicine and Rehabilitation, Rush Medical College, Chicago, Illinois
Ulnar Collateral Ligament Sprain Stress Fractures
BLESSEN C. EAPEN, MD
Section Chief, Polytrauma Rehabilitation Center, Fellowship Program Director, Brain Injury Medicine, South Texas Veterans Health Care System; Associate Professor, Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
Headaches
Occipital Neuralgia Deep Venous Thrombosis Polytrauma Rehabilitation
GEROLD R. EBENBICHLER, MD
Physical Medicine and Rehabilitation and Occupational Medicine, Vienna Medical University, General Hospital of Vienna, Vienna, Austria
Chronic Fatigue Syndrome
OMAR H. EL ABD, MD
Instructor, Physical Medicine and Rehabilitation, Harvard Medical School; Instructor, Physical Medicine and Rehabilitation, Spaulding Rehabilitation, Boston, Massachusetts Low Back Strain or Sprain
MARK I. ELLEN, MD
Associate Professor of Physical Medicine and Rehabilitation, Associate Professor of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
Total Knee Arthroplasty
MAURY ELLENBERG, MD
Clinical Professor, Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, Michigan Lumbar Radiculopathy
MICHAEL J. ELLENBERG, MD
Rehabilitation Physicians PC, Novi, Michigan Lumbar Radiculopathy
LAUREN ELSON, MD
Director of Dance Medicine, Physical Medicine and Rehabilitation, Spaulding Rehabilitation, Harvard University, Charlestown, Massachusetts Post-Mastectomy Pain Syndrome
CHRISTINE ENG, MD
Clinical Instructor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts Elbow Arthritis Kienböck Disease
JESSE D. ENNIS, MD, FRCPC
Physical Medicine and Rehabilitation, Neurorehabilitation Unit, Victoria General Hospital, Victoria, British Columbia, Canada
Spinal Cord Injury (Thoracic)
ERIK ENSRUD, MD
Associate Professor, Orthopedics and Rehabilitation, Oregon Health Sciences University, Portland, Oregon Myopathies Plexopathy—Brachial Plexopathy—Lumbosacral
STEVEN ESCALDI, DO
Medical Director, Spasticity Management Program, Department of Rehabilitation Medicine, JFK-Johnson Rehabilitation Institute, Edison, New Jersey; Clinical Associate Professor, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey Movement Disorders
STEPHAN M. ESSER, MD
Southeast Orthopedic Specialists, Jacksonville, Florida
Chronic Ankle Instability
AVITAL FAST, MD
Chief, Rehabilitation Services, Tel Aviv Medical Center, Tel Aviv, Israel
Cervical Spondylotic Myelopathy
Cervical Degenerative Disease
JONATHAN T. FINNOFF, DO
Professor, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
Suprascapular Neuropathy
Hip Labral Tears
DAVID R. FORBUSH, MD
Assistant Professor of Physical Medicine and Rehabilitation, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
Total Knee Arthroplasty
PATRICK M. FOYE, MD
Interim Chair and Professor, Physical Medicine and Rehabilitation; Director, Coccyx Pain Center, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
MICHAEL FREDERICSON, MD
Professor, Orthopedics and Sports Medicine, Director, Physical Medicine and Rehabilitation, Sports Medicine Fellowship Director, Primary Care, Sports Medicine, Team Physician, Stanford Intercollegiate Athletics, Stanford University, Redwood City, California
Greater Trochanteric Pain Syndrome
Knee Chondral Injuries
JOEL E. FRONTERA, MD
Associate Professor, Vice Chair for Education and Residency Program Director, Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
Spasticity
WALTER R. FRONTERA, MD, PhD, MA (Hon.), FRCP
Professor, Physical Medicine, Rehabilitation and Sports Medicine, Physiology and Biophysics, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
Cervical Facet Arthropathy
CHAN GAO, MD, PhD
Resident, Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Rotator Cuff Tendinopathy
Rotator Cuff Tear
YOUHANS GHEBRENDRIAS, MD
Assistant Clinical Professor, Physical Medicine and Rehabilitation, University of California Irvine, Orange, California
Myofascial Pain Syndrome
MEL B. GLENN, MD
Associate Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts; Chief, Brain Injury Division, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts; Medical Director, NeuroRehabilitation (Massachusetts), Braintree, Massachusetts; Medical Director, Community Rehab Care, Watertown, Massachusetts
Postconcussion Symptoms
JENOJ S. GNANA, MD
Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
PETER GONZALEZ, MD
Private Practice, Orthopaedic Institute of Central Jersey, Toms River, New Jersey
Iliotibial Band Syndrome
THOMAS E. GROOMES, MD
Associate Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Total Knee Arthroplasty
Heterotopic Ossification
DAWN M. GROSSER, MD
Orthopaedic Surgeon, South Texas Bone and Joint, Corpus Christi, Texas
Ankle Arthritis
Bunion and Bunionette
Hallux Rigidus
Posterior Tibial Tendon Dysfunction
JONATHAN S. HALPERIN, MD
Chief, Physical Medicine and Rehabilitation, Sharp Rees
Stealy Medical Group, San Diego, California
Quadriceps Tendinopathy
ALEX HAN, BA
Medical Student, Physical Medicine and Rehabilitation, Brown University, Providence, Rhode Island
Thoracic Sprain or Strain
JOSEPH A. HANAK, MD
Clinical Instructor, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
Tietze Syndrome
TONI J. HANSON, MD
Assistant Professor, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
Thoracic Compression Fracture
DAVID E. HARTIGAN, MD
Assistant Professor, Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
Labral Tears of the Shoulder
SETH D. HERMAN, MD
Director, Brain Injury Medicine Fellowship, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard, Boston, Massachusetts
Postconcussion Symptoms
JOSEPH E. HERRERA, DO
Chairman and Lucy G. Moses Professor, Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
Compartment Syndrome of the Leg
CHESTER HO, MD
Professor and Director, Spinal Cord Injury Research
Chair, Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
Pressure Ulcers
ALICE J. HON, MD
Clinical Assistant Professor, University of California –Irvine, VA Long Beach Healthcare System, Long Beach, California
Central Post-Stroke Pain (Thalamic Pain Syndrome)
JOAN Y. HOU, MD
Staff Physician, Knapp Inpatient Rehabilitation, Department of Physical Medicine and Rehabilitation, Hennepin County Medical Center, Assistant Professor, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota
Deep Venous Thrombosis
TIMOTHY HOWARD, MD
EmergeOrtho, Wilson, North Carolina Arachnoiditis
RYAN HUBBARD, MD
Resident, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
Suprascapular Neuropathy
THOMAS H. HUDGINS, MD
Associate Division Head, Division of Physical Medicine and Rehabilitation, NorthShore University Health System, Glenview, Illinois; Assistant Professor, Department of Orthopedics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
Cervical Sprain or Strain
Piriformis Syndrome
Patellar Tendinopathy (Jumper’s Knee)
Patellofemoral Syndrome
KATARZYNA IBANEZ, MD
Attending Physiatrist, Department of Neurology, Rehabilitation Service, Memorial Sloan Kettering Cancer Center; Assistant Professor of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
Radiation Fibrosis Syndrome
ZACHARIA ISAAC, MD
Director, Interventional Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Medical Director, Comprehensive Spine Care Center, Brigham and Women’s Hospital, Boston, Massachusetts
Lumbar Spinal Stenosis
Sacroiliac Joint Dysfunction
NITIN B. JAIN, MD, MSPH
Associate Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Rotator Cuff Tendinopathy
Rotator Cuff Tear
CARLOS A. JARAMILLO, MD, PhD
Staff Physician, Polytrauma Rehabilitation Center, South Texas Veterans Health Care System; Clinical and Research Faculty, Geriatric Research, Education and Clinical Center, South Texas Veterans Health Care System; Assistant Professor, Department of Rehabilitation Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas Headaches Polytrauma Rehabilitation
PRATHAP JAYARAM, MD
Assistant Professor; Director of Regenerative Sports Medicine, H. Ben Taub Department of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas Knee Chondral Injuries
JEFFERY S. JOHNS, MD
Associate Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center; Medical Director, Vanderbilt Stallworth Rehabilitation Hospital, Nashville, Tennessee Neurogenic Bladder Neurogenic Bowel
JACLYN JOKI, MD
Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey; Director of Physical Medicine and Rehabilitation RWJUH, JFK Johnson Rehabilitation Institute, Edison, New Jersey Hand Rheumatoid Arthritis
PRATHAP JACOB JOSEPH, MD
Assistant Professor and Vice Chair, Clinical Operations, Department of Physical Medicine and Rehabilitation, UT Health McGovern Medical School, Houston, Texas Metatarsalgia
NANETTE C. JOYCE, DO, MAS
Associate Clinical Professor, Physical Medicine and Rehabilitation, University of California, Davis School of Medicine, Sacramento, California Motor Neuron Disease
SE HEE JUNG, MD, PhD
Associate Professor, Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
Phantom Limb Pain
DANIELLE PERRET KARIMI, MD
Associate Clinical Professor, Physical Medicine and Rehabilitation, Associate Clinical Professor, Anesthesiology and Perioperative Care, The University of California Irvine, Orange, California
Myofascial Pain Syndrome
JONATHAN KAY, MD
Professor of Medicine, Division of Rheumatology, University of Massachusetts Medical School; Director of Clinical Research, Division of Rheumatology, UMass Memorial Medical Center, Worcester, Massachusetts
Hand Rheumatoid Arthritis
STUART KIGNER, DPM
Podiatrist, Orthopaedic Surgery, Massachusetts General Hospital; Brigham and Women’s Hospital in IgA nephropathy, Boston, Massachusetts
Metatarsalgia
TODD A. KILE, MD
Consultant, Department of Orthopedic Surgery, Mayo Clinic, Scottsdale, Arizona; Assistant Professor, Mayo Clinic College of Medicine, Rochester, Minnesota
Ankle Arthritis
Bunion and Bunionette
Hallux Rigidus
Posterior Tibial Tendon Dysfunction
JOHN C. KING, MD
Professor, Rehabilitation Medicine, University of Texas Health Science Center, Medical Director, Reeves Rehabilitation Center, University Health System, San Antonio, Texas
Fibular (Peroneal) Neuropathy
HANS E. KNOPP, DO
Interventional Spine and Sports Medicine, PC, Middlebury, Connecticut
Lumbar Degenerative Disease
Temporomandibular Joint Pain
SASHA E. KNOWLTON, MD
Cancer Rehabilitation Fellow, Physical Medicine and Rehabilitation, Memorial Sloan Kettering Cancer Center, New York, New York
Chemotherapy-Induced Peripheral Neuropathy
Trigeminal Neuralgia
JASON H. KORTTE, MS, CCC-SLP
Speech-Language Pathologist, Medstar Good Samaritan Hospital, Affiliate Faculty, Loyola University, Baltimore, Maryland
Speech and Language Disorders
DANA H. KOTLER, MD
Instructor, Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Newton-Wellesley Hospital, Cambridge, Massachusetts
Elbow Arthritis
BRIAN J. KRABAK, MD, MBA
Clinical Professor, Rehabilitation, Orthopedics and Sports Medicine, University of Washington and Seattle Children’s Sports Medicine, Seattle, Washington
Adhesive Capsulitis
Biceps Tendinopathy
Ankle Sprain
WYATT KUPPERMAN, DO
Schwab Rehabilitation Hospital, University of Chicago, Chicago, Illinois
Patellofemoral Syndrome
JENNIFER KURZ, MD
Attending Physician, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Massachusetts General Hospital; Brigham and Woman’s Hospital, Boston, Massachusetts
Costosternal Syndrome
SHI-UK LEE, MD, PhD
Department of Rehabilitation Medicine, Seoul National University College of Medicine; Department of Physical Medicine and Rehabilitation, Seoul National University Boramae Medical Center, Seoul, Korea
Cervical Dystonia
PAUL LENTO, MD
Physical Medicine and Rehabilitation, Sarasota Orthopedic Associates, Florida State University Medical School, Sarasota, Florida
Collateral Ligament Sprain
Iliotibial Band Syndrome
Meniscal Injuries
JAN LEXELL, MD, PhD, DPhil h.c.
Department of Neuroscience, Rehabilitation Medicine, University of Uppsala and Uppsala University Hospital, Uppsala, Sweden
Postpoliomyelitis Syndrome
PETER A.C. LIM, MD
Clinical Professor, Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas; Adjunct Associate Professor, Medicine, Duke-NUS Medical School; Senior Consultant, Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
Transverse Myelitis
CINDY Y. LIN, MD
Clinical Assistant Professor, Sports and Spine Division, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, Washington
Greater Trochanteric Pain Syndrome
LEI LIN, MD, PhD
Clinical Associate Professor, Physical Medicine and Rehabilitation, Rutgers-Robert Wood Johnson Medical School, Edison, New Jersey
Thoracic Outlet Syndrome
KARL-AUGUST LINDGREN, MD, PhD
ORTON Rehabilitation Centre, Helsinki, Finland Thoracic Outlet Syndrome
UMAR MAHMOOD, MD
Kure Pain Management, Stevensville, Maryland Lumbar Spondylolysis and Spondylolisthesis
JUSTIN L. MAKOVICKA, MD
Orthopedic Surgery Resident, Mayo Clinic Arizona, Phoenix, Arizona
Labral Tears of the Shoulder
STEVEN A. MAKOVITCH, DO
Clinical Instructor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, VA Boston Healthcare, Spaulding Rehabilitation Hospital, Boston, Massachusetts Kienböck Disease
VARTGEZ K. MANSOURIAN, MD
Assistant Professor, Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine; Medical Director, Stroke Rehabilitation Program, Vanderbilt Stallworth Rehabilitation Hospital, Nashville, Tennessee Stroke in Young Adults
BEN MARSHALL, DO
Assistant Professor, Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado Collateral Ligament Sprain Meniscal Injuries
JENNIFER N. YACUB MARTIN, MD
Assistant Professor, Department of Physical Medicine and Rehabilitation, Clement J. Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin
Upper Limb Amputations
Diabetic Foot and Peripheral Arterial Disease
KOICHIRO MATSUO, DDS, PhD
Professor and Chair, Department of Dentistry and Oral-Maxillofacial Surgery, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan Dysphagia
JUAN JOSE MAYA, MD
Department of Internal Medicine, Division of Rheumatology, Mayo Clinic Florida, Jacksonville, Florida
Ankylosing Spondylitis
A. SIMONE MAYBIN, MD
Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Lumbar Facet Arthropathy
DONALD MCGEARY, PhD, ABPP
Associate Professor, Department of Psychiatry, Clinical Assistant Professor, Department of Family and Community Medicine, ReACH Scholar, University of Texas Health Science Center at San Antonio, San Antonio, Texas Headaches
KELLY C. MCINNIS, DO
Instructor, Physical Medicine and Rehabilitation, Harvard Medical School; Clinical Associate, Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts
Repetitive Strain Injuries
PETER MELVIN MCINTOSH, MD
Assistant Professor, College of Medicine, Mayo Clinic, Rochester, Minnesota; Consultant, Department of Physical Medicine and Rehabilitation, Mayo Clinic Florida, Jacksonville, Florida
Scapular Winging
Adhesive Capsulitis of the Hip
ALEC L. MELEGER, MD
Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts; Associate Director, Spine Center, Newton-Wellesley Hospital, Newton, Massachusetts
Cervical Spinal Stenosis
WILLIAM F. MICHEO, MD
Professor and Chair, Sports Medicine Fellowship Director, Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico, San Juan, Puerto Rico
Glenohumeral Instability
Anterior Cruciate Ligament Sprain
PAOLO MIMBELLA, MD, MSC
McGovern Medical School—UTHealth, Department of Physical Medicine and Rehabilitation; Academic Chief Resident, Baylor/University of Texas, Houston, Texas
Hamstring Strain
GERARDO MIRANDA-COMAS, MD
Assistant Professor, Rehabilitation Medicine, Sports Medicine Fellowship Director, Icahn School of Medicine at Mount Sinai, New York, New York
Glenohumeral Instability
DANIEL P. MONTERO, MD, CAQSM
Instructor, Orthopedics, Mayo Clinic Florida, Jacksonville, Florida
Hammer Toe
BRITTANY J. MOORE, MD
Resident, Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
Extensor Tendon Injuries
Flexor Tendon Injuries
S. ALI MOSTOUFI, MD
Interventional Physiatrist, Spine, Sports, and Regenerative Medicine, New England Spine Care Associates, Cambridge, Massachusetts; Department of Physical Medicine and Rehabilitation, Tufts University School of Medicine, Boston, Massachusetts
Cervical Radiculopathy
Chronic Pain Syndrome
CHAITANYA S. MUDGAL, MD, MS (Orth), MCh (Orth)
Associate Professor in Orthopaedic Surgery, Harvard Medical School, Orthopaedic Hand Service, Massachusetts General Hospital, Boston, Massachusetts
Wrist Osteoarthritis
Wrist Rheumatoid Arthritis
STEFANO NEGRINI, MD
Chair Rehabilitation, Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Scientific Coordinator Rovato, Fondazione Don Gnocchi, Milan, Italy
Scoliosis and Kyphosis
SHANKER NESATHURAI, MD, MPH, FRCPC
Professor of Medicine and Division Director of Physical Medicine and Rehabilitation, Michael G. DeGroote School of Medicine, McMaster University; Chief of Physical Medicine and Rehabilitation, Hamilton Health Sciences and St. Joseph’s Healthcare, Hamilton, Ontario, Canada; Lecturer in Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Spinal Cord Injury (Thoracic)
CARINA JOY O’NEILL, DO
Medical Director, Physical Medicine and Rehabilitation, Spaulding Rehabilitation, Braintree, Massachusetts; Clinical Instructor, Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts de Quervain Tenosynovitis
EZIAMAKA CHIDI OKAFOR, MD
Resident, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Cervical Spinal Stenosis
ANDREA K. ORIGENES
Medical Student, Midwestern University College of Osteopathic Medicine, Downers Grove, Illinois
Cervical Sprain or Strain
CEDRIC J. ORTIGUERA, MD
Assistant Professor, Orthopedic Surgery, Mayo Clinic Florida, Jacksonville, Florida
Labral Tears of the Shoulder
MICHAEL D. OSBORNE, MD
Consultant, Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida; Assistant Professor, Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota
Chronic Ankle Instability
Arachnoiditis
AJIT B. PAI, MD
Chief, Physical Medicine and Rehabilitation Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia; Assistant Professor, Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
Deep Venous Thrombosis
JEFFREY B. PALMER, MD
Professor Emeritus, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland
Dysphagia
Speech and Language Disorders
SAGAR S. PARIKH, MD
Interventional Pain Physician, Pain Fellowship Director, Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute, Edison, New Jersey; Assistant Professor, Physical Medicine and Rehabilitation, Robert Wood Johnson Medical School, Piscataway, New Jersey
Abdominal Wall Pain
MARCIN PARTYKA, MD, FRCPC
Resident, Physical Medicine and Rehabilitation, Michael G. Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
Spinal Cord Injury (Thoracic)
ATUL T. PATEL, MD, MHSA
Medical Director of Rehabilitation Services, Kansas City Bone and Joint Clinic, PA, Overland Park, Kansas
Trapezius Strain
Pubalgia
SHAWN A. PATEL, MD
Physician, Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
Biceps Tendinopathy
NICOLAS PEREZ, MD
Fellow, Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute, Edison, New Jersey
Abdominal Wall Pain
DWAN PERRY, DO
Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Kentucky, Chandler Medical Center, Lexington, Kentucky
Quadriceps Contusion
EDWARD M. PHILLIPS, MD
Assistant Professor, Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts; Chief, Physical Medicine and Rehabilitation Service, VA Boston Healthcare System, West Roxbury, Massachusetts; Attending Physician, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
Knee Osteoarthritis
Osteoarthritis
DANIEL C. PIMENTEL, MD, PhD
Interventional Physiatrist, Director of Spine Center HCor; Assistant Professor, University of São Paolo, School of Medicine, São Paulo, Brazil
Thoracic Radiculopathy
BENEDIKT PLEUHS, BA
Clinical Research Assistant, Pediatric Emergency Department, Medical College of Wisconsin, Milwaukee, Wisconsin
Cervical Sprain or Strain
THOMAS E. POBRE, MD
Director of Outpatient Services, Physical Medicine and Rehabilitation, Nassau University Medical Center, East Meadow, New York Radial Neuropathy
TERRENCE PUGH, MD
Assistant Professor, Physical Medicine and Rehabilitation, Carolinas Medical Center; Vice-Chief, Section of Rehabilitation, Supportive Care, Levine Cancer Institute; Associate Director of Oncology Rehabilitation, Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, North Carolina Radiation Fibrosis Syndrome
ALISON R. PUTNAM, DO
Providence Medical Group Everett, Physiatry, Everett, Washington Iliotibial Band Syndrome
JAMES RAINVILLE, MD
Assistant Professor, Part-Time, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Chief, Physical Medicine and Rehabilitation, New England Baptist Hospital, Boston, Massachusetts Lumbar Spondylolysis and Spondylolisthesis
V.S. RAMACHANDRAN, MD, PhD
Distinguished Professor, Department of Psychology, University of California, San Diego, La Jolla, California Complex Regional Pain Syndrome
BRIAN E. RICHARDSON, PT
Clinical Director, Sports Physical Therapy Residency Program, Vanderbilt University Medical Center, Nashville, Tennessee
Rotator Cuff Tendinopathy
Rotator Cuff Tear
DAVID RING, MD, PhD
Associate Dean for Comprehensive Care, Department of Surgery and Perioperative Care, Dell Medical School— The University of Texas at Austin, Austin, Texas
Hand Rheumatoid Arthritis
ALEXANDRA RIVERA-VEGA, MD
Staff Physician, Michael E. DeBakey VAMC, Assistant Professor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
Glenohumeral Instability
THOMAS D. RIZZO, JR., MD
Consultant, Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida; Assistant Professor, College of Medicine, Mayo Clinic, Rochester, Minnesota
Acromioclavicular Injuries
Total Hip Replacement
RAUL A. ROSARIO-CONCEPIÓN, MD
Chief Resident, Physical Medicine and Rehabilitation, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
Knee Bursopathy
DARREN C. ROSENBERG, DO
Assistant Professor, Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Thoracic Radiculopathy
Baker Cyst
ROGER P. ROSSI, DO
Professor of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation, Rutgers—Robert Wood Johnson/Johnson Rehabilitation Institute, Edison, New Jersey
Speech and Language Disorders
SEWARD B. RUTKOVE, MD
Professor, Neurology, Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, Massachusetts
Peripheral Neuropathies
SUNIL SABHARWAL, MD, MRCP (UK)
Associate Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Chief, Spinal Cord Injury, Veterans Affairs Boston Health Care System, Boston, Massachusetts
Spinal Cord Injury (Cervical)
Spinal Cord Injury (Lumbosacral)
NOURMA SAJID, MD
Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
LUIS A. SANCHEZ, MD
Fellow, Department of Physical Medicine, Rehabilitation and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
Anterior Cruciate Ligament Sprain
FRANCISCO H. SANTIAGO, MD
Attending Physician, Physical Medicine and Rehabilitation, Bronx-Lebanon Hospital, Bronx, New York
Median Neuropathy
Ulnar Neuropathy (Wrist)
DANIELLE SARNO, MD
Instructor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts; Physiatrist, Interventional Pain Management, Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts Lumbar Spinal Stenosis
ROBERT J. SCARDINA, DPM
Chief and Residency Program Director, Podiatry Service, Massachusetts General Hospital, Boston, Massachusetts
Metatarsalgia
BYRON J. SCHNEIDER, MD
Assistant Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Lumbar Facet Arthropathy
JEFFREY C. SCHNEIDER, MD
Medical Director, Trauma, Burn and Orthopedic Program, Spaulding Rehabilitation Hospital; Assistant Professor, Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Burns
FERNANDO SEPÚLVEDA, MD
Assistant Professor, Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
Anterior Cruciate Ligament Sprain
JOHN SERGENT, MD
Professor of Medicine, Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Rheumatoid Arthritis Systemic Lupus Erythematosus
DANA SESLIJA, MD, MS
Adjunct Professor, Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Windsor, Ontario, Canada
Fibular (Peroneal) Neuropathy
Tibial Neuropathy (Tarsal Tunnel Syndrome)
VIVIAN P. SHAH, MD
Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
JYOTI SHARMA, MD
Associate, Orthopaedic Surgery Department, Geisinger Health System, Danville, Pennsylvania
Wrist Osteoarthritis
Wrist Rheumatoid Arthritis
NUTAN SHARMA, MD, PhD
Associate Professor, Neurology, Harvard Medical School, Cambridge, Massachusetts; Associate Neurologist, Neurology, Massachusetts General Hospital, Boston, Massachusetts; Associate Neurologist, Neurology, Brigham and Women’s Hospital, Boston, Massachusetts Parkinson Disease
ALEXANDER SHENG, MD
Assistant Professor, Sports and Spine, Shirley Ryan AbilityLab, Chicago, Illinois
Posterior Cruciate Ligament Sprain
GLENN G. SHI, MD
Assistant Professor, Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
Hammer Toe
Morton’s Neuroma Plantar Fasciitis
JULIE K. SILVER, MD
Associate Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School; Attending Physician, Spaulding Rehabilitation Hospital; Clinical Associate, Massachusetts General Hospital; Associate in Physiatry, Brigham and Women’s Hospital, Boston, Massachusetts Trigger Finger
CHLOE SLOCUM, MD, MPH
Attending Physician, Department of Physical Medicine and Rehabilitation, Spinal Cord Injury Division, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts
Post-Thoracotomy Pain Syndrome
DAVID M. SLOVIK, MD
Associate Professor of Medicine, Harvard Medical School; Chief, Division of Endocrinology, Newton-Wellesley Hospital, Newton, Massachusetts; Physician, Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
Osteoporosis
SOL M. ABREU SOSA, MD
Assistant Professor, Physical Medicine and Rehabilitation, Rush Medical College, Chicago, Illinois
Ulnar Collateral Ligament Sprain Stress Fractures
KURT SPINDLER, MD
Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
Knee Chondral Injuries
LAUREN SPLITTGERBER, MD
Resident Physician, Physical Medicine and Rehabilitation, McGaw Medical Center of Northwestern University/ Shirley Ryan AbilityLab, Chicago, Illinois
Posterior Cruciate Ligament Sprain
STACY M. STARK, DO
Assistant Professor, Vice Chair of Education, Residency Program Director, Department of Physical Medicine and Rehabilitation, Division Chief, Pediatric Rehabilitation Medicine, Medical Director, Rehabilitation Services, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
Cerebral Palsy
JOEL STEIN, MD
Simon Baruch Professor, Rehabilitation and Regenerative Medicine, Columbia University; Professor, Rehabilitation Medicine, Weill Cornell Medical College; Physiatrist-inChief, Rehabilitation Medicine, NewYork-Presbyterian Hospital, New York, New York Stroke
SONJA K. STILP, MD
Private Practice, Boulder, Colorado
Iliotibial Band Syndrome
TODD P. STITIK, MD
Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey
Hip Osteoarthritis
MICHAEL F. STRETANSKI, DO, AME
Medical Director/Fellowship Director, Interventional Pain Management, Interventional Spine and Pain Rehabilitation Center, Mansfield, Ohio; Medical Director, Put-in-Bay
Concierge Medical Services, Put-in-Bay, Ohio
Biceps Tendon Rupture
Shoulder Arthritis
Dupuytren Contracture
Hand and Wrist Ganglia
Shin Splints
Achilles Tendinopathy
MICHAEL D. STUBBLEFIELD, MD
Associate Attending Physiatrist and Chief, Rehabilitation Service, Department of Neurology, Memorial Sloan Kettering Cancer Center; Associate Professor of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York
Radiation Fibrosis Syndrome
BRUNO S. SUBBARAO, DO
Medical Director of Polytrauma/Transition and Care Management Programs, Phoenix Veterans Healthcare System, Phoenix, Arizona
Occipital Neuralgia
JOHN TALIAFERRO, MD
Resident Physician, Orthopaedic Surgery, University of Florida, Jacksonville, Florida
Plantar Fasciitis
REBECCA N. TAPIA, MD
Medical Director, Polytrauma Network Site, Polytrauma/ Physical Medicine and Rehabilitation, South Texas Veterans Health Care System, Adjunct Assistant Professor, Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas Polytrauma Rehabilitation
ANN-MARIE THOMAS, MD, PT
Assistant Professor, Physical Medicine and Rehabilitation, Harvard Medical School; Staff Physiatrist, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital; Clinical Associate, Physical Medicine and Rehabilitation, Massachusetts General Hospital; Associate Physiatrist in Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Multiple Sclerosis
JIAXIN TRAN, MD
Physical Medicine and Rehabilitation Hospitalist, Madonna Rehabilitation Hospital, Lincoln, Nebraska Complex Regional Pain Syndrome
BIANCA A. TRIBUZIO, DO
Staff Physician, Physical Medicine and Rehabilitation, Sharp Rees-Stealy, San Diego, California Quadriceps Tendinopathy
GUY TRUDEL, MD
Professor, Medicine, Division of Physical Medicine and Rehabilitation, University of Ottawa, Ottawa, Ontario, Canada
Joint Contractures
HEIKKI UUSTAL, MD
Attending Physiatrist, Rehabilitation Medicine, JFK Johnson Rehab Institute, Edison, New Jersey; Associate Professor, Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey Mallet Toe
RAMON VALLARINO, JR., MD
Attending Physician, Department of Neurosciences, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
Median Neuropathy Ulnar Neuropathy (Wrist)
MONICA VERDUZCO-GUTIERREZ, MD
Associate Professor and Vice Chair of Quality, Compliance and Patient Safety, Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas Spasticity
ANKUR VERMA, DO
Private Practice, Chicago, Illinois Patellofemoral Syndrome
ARIANA VORA, MD
Instructor, Physical Medicine and Rehabilitation, Harvard Medical School; Staff Physiatrist, Physical Medicine and Rehabilitation, Massachusetts General Hospital; Staff Physiatrist, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
Coccydynia
Postherpetic Neuralgia
MICHAEL C. WAINBERG, MD, MSC
Senior Associate Consultant, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
Trigger Finger
ROGER WANG, DO
Schwab Rehabilitation Hospital, University of Chicago, Chicago, Illinois
Piriformis Syndrome
JAY M. WEISS, MD
Medical Director, Long Island Physical Medicine and Rehabilitation, Syosset, New York
Lateral Epicondylitis
Medial Epicondylitis
Ulnar Neuropathy (Elbow)
LYN D. WEISS, MD
Chairman and Program Director, Physical Medicine and Rehabilitation, Nassau University Medical Center, East Meadow, New York
Lateral Epicondylitis
Medial Epicondylitis
Radial Neuropathy
Ulnar Neuropathy (Elbow)
SARAH A. WELCH, DO, MA
Resident Physician, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Cervical Facet Arthropathy
DAVID WEXLER, MD, FRCS(TR&ORTH)
Attending, Orthopedics, Maine General Medical Center, Augusta, Maine
Ankle Arthritis
Bunion and Bunionette
Hallux Rigidus
Posterior Tibial Tendon Dysfunction
J. MICHAEL WIETING, DO, MEd
Associate Dean of Clinical Medicine and Professor of Physical Medicine and Rehabilitation, Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Harrogate, Michigan; Clinical Professor, Department of Physical Medicine and Rehabilitation, Michigan State University-College of Osteopathic Medicine, East Lansing, Michigan
Quadriceps Contusion
ALLEN NEIL WILKINS, MD
Assistant Clinical Professor, Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons; Medical Director, New York Rehabilitation Medicine, New York, New York
Foot and Ankle Bursitis
AARON JAY YANG, MD
Assistant Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
Cervical Facet Arthropathy
FABIO ZAINA, MD
Italian Scientific Spine Institute, Milan, Italy
Scoliosis and Kyphosis
MEIJUAN ZHAO, MD
Assistant Professor, Physical Medicine and Rehabilitation, Harvard Medical School; Staff Physiatrist, Physical Medicine and Rehabilitation, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Boston, Massachusetts
Median Neuropathy (Carpal Tunnel Syndrome)
This book was created with the purpose of discussing a variety of medical conditions that any physiatrist, internist, family physician, orthopedist, rheumatologist, or neurologist will likely encounter in his or her medical practice. We particularly wanted to emphasize the clinical aspects of both musculoskeletal injuries and chronic medical conditions requiring rehabilitation from the perspective of a practitioner in an ambulatory setting. In the second edition we maintained the structure of the book and added an entirely new section on the ambulatory management of conditions associated with pain as a key symptom. The third edition included the ICD-9 and 10 codes as well as some new topics.
This, the fourth edition of Essentials of Physical Medicine and Rehabilitation, includes a new section on technology in each of the chapters where recently developed technologies or devices have been added to the therapeutic and rehabilitation strategies. This edition again covers many individual diagnoses in a deliberately succinct and specific format. The first section contains 94 chapters on specific musculoskeletal diagnoses, conveniently organized by anatomic region and in alphabetical order. The second section describes the management of pain in 24 specific conditions and includes a new chapter on abdominal wall pain. The third section covers 45 common medical conditions that are typically chronic and benefit from long-term rehabilitative interventions. Although some of these conditions
CHAPTER X. FORGIVEN.
IT was a very, very sad time for Hetty. She did not know, when she used to cry and bewail herself over her misfortunes, that she could be as unhappy as she was now. She longed for news of little Flo, and many a time did she steal up to Adelaide Terrace to question Mrs. Goodenough, at times when she knew that Mr. Eyre was out.
Worthy Mrs. Goodenough gave her scant information, and less comfort. If she might be believed, Mr. Eyre spent a good deal of his scanty leisure in telling her that he thought Hetty very little better than a murderer, and that she should never so much as see Miss Flo again.
Hetty was so dejected that she believed all this, and even thought that Mr. Eyre did not say a word too much; but Matty stoutly declared that Mrs. Goodenough invented these speeches for Hetty's benefit.
Mrs. Hardy had no reason to complain of Hetty now, for she worked hard all day, and never cared to go out, except for her melancholy pilgrimage to Adelaide Terrace, or to go to church.
Meantime, little Flo was really very ill, and suffering greatly both in mind and body. Her terror about the big black dog was such that the doctor said that no questions must be asked about her part in the day's misadventures, nor must she be in any way reminded of them.
Mrs. Eyre, however, did not forget poor Hetty, and she took some trouble to find out that the story she had told her master was the true one. The shrimp-girl, and a lad who had met the poor girl in the lane, and put her into the right road, confirmed Hetty's story. Not many women, with little Flo before their eyes, would have taken so much trouble about poor, heedless Hetty, who certainly was fortunate in her mistress.
After about a month Flo got better. The pain decreased, and she became calmer and more like her little self. Of course, Mrs. Eyre was anxious to get home, for the three children there were both unhappy and troublesome under Mrs. Goodenough's care. So as soon as it was at all safe Mr. Eyre came to R—, and Flo was carefully conveyed home.
Up to this time the child had not spoken of Hetty since her mother had silenced her constant cry for her. But as she grew stronger, and returned to her familiar home and her familiar habits, Mrs. Eyre became aware that there was something weighing on little Flo's heart,—some question that was often on her lips, though she seemed afraid to ask it. A little questioning soon made the child speak out.
"Mamma, you bid me speak no more of Hetty. I know the big dog must have killed Zelica, but did he kill my dear Hetty too?"
"Oh no, my dear child. Hetty is quite well, and safe in her mother's house."
"Then why might I not speak of her?"
"You misunderstood me, dear; you kept calling, calling, and I only meant to quiet you."
"But if Hetty was not hurt, why did she not stay with me and nurse me, mamma?"
"Well; dear, Hetty was to blame about that day—she had left the hut while you were asleep, to search for Zelica, I believe; but, indeed, I do not know exactly what happened. Papa sent Hetty away."
Flo was too well taught to question papa's doings; but that very evening she began begging him to bring Hetty back.
"I want her so much. I do love Hetty. Just tell her that 'Miss Flo' wants her, and I know she will come at once. She loves me so."
"My dear, I sent her away because it was through her carelessness that this accident happened to you. When mamma has time, she will look about for a nice, kind girl to carry you; and now we'll say no more about Hetty."
To this hint Flo declined to attend. She was very weak, and mamma had others to attend to now, and could not devote herself to Flo as she did while at R—, and Flo cried for Hetty far too often for her own good, and began to look as bad as ever.
Hetty, no longer daring to come to the house, used now to waylay Mrs. Goodenough on her way home, to ask about Miss Flo. One day the old woman did not appear at her usual time; it was quite evening before she came, but Hetty waited all the time.
"Well, Hetty, here you are, to bother me about that child, that's the worrit of the whole house! The crossest, complainingest little worry that ever I did see! Morning, noon, and night, the cry is—"
Here Mrs. Goodenough paused. She had very nearly said the word "'Hetty,'" but that, she thought, would rejoice the poor girl, so she substituted "'Zelica.'"
"'Zelica! I want Zelica!' That's always on her lips; little peevish brat! I wonder how her mother keeps her hands off her!"
"I declare," cried Hetty, "I never thought of that. I suppose they think Zelica is lost."
"Lost she surely is, and a good thing too. But that redic'lous child thinks some dog ate her! She was in such a state this morning, declaring I hurt her lifting her up, that we could get nothing done. That's why I'm late. Mrs. Eyre's going to get a girl in your place, otherwise I'd have to quit; but I suppose I shan't be turned out this time, as you're not there to carry tales."
All this did Mrs. Goodenough say, with the amiable wish to make Hetty miserable; but this time she failed, for Hetty did not know what she was saying. She was thinking about Zelica, and Zelica's little mistress, and now with a hasty "good-evening" she turned away and went quickly home. Mrs. Goodenough immediately made a kind of general proclamation that "Hetty Hardy was getting to be a greater fool every day."
Hetty went home, and procured a sheet of notepaper and Matty's pen and ink. She then sat down to write. It took her a long time, but at last, with a deep sigh, she folded up her paper, caught up Zelica from her comfortable nook by the fire, and ran out into the now almost dark evening.
The Eyres were at supper, or tea, as they called it. Flo was on her sofa, looking smaller than ever; presently Lina and Edgar ran off to play, and Mr. Eyre drew a chair over and sat down near Flo.
"Come, my little girl, you haven't eaten any of the nice bread and jam I cut for you. Try to eat a little bit, Flo. Why are you crying? You make poor mamma and me very sad."
"I can't help it, papa. I am so sorry for poor dear Hetty. I do want Hetty—I love her."
"What is that?" cried Mrs. Eyre, as a slight noise was heard.
"It was the window. I suppose the sash has closed a bit. I must see to it to-morrow, or it may catch somebody's fingers."
But the sash had not closed—quite the contrary. Some one outside had pushed it up a tiny bit more, and behold!—in walked, fat, snowwhite, and beautiful as ever, Mrs. Zelica! Purring loudly, she marched over to the sofa, sprang up, curled herself up in her own particular place, and looked at the astonished assembly with a condescending and self-satisfied air. What a fuss a little dog would have been in! What waggings of the tail, and ecstatic wriggles, mingled with small strangled squeals of joy at seeing his dear mistress again! But Zelica, being but a cat, just blinked at them all, and felt important.
"Why! Oh, my Zelica! Is this you? Then he didn't eat you? Where have you been? Who brought you? Oh, mamma! 'Twas Hetty—my dear, dear Hetty! Oh, run, call her to me! I do love Hetty!"
Mr. Eyre sprang up and went to the door; but Hetty was gone.
Flo did not know how to make enough of Zelica. But the loving little heart was not satisfied. Mrs. Eyre, who had gone to the window when her husband ran to the door, had found poor Hetty's letter, but she slipped it into her pocket, and said nothing about it until the children were in bed. Then she said,—
"John, there was a letter left on the window-sill. I have it here. I did not want to excite poor Flo. Here it is, dear; read it to me."
For she had baby in her arms.
"'My dear mistress,'" began John, in a stern tone of voice, which, however, softened as he read on,—
"'I hope I may be forgiven for writing to you. Mrs. Goodenough told me to-night that Miss Flo still cries after Zelica. I did not know that she was well enough to care for her yet. I found her at the station that day; she
must have followed me there.'"
"'Dear mistress, try to forgive me. I am too sorry to know how to say it. I do not feel as if I could ever be happy any more. After all your kindness, and the master's, such a return to make and, loving Miss Flo with all my heart, to be so wicked about her. I know master was right to send me off, and he never could trust me any more. I am glad Miss Flo has forgotten me. I pray continually that she may grow strong and well, and I hope your new girl will be fond of her, and patient with her.'"
"'If you could say you forgive me, maybe I could be more at rest. Sometimes I get stupid, thinking of Miss Flo; for indeed, ma'am, though you may well not believe it, I do love both of you, and I think I shall never forget what I felt when I got back to the hut, and could not find her.'"
"'I remain, ma'am,'"
"'Your poor, bad servant,'"
"'HESTER HARDY.'"
"Poor girl," said John Eyre to himself, as he folded up the letter. "That old Goodenough! Why, Flo thought Zelica was dead; and as to forgetting Hetty, I wish she had!"
"It would be very ungrateful of her if she had, for Hetty was very good to her."
"Poor girl!" said the master again.
"John, dear, I must have a girl; and, to be frank with you, I would rather have Hetty than a stranger. She is so gentle and patient, and so perfectly truthful. She is a really good girl, and it is not so easy to find a really good girl. Besides, Flo is too ill to be reasonable, and she will not like any stranger, because she is longing for Hetty."
"Well, dear, I know I told the girl never to let me see her face again, but—I suppose we had better make our poor little Flora as happy as we can while we have her with us. But I tell you fairly, I think we ought never to lose sight of the girl when she has the cart of Flo. She is so terribly heedless, though, as you say, a good girl for all that."
"Then I may see her to-morrow?"
"Yes; but don't tell Flo till you are sure of her."
So it came about that once again Mrs. Eyre tapped on the halfclosed door of Mrs. Hardy's house, and was told to "come in."
"Why, if it isn't Mrs. Eyre!" cried Matty joyfully.
"Mrs. Eyre! Matty, you're a—But it is, for all that. Ma'am, I'm nearly ashamed to face you."
"You have no cause to be, Mrs. Hardy. Hetty is a good girl, and, if she was heedless, we must remember that she is very young. It was a great misfortune; but, you know, if the dog had not awakened my poor little girl, no harm would have been done. Where is Hetty?"
"I sent her into town for some things we wanted, but she must soon be home. A dog, did you say? I've heard nothing of a dog. Indeed, Hetty does not rightly know yet what happened to Miss Flora."
"Well, Hetty went, as you, I am sure, know, to look for the little cat. Zelica led her a regular chase, and when she got back the child was gone."
"Yes," said Matty, "and the shawls on the path, and the cat's basket all torn, and some shrimps a girl gave her all mashed up. Oh, ma'am! she dreams of it often—you never saw the like."
"What had really happened was this. Flo woke up to find the dog—a big, rough-haired creature-tearing at the cat's basket; and, I confess, I think it was well for Zelica that she was not in it; but the dog would not have hurt Flo on any account; in fact, he did not touch her. She screamed for Hetty, the dog got at the shrimps and tried to eat them, and while he was at that work my poor little girl got up and tried to run away. She actually dragged herself some way down the steep path, when the dog came after her, and she fell. Mr. Eyre thinks that the creature saved her from falling over the edge, for he was sitting between her and it, in great distress. He belongs to the stationmaster, and is a most good-natured dog, very fond of children."
Matty had seen her sister come in, but Mrs. Eyre did not, her back being turned to the door. Hetty stood, listening and trembling, and now seemed about to steal out again; but Matty stopped her.
"Now, Hetty," said she, "you know what really happened."
Mrs. Eyre turned round, and Hetty covered her face with her hands. Mrs. Eyre fully expected a burst of tears, and "Oh, I'm so sorry, ma'am!" but there were neither tears nor words.
"My poor girl! My poor Hetty! Have you never a word to say to me?"
"No, not one." Mrs. Hardy spoke for her. "There's something come to the girl, ma'am, for dear knows her tears and her tongue used to be ready enough. I used to be tired hearing, 'Oh I'm so sorry, mother!'"
"Oh, I used to say that," said Hetty; "but I was only sorry because things were broken, or because you were angry. I was not sorry for my own fault, because I did not think it a fault—only a misfortune. Though Matty warned me, and made me promise to pray against it, I never did—I forgot. I thought how unlucky I was to be so
thoughtless; but since I've been at home I've been thinking, and I see now that it's a sin. Oh, ma'am, if you could only forgive me, I'd take heart and try to do better. I'll take Matty's way now, for I'm sure it's the right one."
"You are quite right, Hetty. We are all of us more given to one fault than to others, and only God can cure us of them. He gives us time, and grace, and many lessons; some, sad ones. This has been a sad one to you, but you see it has opened your eyes to your sin. As to forgiving you, I do indeed, Hetty, and so does Mr. Eyre."
"And Miss Flo? Oh! Does she forget me altogether?"
"Forget you? No, indeed—she is never done crying for you. And she is so ill and so weak that you must come back to her, Hetty."
Hetty opened both mouth and eyes as wide as ever she could, and uttered the most extraordinary shout; the poor girl really did not know what she was doing.
"Hetty! Behave, do! To yell like that in a lady's very ears! Eh! Here come the tears! I've got my poor Hetty back again. I didn't know that one with a silent tongue and dry eyes. You're a lucky girl, Hetty, to have such people to do with as your master and mistress; and indeed, ma'am, the girl's been breaking her heart after you."
Matty took her sister away into the other room, where she kissed her, and coaxed her, and cried with her, and altogether contrived to quiet her so that she was in a fit state to set out at once with her mistress.
"Dan shall bring your things up in the evening, Hetty," said her mother. "And now, my dearie dear, remember this time as long as you live, and don't fall back into idle ways. Remember what Matty said to you: you'll find it's true. These thoughtless doings are real sins, and it's only God can change your heart. God bless you, Hetty! I'm glad for you, child."
On the way to Adelaide Terrace Hetty asked many questions about Flo's state.
"I don't see how you can bear the sight of me, ma'am, nor Miss Flo either."
"You'll soon know what she thinks about it, Hetty. And you know, if you had got back and found her still asleep, so that no harm was done, your fault would have been exactly the same, yet you would have expected me to forgive you. It seems to me, therefore, that we ought to forgive you now. You must learn not to measure a fault by its consequences; you were wrong to leave the child, and it would have been just as wrong if poor Black Rover had not visited the hut while you were absent. Do you understand, Hetty?"
"I think I do, ma'am. Oh, I must try very hard."
"Ah! Hetty, trying hard won't do, not by itself. I will talk to you about this some day soon. But now, here we are at home," Mrs. Eyre said, as she knocked at the door.
Mrs. Goodenough opened it; her face was really worth seeing when she recognised Hetty
"You see, Mrs. Goodenough, I've brought Hetty Hardy back, and you will be pleased, I hope, to hear that it is partly your doing. She wrote to me after hearing from you that Miss Flo was still fretting after the cat. Stay here for a moment, Hetty; I will just say a word to the child and then call you."
But it was Flo's weak little voice that called—
"Hetty! Oh Hetty! My own good Hetty! Come to me quick!"
It was not for a few days that Mrs. Eyre found time for the talk with Hetty which she had promised her. But one morning, Flo being asleep, and the others out, Mrs. Eyre said: "Hetty, you know you and
I were to have a serious talk; for I did not say what I wished to say to you that evening."
"I remember, ma'am. You were saying that trying hard won't do, by itself. Ma'am, if you'll believe me, Matty told me that when I was coming here, that first time, and I never minded. I didn't really understand. But I do now. I see plain enough that it is not in my own strength that I can cure my heedlessness. And I know now that it is a sin, and not just a misfortune, as I used to call it. But indeed, ma'am, I do not think I could ever forget this lesson."
"Perhaps not. But, Hetty, try to think of what I am going to say to you. You are an affectionate girl, and so, to please those you love, you would do nearly anything. When you ran off to search for Zelica, I know well it was because the loss of the little cat would have grieved Miss Flo so much. But you see what came of it, and you know now that you did wrong. Now, had you asked yourself, not what would please Miss Flo, but what it was your duty to do—then you would have stayed at your post, and the child would have been safe."
"So it always is, Hetty. The moment our motive is less than the highest; the moment we act to please this person or that, without remembering that we have to please God, that moment we go wrong. I want you to pray, as Matty said to you; but, dear Hetty, pray that God will give you such a love for Him, your Father, who sent His Son to save you from your sins, that to please him may become the first thought of your heart. Will you do this, Hetty? Do you understand me?"
"I do, ma'am. You've said the like to me before, and so has Matty, but I didn't heed; I seemed not to understand. But all the time I was so unhappy about Miss Flo, those thoughts seemed to come back to me. And I will pray, as you tell me, ma'am. Indeed, I do love Him even now, though not as I ought; for He has been very merciful to me. Oh, ma'am!—when I think that she might have been killed! How could I have borne it, when it was my doing?"
"Indeed, Hetty, we all have much to be thankful for."
Well, if Hetty was not entirely cured of her heedlessness, she was certainly cured of treating it as a mere misfortune, for which she was to be pitied. And the best proof of her improvement was that in no long time Mr. Eyre quite laid aside his distrust of her, and ceased to be uneasy if she was left in charge of Flo.
Flo was very ill for a long time, and often they thought that a few weeks more would see the close of her suffering and her life. But she at last began to improve; and, to the great joy of all who loved her, she continued to get steadily better, until at last she could walk about nearly as well as Lina. She grew a great deal, too, and health brought back her pretty pink colour, and the unchildlike gravity vanished from her face.
Indeed, if the truth must be told, Miss Flora was rather a troublesome lassie for a time; for it seemed as if all the fun and frolic she had missed had to be got through somehow. But she sobered down again, and is a very good girl, and a great comfort to her parents. Lina is married, and Flo is the home daughter, helping her mother, and caring for the younger children.
As to Hetty, after ten years of faithful service, she left her dear mistress, and still dearer Miss Flo, to become the wife of Fred Smith, who is now postmaster in the very office where she was once too late for the London post, thanks to the attractions of Punch and Judy. And as Fred is a good, steady, God-fearing man, we may hope that she will be as happy as she deserves to be, I think; even though she once earned the name of Heedless Hetty.
Butler & Tanner, The Selwood Printing Works, Frome, and London.
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