Lower limb paralysis: its effect on the recanalization of deep-vein thrombosis

Fifty patients with lower limb deep-vein thrombosis (DVT) confirmed by venography were studied prospectively to determine the time required for recanalization. The patients were anticoagulated with heparin and warfarin for at least three months; impedance plethysmography, Doppler, and duplex scans were repeated at scheduled intervals. The 24 patients who were paralyzed took longer for recanalization than did the 26 nonparalyzed patients; this difference was statistically significant between the paraplegic-quadriplegic and nonparalyzed groups (54 vs 33 days; t = 2.12, p = .04). Patients with motor complete paraplegia or quadriplegia took longest for recanalization (57 days). Although most variables were not statistically significant on comparison, a somewhat longer recanalization time was seen in men and in those with DVTs located more proximally. Because of delay in recanalization, patients with lower limb paralysis may have persistent swelling due to venous insufficiency and may be at greater risk for development of the postphlebitic syndrome.

A second traumatic spinal cord injury: associated risk factors. Case report and review

Despite advances in acute care and long term management, traumatic spinal cord injury remains a devastating and disabling event. This report describes the case of a second traumatic spinal cord injury in a previously rehabilitated and functionally independent paraplegic. Factors potentially associated with the second spinal cord injury in this patient include wheelchair use, previous spinal fusion, alcohol use and sensation-seeking behavior. These factors, which are common to many spinal cord injured patients, could potentially be risk factors for a second traumatic spinal injury.

Cognitive deficits in spinal cord injury: epidemiology and outcome

Cognitive deficits are common among patients with acute spinal cord injury (SCI), but reported prevalence figures vary because of different methods of study. Factors associated with cognitive deficits in patients with SCI include age, educational background, history of learning disability, chronic alcohol and substance abuse, and concomitant or recurrent traumatic brain injury. Psychologic testing of patients with and without cognitive deficits indicates that impaired psychosocial adjustment and adaptation are more frequent in SCI patients who have evidence of cognitive deficits. Various associations have been found between neuropsychologic test performance and major depression. Cognitive functioning and premorbid educational level appear to be associated with medical stability, the patient's ability to assimilate the necessary skills for survival and adaptation after SCI, and readmission patterns after discharge for initial inpatient rehabilitation.

Neuromuscular stimulation in spinal cord injury. II: Prevention of secondary complications

The spinal cord injured patient has been the focus of clinical and research efforts to restore functional movement and to obtain therapeutic benefits by electric stimulation of upper motor neuron paralyzed muscles. This review article treats developments in this field from 1983 to 1990. Efforts have been directed to restoring ventilatory and bladder function, and to preventing secondary complications. Electric stimulation for improving ventilatory function has had reasonable success, and systems are commercially available. Electric stimulation for improving bladder function remains in the research stage in the US, although it has had some clinical success reported in Europe. Electric stimulation techniques to prevent or treat secondary complications have been applied to pressure ulcers, deep-venous thrombosis, contractures, spasticity, deconditioning due to lack of exercise, and muscle atrophy. Therapeutic electric stimulation techniques are largely research techniques. Much additional work remains to be done to solve the difficult problems associated with applying this technology in the treatment of patients with spinal cord injury.

Neuromuscular stimulation in spinal cord injury: I: Restoration of functional movement of the extremities

The spinal cord injured patient has been the focus of clinical and research efforts to restore functional movement and obtain therapeutic benefits by electric stimulation of upper-motor-neuron paralyzed muscles. Our review articles treat developments in this field from 1983 to 1990. Efforts have been directed to restoring hand function, standing, and walking (covered in part I), as well as prevention of secondary complications through ventilatory function, bladder function, and achieving therapeutic effects of electric stimulation (covered in Part II). The technology for hand function, standing, and walking is used primarily in the research laboratory, as clinical applications are minimal. Much work remains to be done to solve the difficult problems associated with applying this promising technology to spinal cord injury.

Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes

Brown-Sequard syndrome (BSS) and Brown-Sequard-plus syndrome (BSPS) are characterised by asymmetrical paresis with hypalgesia more marked on the less paretic side. This study examined the clinical features of 38 patients (30 males and 8 females; mean age = 32 years) with traumatic cervical BSS or BSPS who underwent comprehensive inpatient rehabilitation. Twenty two injuries were caused by road traffic accidents, 8 by penetrating injuries, 5 by diving injuries, and 3 by other causes. After an average of 35 days in acute care and 79 days in rehabilitation, 37 patients had increased muscle strength, all 38 patients improved functional abilities, 29 patients walked independently, 34 had spontaneous bladder emptying, 36 were discharged home, and 14 were employed. Statistically significant increases (p less than 0.001) were made in modified Barthel index functional scores between admission and discharge. Patients with BSPS had a better prognosis than did those with 'pure' BSS. Patients with predominant upper limb weakness had more favourable outcomes than did those with predominant lower limb weakness. Few other potentially predictive demographic, injury, or neurological factors were associated with functional outcome. Patients with BSS or BSPS generally have a good prognosis for neurological and functional improvement.

Superior mesenteric artery syndrome in acute traumatic quadriplegia: case reports and literature review

Superior mesenteric artery syndrome is a condition in which the third portion of the duodenum is intermittently compressed by the overlying superior mesenteric artery, resulting in gastrointestinal obstruction. Predisposing factors include rapid weight loss, prolonged supine positioning, and using a spinal orthosis, all of which are common among acute traumatic quadriplegic patients. This paper presents three patients, aged 24, 16, and 20 years, with traumatic quadriplegia treated with supine positioning and cervical orthoses, who had postprandial nausea and emesis, bloating, and abdominal pain during rehabilitation. Upper gastrointestinal radiographic series demonstrated abrupt duodenal obstruction to barium flow in all three patients. Two of the patients had complete relief of symptoms with conservative management, and one required surgical duodenojejunostomy. Enhanced awareness of this condition may result in improved recognition of this disease as a cause of persistent, unexplained gastrointestinal disturbances in quadriplegic persons, thereby optimizing its treatment and reducing its potential morbidity.

Estimating the user population of a simple electrical stimulation system for standing

Many laboratory demonstrations have been reported on standing or walking with the aid of electrical stimulation. These demonstrations have typically been in small numbers of selected spinal cord injured individuals. The extent to which this technology might ultimately be applicable to the spinal cord injured population at large is not presently known. This study reports estimates of the size of the potential user population of a specific surface electrical stimulation device and protocol. The medical records were reviewed of 192 patients with traumatic thoracic, lumbar, or sacral spinal cord injury resulting in paraplegia. Based on the inclusionary criteria, between 20 and 48 patients (10.4% and 25%) of this sample population could be considered eligible for this surface stimulation protocol. As approximately 45% of the USA population of spinal cord injured individuals have paraplegia, the results suggest that between 4.7% and 11.25% of all spinal cord injured persons in the USA might be potential users of this particular electrical stimulation technology.

Classification of pressure ulcers

Several systems exist for classifying pressure ulcers, though none of them have been evaluated for interrater reliability. A new grading scale was compared with the commonly used Shea classification. This new scale was developed to provide a more complete description of pressure ulcer healing. The advantages of this scale include a classification of red areas as ulcers to help prevent further deterioration and classification of healed sores to note potential problems. The Yarkony-Kirk scale classifies a red area as a grade 1 ulcer, and involvement of the epidermis and dermis with no subcutaneous fat observed as a grade 2 ulcer. Grade 3 indicates exposed subcutaneous fat with no muscle observed. Exposed muscle without bone involvement is classified as a grade 4 ulcer, and grade 5 describes exposed bone with no joint space involvement. Grade 6 indicates joint space involvement. There is a classification of pressure sore healed to indicate a healed pressure ulcer. Interrater reliability was assessed by two nurses. In spite of an increased number of categories for the Yarkony-Kirk scale, there was no decline in reliability. Reliability was excellent with an interrater correlation of 0.90 for the Yarkony-Kirk scale and 0.86 for the Shea classification when measured for 72 patients. Eighty-five percent of the ratings for the Yarkony-Kirk scale were identical, whereas only 68% were identical for the Shea classification. Three percent of the ratings for the Shea classification were greater than +/- 1 category; 6% of the ratings for the Yarkony-Kirk scale were greater than +/- 1 category. This scale appears to possess good reliability and to describe pressure ulcers more completely. This scale may also be used to teach prevention activities as well as ulcer classification.

Spinal cord injury care system: fifteen-year experience at the Rehabilitation Institute of Chicago

A statistical study of 15 years of the spinal cord injury care system of the Rehabilitation Institute of Chicago is reported. The Rehabilitation Institute of Chicago (RIC) is the rehabilitation component of the Midwest Regional Spinal Cord Injury Care System, a collaborative programme with Northwestern Memorial Hospital and Northwestern University. Data are reported on 1382 patients, a representative sample of the over 2000 patients treated since the inception of the centre. The sample was predominantly male (83%, N = 1147) and caucasian (64%, N = 888). The most common aetiology was motor vehicle accidents (36%, N = 505). During the 15-year period there were significant decreases in both acute and rehabilitation lengths of stay. Ninety three per cent of the patients were discharged home. Rehabilitation benefits were demonstrated by improvements in the Modified Barthel Index. The research, educational and clinical programmes are described.

Cognitive dysfunction in spinal cord injury patients: sensitivity of the Functional Independence Measure subscales vs neuropsychologic assessment

The Functional Independence Measure (FIM) has been developed to provide an objective measure of functional gains during acute and chronic rehabilitation of disabled individuals, including those with spinal cord injury (SCI). A unique characteristic of the FIM, as compared with other functional scales, is that it reflects abilities in the areas of communication and social cognition. In order to examine the external validity of these subscales, 41 acute SCI patients were evaluated with the FIM just before discharge from acute rehabilitation. The subscale scores were compared to the results of a comprehensive, predominantly motor-free, neuropsychologic battery administered 74.8 +/- 5.3 days postinjury. Evaluation of scatter plots indicated that there were no relationships between any neuropsychologic test results and the discharge FIM social cognition or communication subscale scores. This was attributed to a ceiling effect in the FIM ratings. The results of this study suggest that the FIM cannot be a substitute for comprehensive neuropsychologic assessment in SCI patients.

Dysvascular amputee rehabilitation. The role of continuous noninvasive cardiovascular monitoring during physical therapy

Recognition of cardiac problems and their impact on the treatment of dysvascular amputees is important during rehabilitation because the energy demands and cardiac work loads of functional activities are substantially greater when performed by persons with amputation than when performed by control subjects. For this reason, monitoring the cardiovascular response to therapeutic exercise might be expected to enhance the medical and rehabilitative management of dysvascular amputees. In the present study, 31 amputees with peripheral vascular disease underwent continuous noninvasive dynamic cardiovascular monitoring during an initial physical therapy session. The sample had a mean age of 65 yr. There were 20 females. Twenty patients had unilateral below knee amputation. Fifty-two percent had a preamputation history of cardiac disease and six experienced major cardiovascular complications during rehabilitation. After a mean acute hospitalization of 20 days and a mean rehabilitation stay of 36 days, 11 patients were walking independently and 25 were discharged to home. During the monitored physical therapy session, patients achieved a mean maximum heart rate of 113 beats/min, mean maximum blood pressure of 159/81, mean maximum rate-pressure product of 14,546, and mean percent of age-predicted maximal heart rate of 73%. Seventeen (55%) patients demonstrated abnormalities during the monitored session, four of whom had no prior history of heart disease. These changes consisted predominantly of ST-T segment abnormalities, but also included exercise-induced arrhythmias and decreases in blood pressure. Patients with a history of heart disease demonstrated significantly more abnormalities during the monitored session than did those without a history of heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation outcomes in patients with complete thoracic spinal cord injury

This paper describes the functional outcomes and lengths of stay of 184 patients discharged from comprehensive rehabilitation with complete thoracic traumatic spinal cord injuries. The 100-point modified Barthel Index (MBI) was used to assess functional abilities. There were statistically significant improvements in the mean total MBI score for the entire sample from 35.2 at rehabilitation admission to 71.0 at discharge. The mean lengths of stay were 46 days in acute care and 84 days in the rehabilitation facility. There were 79 patients with lesions between T1 and T6 ("high paraplegics") and 105 patients with lesions between T7 and T12 ("low paraplegics"). There were no significant differences in the mean MBI scores, self-care subscores, mobility subscores, acute lengths of stay or rehabilitation lengths of stay between high and low paraplegic patients. However, low paraplegic patients were more likely to walk than were the high paraplegic patients. Surgical stabilization was performed on 36% of the sample; total MBI scores were similar for surgically stabilized and nonsurgically stabilized patients. High and low thoracic paraplegic patients achieved significant functional gains during rehabilitation. These functional gains occurred in a setting which provided for the vocational, psychosocial and recreational needs of the individual, and which fostered independence, community participation and a return to a healthy and active lifestyle.

The timer-logger-communicator gait monitor: recording temporal gait parameters using a portable computerized device

A portable microprocessor-based device, the timer-logger-communicator (TLC), was adapted and connected to footswitches to monitor and record temporal gait parameters in 25 hemiplegic and 30 normal subjects. Controls walked at 1.36 m/s with symmetric gait. Hemiplegic subjects had a mean walking speed of 0.43 m/s, asymmetric gait, and varying proportions of time spent in each phase, consistent with previously reported gait parameters. Trends in objective gait measures more closely paralleled trends in functional ambulation classification than in Brunnstrom motor recovery stages. The TLC gait monitor is a useful instrument to measure temporal parameters of gait in the clinical setting.

Traumatic central cord syndrome: clinical features and functional outcomes

This retrospective study examined clinical features of 81 rehabilitated patients with traumatic central cord syndrome and identified factors which predicted more favorable rehabilitation outcomes. The sample had two age peaks and a mean age of 46 years. Most injuries were caused by vehicular accidents, but falls were more common among older persons. Predominant upper extremity weakness was proximal in 4%, distal in 36%, and generalized in the remainder. Forty-one percent also had significant lower limb weakness. More than 90% of the patients experienced neurologic recovery of upper and/or lower limb strength. After an average acute hospitalization of 30 days and a mean rehabilitation stay of 70 days, most patients performed each of 14 functional skills independently, 84% had bladder continence, and 89% were discharged home. Statistically significant improvements were noted for mean Modified Barthel Index scores between rehabilitation admission and discharge. Favorable rehabilitation outcomes were associated most frequently with younger age, preinjury employment, absence of lower extremity impairment on admission, and documented upper or lower extremity strength recovery during rehabilitation. Central cord syndrome generally has a good prognosis for neurologic and functional improvement during rehabilitation.

Fever, bacteriuria, and pyuria in spinal cord injured patients with indwelling urethral catheters

Little is known about the significance of pyuria in spinal cord injury patients with indwelling urethral catheters (IUCs). The hospital courses of 32 such patients admitted to a rehabilitation hospital from January 1986 to December 1987 were reviewed to determine the incidence of unexplained febrile episodes, ie, no obvious nonurinary source of infection. All patients had positive admission urine cultures (greater than 100,000 colony-forming units/mL). Patients were divided into two groups based on the level of pyuria in admission urinalyses. Group A (the low pyuria group) was composed of 22 patients with less than or equal to 50 white blood cells per high-power field (WBC/HPF). Group B (the high pyuria group) was composed of ten patients with less than 50 WBC/HPF. None were admitted to the rehabilitation program taking antibiotics; none were prophylactically treated for urinary tract infection. The difference in incidence of fever between febrile episodes. Group B had an incidence of 6/10 (60%) febrile episodes. The difference in incidence of fever between the groups was statistically significant (chi2 = 7.31, p less than .01). These results suggest that SCI patients with IUCs and gross pyuria may be at risk for increased morbidity secondary untreated urinary tract infection.

Functional outcome following spinal cord injury. A comparison of specialized spinal cord injury center vs general hospital short-term care

The functional outcomes of 185 patients with spinal cord injuries undergoing rehabilitation who were initially treated in a specialized short-term care unit (center patients) were compared with those of 153 patients initially treated in general hospitals (noncenter patients). After stabilization, all patients were admitted to the Rehabilitation Institute of Chicago (Ill) and received the same rehabilitation program. The groups were comparable in terms of demographic, injury, and medical characteristics at the time of rehabilitation center admission, but the duration from injury to rehabilitation was more than twice as long for noncenter patients. While center patients were discharged from the rehabilitation center at equivalent functional skill levels, their daily rate of functional gains during the rehabilitation center stay was significantly greater than that of noncenter patients although the length of stay at the rehabilitation center was comparable for the two groups. These results support the practice of specialized short-term spinal cord injury care as a means of enhancing rehabilitation outcome.

Rehabilitation technology for standing and walking after spinal cord injury

The purpose of this paper is to review the rehabilitation technology available for standing and walking by the spinal-cord injured. Existing aids for standing and walking and those aids under development in research laboratories are discussed. One conclusion is that therapeutic and perhaps functional standing could be achieved in a greater number of individuals using existing technology; however it must also be realized that some barriers still exist which prevent various technologies from being more widely used. Studies which measure the benefits of standing, and more fully establish minimum standing times to achieve these benefits, are needed. Standing is a necessary component of many tasks, and it is unlikely single type of standing aid is likely to perform adequately in every situation that requires standing. Therefore it may be prudent to have a variety of standing aids available to patients.

Genetic variation in an inbred plant: variation in tissue cultures of soybean [Glycine max (L.) Merrill]

Although soybean [Glycine max (L.) Merrill] grows as an inbreeding, generally homozygous, plant, the germplasm of the species contains large amounts of genetic variation. Analysis of soybean DNA has indicated that variation of RFLP (restriction fragment length polymorphism) markers within the species usually entails only two alleles at any one locus and that mixtures of such dimorphic loci account for virtually all of the restriction fragment variation seen in soybean (G. max), and in its ancestors, G. soja and G. gracilis. We report here that tissue cultures prepared from root tissue of individual soybean plants develop RFLP allelic differences at various loci. However, these newly generated alleles are almost always the same as ones previously found and characterized in other varieties of cultivated soybean (cultivars). This repeated generation of particular alleles suggests that much of the genetic variation seen in soybean could be the consequence of specific, relatively frequently employed, recombinational events. Such a mechanism would allow inbred cultivars to generate genetic variation (in the form of alternative alleles) in a controlled manner, perhaps in response to stress.

Rehabilitation outcomes in C6 tetraplegia

This study reports on the rehabilitation outcome of 69 C6 tetraplegic patients admitted to the Rehabilitation Institute of Chicago during an 8 year period. All patients' last normal level was C6 bilaterally. A 100-point modified Barthel Index was used to obtain measures of functional independence in 15 self-care and mobility tasks. The population consisted of 54 males and 15 females with an average age of 29.2 years. The average number of days from injury to admission to the rehabilitation unit was 58.6 and the average length of rehabilitation stay was 108.4 days. The average Modified Barthel Index score increased from 16.6 on admission to 50.1 on discharge. The Self-Care Subscore increased from 12.8 to 32.2 and the Mobility subscore from 3.7 to 17.9. There were statistically significant increases in the number of patients able to perform all tasks except ability to don an orthosis and ability to walk 50 yards. This study documents a significant increase in function of C6 spinal cord injured patients during rehabilitation.

Functional skills after spinal cord injury rehabilitation: three-year longitudinal follow-up

Reports that spinal cord injury (SCI) patients maintain or improve functional abilities after initial rehabilitation have been limited by small sample size, inadequate functional measures, cross-sectional assessment at only one point in time, and lack of detailed statistical analysis. This study evaluated the follow-up functional status levels of 236 patients with traumatic SCI who completed comprehensive inpatient rehabilitation and were also followed for three years. The sample population was 83% men, with a mean age of 27.0 years. The 100-point Modified Barthel Index (MBI) was used to assess functional abilities. The 75 patients with complete quadriplegia had mean MBI scores of 30.3 at rehabilitation discharge and 37.8 at three-year follow-up. The 53 patients with incomplete quadriplegia were discharged with a mean MBI score of 53.8, and scored 68.3 at three-year follow up. The mean MBI scores for the 66 patients with complete paraplegia were 72.0 at discharge and 75.6 at three-year follow-up. The 42 patients with incomplete paraplegia had mean MBI scores of 77.0 at discharge and 86.1 at three-year follow-up. Each of the four groups demonstrated stability or increases in the proportions of patients who were independent in performance of each of the 14 MBI component tasks from discharge to follow-up. The finding that SCI patients, in this large series, maintained or improved functional levels for three years after discharge is consistent with previous studies and is reassuring to rehabilitation providers.

Stroke rehabilitation outcome: impact of coronary artery disease

The frequency of clinically significant coronary artery disease (CAD) among stroke patients and the impact of CAD on stroke rehabilitation were studied in 132 patients with first thrombotic or embolic stroke who participated in comprehensive rehabilitation. Sixty-one patients (46%) had a history of CAD, and 16 of the 61 also had congestive heart failure (CAD-CHF). Patients with CAD, and especially those with CAD-CHF, had significantly longer intervals from stroke onset to rehabilitation admission (p less than 0.001), and once in rehabilitation they experienced three times as many cardiac complications (p less than 0.001). While all patient groups improved function during rehabilitation, those with CAD and CAD-CHF improved significantly less than did those without CAD (p less than 0.01). Patients with CAD did least well with rolling, moving in bed, transferring from a wheelchair to bed, and walking. CHF not only adversely influenced overall function and mobility task performance but also affected the potential for achieving functional gains. These data suggest that specific measures of function and rehabilitation are affected by CAD and that the levels of achievement for patients with CAD-CHF are limited.

Spinal cord injury rehabilitation outcome: the impact of age

The effect of age on self-care and mobility skill performance after spinal cord injury was studied using a 15-task modified Barthel Index (MBI) to score functional abilities for 708 patients aged 6 through 88 years. Analysis of covariance showed no relationship between age and discharge MBI score; however, patients with paraplegia, incomplete lesions, and greater admission functional ratings had greater discharge functional scores than did those with quadriplegia, complete lesions, and lower admission scores, respectively. Advancing age was associated with increased dependence in only seven functional skills (bathing, upper and lower body dressing, stair climbing, and transfers to chair, toilet and bath) and only for patients with complete paraplegia. Other MBI component tasks and patients with complete quadriplegia, incomplete paraplegia and incomplete quadriplegia demonstrated no relationship between age and skill performance. Results of this study support the practice of providing comprehensive rehabilitation services to all patients following spinal cord injury regardless of age.

Multivariate analysis of improvement and outcome following stroke rehabilitation

This study documented the status of 432 patients and characteristics of functional improvements and outcomes achieved by 163 patients who participated in comprehensive stroke rehabilitation. Scores on the 100-point Activities of Daily Living Index improved from hospital admission to discharge and declined slightly at follow-up. An average Activities of Daily Living Index point gain of 0.6 per day was found that was unrelated to age, sex, side of hemiparesis, or admission functional status. Seventy-nine percent of the patients were discharged home; 85% were home at follow-up. Eleven percent of the patients were working at follow-up. Patients traveled outside their homes an average of 24.6 days during the three months immediately following discharge. A significant number of patients achieved favorable functional housing, employment, and social outcomes. This study supported referral for rehabilitation services regardless of age, side of hemiparesis, or degree of impairment.