Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin

Feasibility, Validity, and Reliability of Lower Limb Tactile and Body Awareness Assessments in Children With Upper Motor Neuron Lesions

OBJECTIVE

To investigate the feasibility, discriminative and convergent validity, and inter-rater reliability of a lower limb tactile function and 2 body awareness assessments in children with upper motor neuron (UMN) lesions.

DESIGN

Cross-sectional psychometric study.

SETTING

Pediatric rehabilitation center.

PARTICIPANTS

Forty individuals with UMN lesions (mean age 11.7 years, SD 3.4 years; 27 girls) and 40 neurotypically developing children of the same age participated (N=80).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We assessed the tactile threshold (TT) with monofilaments and body awareness with tactile localization tasks (TLTs) for structural (TLTaction) and spatial (TLTperception) body representation at the foot sole. We compared the test outcomes between children with UMN lesions and neurotypically developing children with the Wilcoxon signed-rank test. Furthermore, we quantified the relations between the 3 tests with Spearman correlations (rs) and the interrater reliability with quadratic weighted kappa (κQW).

RESULTS

About 80% of the children with UMN lesions perceived the tests easy to perform. The children with UMN lesions had significantly reduced somatosensory function compared with the neurotypically developing children. For the more affected leg, we found good relations between the TT and the TLTaction (rs=0.71; P<.001) and between the 2 TLTs (rs=0.66; P<.001), and a fair relation between the TT and the TLTperception (rs=0.31; P=.06). The inter-rater reliability analyses for the sum scores showed almost perfect agreement for the TT (κQW more affected leg 0.86; less affected leg 0.81), substantial agreement for TLTaction (κQW more affected leg 0.76; less affected leg 0.63), and almost perfect agreement for TLTperception (κQW more affected leg 0.88; less affected leg 0.74).

CONCLUSION

The 3 tests are feasible to assess lower limb somatosensory function in children with UMN lesions. Discriminative and convergent validity and reliability of the 3 tests were confirmed. Further studies should investigate responsiveness and association with motor function of these outcome measures.

Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines

The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury.

Joint Contractures Resulting From Prolonged Immobilization: Etiology, Prevention, and Management

Patients who are immobilized for a prolonged period are at risk for developing joint contractures, which often affect functional outcomes. Nonsurgical interventions are useful for preventing joint contractures. However, once contractures develop, these interventions frequently fail to restore function over the long term. To increase the rehabilitation potential of an extremity with refractory function-limiting contractures, surgery is often required.

Upper limb casting in stroke rehabilitation: rationale, options, and techniques

Upper limb casts have been recommended for stroke survivors with moderate to severe spasticity. The objective of this article is to (a) review the rationale of 2 theoretical models that address spasticity and its consequences, (b) describe 4 casting options reported in the literature, (c) present the evidence for each cast type, and (d) suggest techniques that ensure safe and efficient fabrication of casts. This review underscores the critical need for high-evidence research on the efficacy of casting and the potential long-term benefits to this population. Current evidence lacks controlled research designs, robust sample sizes, and sensitive outcome measures. However, selective groups of stroke survivors have benefited from each type of casting. Future studies are required to assess the impact of casting on upper limb function, especially for those persons with wrist and hand spasticity, and to evaluate the efficacy of those casts not widely adopted in current practice such as inhibitory and drop-out casts.

Cohort study of atypical pressure ulcers development

Atypical pressure ulcers (APU) are distinguished from common pressure ulcers (PU) with both unusual location and different aetiology. The occurrence and attempts to characterise APU remain unrecognised. The purpose of this cohort study was to analyse the occurrence of atypical location and the circumstances of the causation, and draw attention to the prevention and treatment by a multidisciplinary team. The cohort study spanned three and a half years totalling 174 patients. The unit incorporates two weekly combined staff meetings. One concentrates on wound assessment with treatment decisions made by the physician and nurse, and the other, a multidisciplinary team reviewing all patients and coordinating treatment. The main finding of this study identified APU occurrence rate of 21% within acquired PU over a three and a half year period. Severe spasticity constituted the largest group in this study and the most difficult to cure wounds, located in medial aspects of knees, elbows and palms. Medical devices caused the second largest occurrence of atypical wounds, located in the nape of the neck, penis and nostrils. Bony deformities were the third recognisable atypical wound group located in shoulder blades and upper spine. These three categories are definable and time observable. APU are important to be recognisable, and can be healed as well as being prevented. The prominent role of the multidisciplinary team is primary in identification, prevention and treatment.

The effects of polarized light therapy in pressure ulcer healing

Background/Aim. Neglecting polarized light as an adjuvant therapy for pressure ulcers and methodology distinctions in the trials engaging polarized light are the reasons for many dilemmas and contradictions. The aim of this study was to establish the effects of polarized light therapy in pressure ulcer healing. Methods. This prospective randomized single-blind study involved 40 patients with stage I-III of pressure ulcer. The patients in the experimental group (E) were subjected, besides polarized light therapy, to standard wound cleaning and dressing. Standard wound cleaning and dressing were the only treatment used in the control group (C). A polarized light source was a Bioptron lamp. Polarized light therapy was applied for six min daily, five times a week, four weeks. The Pressure Ulcer Scale for Healing (PUSH) was used in the assessment of outcome. Statistic analysis included Mann Whitney Test, Fisher Exact Test, Wilcoxon Signed Rank test. Results. There were significant differences between the groups at the end of the treatment regarding the surface of pressure ulcer (E: 10.80?19.18; C: 22,97?25,47; p = 0.0005), rank of pressure ulcer (E: 5.90?2.48; C: 8.6?1.05; p = 0.0005) and total PUSH score (E: 7.35?3.17; C: 11.85?2.35; p = 0,0003). The patients in the experimental group had significantly better values of the parameters monitored than the patients in the control group. Conclusion. After a four-week polarized light therapy 20 patients with stage I-III ulcer had significant improvement in pressure ulcer healing, so it could be useful to apply polarized light in the treatment of pressure ulcers.

Análise dos efeitos da utilização da tala seriada em crianças portadoras de paralisia cerebral: uma revisão sistemática da literatura

OBJETIVOS: realizar uma revisão sistemática da literatura através da seleção e análise criteriosa de artigos científicos que investigaram os efeitos da tala seriada em crianças com diagnóstico clínico de paralisia cerebral espástica. MÉTODOS: busca sistemática na literatura foi realizada no período de março a agosto de 2004, nas bases de dados eletrônicas Medline, Lilacs e PEDro publicados nas línguas inglês e português, no período de 1980 a 2004. O nível de evidência dos artigos estudados foi qualificado utilizando-se a escala Magee. RESULTADOS: os quatro artigos incluídos nessa revisão preencheram todos os critérios de inclusão e foram classificados como fracos de acordo com a escala Magee (índice de concordância Kappa K=1,0) devido às limitações metodológicas apresentadas. CONCLUSÕES: as evidências utilizadas nessa revisão sistemática não apresentam nível que possa suportar a utilização clínica da tala seriada em crianças com paralisia cerebral. Futuras pesquisas devem ser realizadas em observância à necessidade de maior rigor metodológico dos estudos para a fundamentação da prática baseada em evidência.

The influence of illness duration and level of consciousness on the treatment effect and complication rate of serial casting in patients with severe cerebral spasticity

OBJECTIVE

To compare the improvement and complication rates for serial casting in patients with shorter as opposed to longer illness duration, and in patients with lower as opposed to higher levels of consciousness.

DESIGN

A retrospective case-comparison study.

SETTING

A rehabilitation centre for adult persons with neurological disorders.

SUBJECTS

Sixty-eight patients with cerebral spasticity of different aetiologies were treated with serial casting to relieve fixed contractures.

INTERVENTION

Serial casting with either < 90 days (group A, 36 joints, 24 patients) or > or = 90 days (group B, 85 joints, 44 patients) duration of illness and either < 12 (group 1, 49 joints, 25 patients) or > or = 12 (group 2, 72 joints, 43 patients) Glasgow Coma Scale (GCS) scores.

MAIN OUTCOME MEASURES

Percentage of normal maximum range of motion (ROM) at the completion of casting and one month after discontinuation, and number of complications due to casting procedure.

RESULTS

No differences in ROM improvement between duration groups (F = 0.43, p = 0.51) and GCS groups (F = 1.3, p = 0.26) were observed. Complications in serial casting were found in 25.0% in group A, in 10.6% in group B (chi-squared = 4.2, p = 0.042), in 24.5% in group 1, and in 8.3% in group 2 (chi-squared = 6.0, p = 0.014).

CONCLUSION

This study suggests that serial casting in patients with longer illness duration and higher levels of consciousness provides improvements in ROM comparable with an earlier treatment in patients with more impaired consciousness, but results in a lower occurrence of complications.

Effectiveness of serial casting in patients with severe cerebral spasticity: a comparison study

OBJECTIVE

To compare the improvement and complication rate between a technique using a short casting interval and a more conventional changing interval.

DESIGN

A retrospective case-comparison study.

SETTING

A rehabilitation center for adults with neurologic disorders.

PARTICIPANTS

One hundred five patients with cerebral spasticity of different etiologies treated with serial casting to relieve fixed contractures caused by increased muscle tone.

INTERVENTION

Serial casting of 172 joints (42 elbow, 41 wrist, 21 knee, 68 ankle joints), with cast-changing intervals of 5 to 7 days (group 1:92 joints, 56 patients), or 1 to 4 days (group 2:80 joints, 49 patients).

MAIN OUTCOME MEASURES

Percentage of normal maximum range of motion (ROM) at the completion of casting and 1 month after discontinuation, and the number of complications resulting from casting procedure.

RESULTS

Improved percentage ROM immediately after serial casting and 1 month later in both groups (F=1469.5, P<.001). No differences in ROM improvement between groups were observed (F=0.3, P=.72). Complications in serial casting were found in 19.8% of 172 casting procedures, in 29.3% in group 1 and in 8.8% in group 2 (chi(2)=10.2, P=.001). Discontinuations of treatment because of casting complications or other reasons were observed in 12.8% of the entire sample, in 18.5% in group 1 and in 6.3% in group 2 (chi(2)=4.7 P=.03).

CONCLUSION

Casting is effective in the treatment of fixed contractures of the upper and lower extremities caused by increased muscle tone of cerebral origin. Short changing intervals in serial casting provide improvements in ROM comparable with conventional changing intervals, and result in fewer complications.