[Capabilities of physiotherapy for orbital trauma]

The article describes the results of conservative treatment of 78 patients with injuries of ocular adnexa (isolated fractures of orbital walls as well as cicatrical deformities of orbits and eyelids). Ophthalmological assessment was made both in the early and the late periods following blunt trauma. All patients underwent a standard assessment of functional ability of the eye and, additionally, an orbital computed tomography scan to characterize the fractures. In all cases physiotherapy (endonasal electrophoresis with proteolytic enzymes) was carried out to resolve the orbital hemorrhage. Binocular vision evaluation was done to control the effectiveness of the treatment. For that, the extent of diplopia in the central field and the total area of peripheral double vision were measured and the vertical edges of the diplopia zone were defined.

[Double disinsertion of inferior and medial rectus muscle after injury. A case report]

We report a rare case of double disinsertion of inferior and medial rectus muscles of the left eye. After injury, the patient presented ocular ascension. The eye's position made the clinical examination difficult. The patient underwent two surgical treatments to find and reattach the deficient muscles. In spite of a laborious search, we obtained a good anatomic result. Oculomotor disorders require orthoptic training. To avoid diagnostic errors and to reduce oculomotor after effects, vigilance is required during examination.

[Latest standards of muscle injury prophylactic activities, treatment and rehabilitation]

Muscle injury represents the highest proportion of sport-linked contusions. Experimental and clinical studies aim at increasingly detailed recognition of muscle physiology and pathophysiology. It would allow to set up functional standards and permit to minimize risk of contusions associated with sport activities. In cases of such contusions it would restrict its sequele and would abbreviate the duration of treatment. In the study elements of prophylaxis, treatment and rehabilitation of injured muscles will be discussed, based on current scientific results. Review study includes data from studies investigating prophylactic activities, types of teratment and the effects of different rehabilitation strategy. Latest standards from First European Congress of Football Medicine, Munich 2004, were also taken into account. The prophylactic activities should focus on education attempting to popularize the knowledge of the role of warm-up activities which precede proper physical effort, muscle stretching and activities augmenting muscle strength. The treatment of muscle injury is related to the extent of their damage. First actions should be focused on the RICE principle (Rest, Ice, Compression, Elevation). In case of torn tissues, local injections of anesthetics, anti-inflammatory agents and regeneration-promoting agents used to be applied. Application of NSAIDs and anti-thrombotic prophylaxis is sound but due to their side effects it is recommended as frequently as it is counterindicated by physicians. A threshold in the therapy, not always noted by therapeutists, involves rapid mobilization of the injured tissue. This involves mobility exercises starting at 3-5 days post-trauma, with no load at the beginning, but starting at days 4 to 6 asssociated with appropriate loading. The recently conducted studies aim at stimulation of rapid muscle regeneration, inhibition of scar formation in the site of injury and elimination of already existing scars. The latter seems most difficult due to the high risk of the repeated muscle injury in the same site. The rehabilitation following trauma with particular attention paid to proprioceptive training is equally important. The risk of another contusion cannot be reduced to minimum until the pre-contusion proprioception level is achieved in the contused extremity.

Long-term outcomes of major trauma without head injury in the West of Scotland: pilot case???control study

The aim of this study was to identify the outcomes of survivors of blunt major trauma (without head injury) 2 years or more following injury. The study uses a case-control design, is set in the West of Scotland and includes trauma patients treated in Greater Glasgow NHS Board hospitals. Participants consisted of patients who had sustained major trauma (injury severity score >15) with little or no head injury at least 2 years before assessment, identified from the Scottish Trauma Audit Group database, and age and sex-matched controls nominated by the index case's general practitioner. Nineteen cases and seven controls completed the study from 223 potential cases and 39 potential controls. Participants and non-participants had comparable injury severity score, probability of survival (Ps) and length of stay. American Medical Association impairment scores show survivors were more impaired than controls (25.9 vs 7.4%, P=0.043). No differences were observed in Functional Independence Measure (FIM) or Community Integration Questionnaire (CIQ) scores, although a type II error is possible. Short-form 36 (SF36) Physical Component Summary (PCS) scores of survivors showed no difference compared with controls although survivors' PCS scores were below UK and US means (P=0.008). SF36 Mental Component Summary (MCS) scores of survivors were below those of controls (45.07 vs 56.65, P=0.004) and normal values of the UK population (P=0.036). No differences in work status were noted, but small sample sizes were used. Non-head-injured survivors of major trauma in the West of Scotland have poorer health status (SF36), physically and mentally, than the UK population. They have greater impairment, but have an employment status comparable to that of the controls. The lack of differences in FIM and CIQ scores between survivors and controls may be due to small sample sizes.

Do trauma centers improve functional outcomes: a national trauma databank analysis?

BACKGROUND

The development of a tiered trauma care system has lead to improved survival for the critically injured. The question as to whether the increased survival associated with the establishment of tiered levels of trauma care is paralleled by an improved functional outcome has not, however, been addressed.

METHODS

Multivariate logistic regression analysis of the National Trauma Data Bank from 1994 to 2001 was performed with functional independence measure (FIM) as the primary outcome. Trauma centers were dichotomized as Level II or above versus Level III or below. Blunt and penetrating trauma patients were analyzed separately. Other covariates included age, gender, shock, comorbidities, alcohol, drugs, as well as head, chest, abdominal, spine, and lower extremity injury. Confidence intervals were set at an alpha of 0.05.

RESULTS

A total of 474,024 patients were analyzed. Among minimally injured penetrating trauma patients, those receiving care at a higher tiered center had a higher likelihood of total independence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0, 2.0). Among minimal, moderate and severely injured blunt trauma patients those receiving care at a higher tiered center had a higher likelihood of total independence (OR = 1.2, 95% CI = 1.0, 1.4, OR = 1.3, 95% CI = 1.1, 1.6, OR = 1.3, 95% CI = 1.3, 1.5, respectively).

CONCLUSIONS

These data indicate that the complex care delivered by advanced level trauma centers is associated with improved functional outcomes. Further investigations to identify the reasons for differences in these outcomes are necessary to improve care at lower tiered hospitals particularly for minimally injured patients.

The new injury severity score: better prediction of functional recovery after musculoskeletal injury

OBJECTIVES

Injury Severity Score (ISS) is the most widely used method of assessing severity of injury in blunt trauma. It has been recognized that, by only allowing the score to consider the worst injury for each body system, ISS underestimates the problems of multiple musculoskeletal injuries. The New ISS (NISS) allows the three most severe injuries to be scored, irrespective of region affected, and may give better prediction of functional recovery in these patients.

METHODS

A prospective cohort study of 200 patients with musculoskeletal injuries, examining the predictive value of ISS and NISS on functional recovery as measured by patient-derived outcome measures (Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment).

RESULTS

NISS was greater than ISS in 34 patients (17%). NISS showed closer correlation with total scores and subscores of the outcomes measures than did ISS (Spearman's rho ranked test, P < 0.05).

CONCLUSIONS

NISS, a simple modification from ISS, better predicts functional outcomes in survivors of musculoskeletal trauma, and offers an improvement in the assessment of effectiveness of trauma care delivery.

Environmental enrichment increases progenitor cell survival in the dentate gyrus following lateral fluid percussion injury

Neurons in the hilus of the dentate gyrus are lost following a lateral fluid percussion injury. Environmental enrichment is known to increase neurogenesis in the dentate in intact rats, suggesting that it might also do so following fluid percussion injury, and potentially provide replacements for lost neurons. We report that 1 h of daily environmental enrichment for 3 weeks increased the number of progenitor cells in the dentate following fluid percussion injury, but only on the ipsilesional side. In the dentate granule cell layer, but not the hilus, most progenitors had a neuronal phenotype. The rate of on going cell proliferation was similar across groups. Collectively, these results suggest that the beneficial effects of environmental enrichment on behavioral recovery following FP injury are not attributable to neuronal replacement in the hilus but may be related to increased neurogenesis in the granule cell layer.

Enforced exercise after blunt trauma significantly affects biomechanical and histological changes in rabbit retro-patellar cartilage

Our laboratory has developed an animal model to study factors leading to chronic disease in a blunt impacted joint. Studies to date indicate post trauma softening of the impacted joint cartilage, but a limited degree of histological degradation in the tissue. The model utilizes treadmill exercise of the animal post trauma. The hypothesis of the current study was that post trauma exercise helps limit histological and mechanical degradation of the impacted retro-patellar cartilage. The study involved a group of animals with enforced exercise on a treadmill and another group with cage-activity post trauma. The animals were sacrificed after 24 months. Mechanical and histological analyses were performed on the retro-patellar cartilage from each group. The impacted versus contra-lateral, non-impacted retro-patellar cartilage was mechanically softened in the exercise group, but not in the cage-activity group. Histological analyses of the tissue from the cage-activity group indicated that this cartilage had less surface integrity, more ossification/calcification, and more erosion than that in the impacted tissue from the exercise group. These tissue changes may lead to an apparent stiffening effect in the impacted cartilage from the cage-activity group at 24 months post-trauma. Potential relationships between the intensity and frequency of post trauma exercise and the mechanical character and histological degradation of the impacted cartilage need additional study. The study indicates that post-trauma exercise can significantly alter the outcome of a blunt knee joint trauma in this experimental animal model.

Quality of Life and Functional Outcome after Pediatric Trauma

BACKGROUND

Injury is the leading cause of preventable morbidity and functional limitation in children. Long-term sequelae are measured best by the degree of impairment after recovery from the acute traumatic event. The specific aim of this study was to determine the quality of life and functional status of moderately to severely injured pediatric trauma patients at hospital discharge and at 1, 6, and 12 months postinjury.

METHODS

We conducted a prospective longitudinal study of children aged 1 to 18 years with blunt injury and Injury Severity Score >/= 9, excluding head and spinal cord injury. Children were evaluated at hospital discharge and at 1, 6, and 12 months postinjury, using the Child Health Questionnaire (CHQ), the Functional Independence Measure, and the Impact on Family Scale. Baseline and 1- and 6-month data analyses are reported.

RESULTS

One hundred sixty-two children were enrolled in the study, and 156 had completed 6-month data entry. The mean age was 9.3 +/- 5.3 years, and the mean Injury Severity Score was 14 +/- 7.4. The most common cause of injury was motor vehicular-related (43%). Fifty-eight (37%) had multisystem injuries. Femur fracture represented the most common injury (54.8%). Families experienced economic, social, and personal strain, as measured by the Impact on Family scale. There was a significant improvement in CHQ and Functional Independence Measure scores between baseline and 1 month and between 1 month and 6 months postinjury. However, at 6 months, physical scores remained lower than age-matched norms.

CONCLUSION

Injury in children results in a significant burden on families. Although children demonstrate a rapid recovery of function and quality of life after blunt injury, physical function remains lower than age-matched norms at 6 months postinjury. It is unclear whether this represents a plateau in recovery or whether further improvements can be expected over longer time intervals.

Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes

This study sought to evaluate injury causes and patient outcomes in young children with abdominal injuries. Cases of blunt abdominal injury (N = 927) to children ages 0 to 4 years were extracted from the National Pediatric Trauma Registry. Measures included hospital utilization (days hospitalized, intensive care unit use, and surgery) and patient outcome (in-hospital fatality, discharge to rehabilitation facility, home rehabilitation, and home nursing). The three most common mechanisms of abdominal injury were motor vehicles (61.27%), child abuse (15.75%), and falls (13.59%). Hospital utilization was higher in patients with multisystem injuries. Patient outcomes were more severe in abused children or those with concomitant central nervous system (CNS) injury; these were the only variables independently associated with increased mortality in this sample. Pediatric abdominal trauma leads to intense use of hospital resources and a high risk of in-hospital mortality. Child abuse, compared to falls, is independently associated with a 6-fold increase in in-hospital mortality.

Blows to the head during development can predispose to violent criminal behaviour: rehabilitation of consequences of head injury is a measure for crime prevention

Criminal behaviour and violence may be the consequence of head injuries acquired during childhood and youth (gang fights, domestic violence, small blows to the head while driving, falls and so forth). In this study, a comparison was made of the school and head injury histories of violent and non-violent prisoners. It was found that the delinquent subjects in both groups had a history of academic difficulties. However, what differentiated the violent from the non-violent group was a history of having suffered head injuries that were never treated. Problems at school are not enough themselves to predict violent behaviour. A history of discrete neurological damage as a consequence to blows received to the head must also be present. The results suggest to the authors that the treatment of the cognitive, behavioural and emotional consequences of brain injury could be a measure for crime prevention. Measures both for prevention and rehabilitation are discussed.

Long-term outcomes after injury in the elderly

BACKGROUND

The lasting impact of injury on lifestyle in the elderly remains poorly defined. The purpose of this study was to determine the long-term quality-of-life outcomes in elderly trauma patients.

METHODS

The trauma registry at a regional trauma center was used to identify hospital survivors of injury > or = 65 years old discharged from April 1996 to March 1999. The 36-Item Short Form (SF-36) Health Survey was administered to this group by telephone interview and the scores compared with age-adjusted Canadian norms. Comparisons with test were made for continuous data.

RESULTS

Complete data collection was achieved in 128 of 171 (75%) study patients. The mean Injury Severity Score was 21, the mean initial Glasgow Coma Scale score was 13, and the mean age was 74. Most (97%) were victims of blunt trauma. Compared with Canadian age-adjusted norms, there was a significant (p < 0.05) decrease in seven of eight SF-36 domains: Physical Functioning, Role-Physical and Role-Emotional (limitations secondary to physical and emotional health), Social Functioning, Mental Health, Vitality, and General Health. Before injury, most (98%) were living independently at home. However, at long-term follow-up (mean, 2.8 years; range, 1.5-4.5 years), only 63% were living independently and 20% still required home care.

CONCLUSION

Although the majority of elderly injury survivors achieve independent living, long-term follow-up indicates significant residual disability in quality of life as measured by the SF-36.

Blunt versus penetrating violent traumatic brain injury: frequency and factors associated with secondary conditions and complications

OBJECTIVE

To compare types and frequency of medical complications and comorbidities associated with violence-related penetrating traumatic brain injury (TBI) as compared to violence-related blunt TBI.

METHOD

Data were collected prospectively at four medical centers participating in the TBI Model Systems (TBIMS) of Care project. A total of 317 individuals met the inclusion criteria for the TBIMS (i.e., showed evidence of a TBI, were age 16 or older, presented to the TBIMS emergency department within 24 hours of injury, and received acute and rehabilitation services within the model system).

MAIN OUTCOME MEASURES

Frequency of medical complications and comorbid diseases.

RESULTS

Patients with penetrating injuries suffered significantly higher rates of respiratory failure (P =.004), pneumonitis/pneumonia, (P =.002), skull fracture (P =.001), cerebrospinal fluid leak (P =.0005), and hypotonia (P =.001) than did patients with blunt injuries. Prediction of complications and comorbidities via multiple regression revealed that a penetrating violent injury and the severity of injury were independent predictors of a higher rate of medical complications, whereas age and gender did not account for unique variance in the equation.

CONCLUSIONS

Penetrating injuries are associated with higher rates of certain medical complications, especially to the pulmonary and central nervous systems. Acute care physicians and physiatrists must be prepared to treat these complications more often in patients with penetrating injuries.

Standardized outcome evaluation after blunt multiple injuries by scoring systems: a clinical follow-up investigation 2 years after injury

OBJECTIVE

The objective of this study was to evaluate the state of rehabilitation in patients with blunt multiple injuries 2 years after their initial injuries, using several standardized scales and a recently described comprehensive scoring system, by means of a prospective clinical multicenter study.

METHODS

Two years after the initial injury, patients with blunt multiple injuries (Injury Severity Score > or = 16) underwent a clinical follow-up in 5 German Level I trauma centers. The reassessment included a complete head-to-toe examination of the musculoskeletal system and a neurologic examination. The following patient-assessed health status scores were used to determine the quality of life: Short-Form 12, Functional Independence Measurement, and Musculoskeletal Function Assessment. Moreover, a comprehensive scoring system developed in our department (Hannover Score for Polytrauma Outcome [HASPOC]) was used that includes provider-report (physician's examination) and self-report (score systems) criteria.

RESULTS

Two hundred fifty-four of 312 patients who had been injured between January 1995 and July 1996 were reexamined between January 1, 1997, and July 1, 1998. Among the remaining 58 patients, 9 had died by the time of follow-up, and 49 patients had not accepted the invitation. The mean age of those patients who underwent reexamination was 36 +/- 13 years, the mean Injury Severity Score was 24 +/- 6, and the mean initial Glasgow Coma Scale score was 11 +/- 4 (Abbreviated Injury Scale (AIS) head score of 3.3 +/- 1.1; AIS face, 1.4 +/- 0.1; AIS chest, 3.0 +/- 0.8; AIS abdomen, 1.7 +/- 0.6; and AIS extremities, 3.4 +/- 0.8). The general outcome (Short-Form 12) was as follows: grade I, 9%; grade II, 25%; grade III, 29%; grade IV, 25%; grade V, 6%; and grade VI, 6%. The outcome of the injured extremity demonstrated moderate or severe restrictions according to the Musculoskeletal Function Assessment in 41% of injuries of the lower extremity and in 16% of injuries of the upper extremity. Among patients with injuries to the lower extremity, 52% experienced pain or impaired ability to walk related to an injury of the foot or ankle, 31% indicated pain after a knee or thigh injury, and 27% indicated pain after a femoral or hip injury. The most severe deficits in the range of motion occurred in the foot and the ankle region (13.4% deficit of range of motion < 20% of normal range, p < 0.05 to other injuries). The results of the outcome obtained by self-report correlated with the clinical examination when a scoring system was used that was described recently, the HASPOC.

CONCLUSION

In a standardized multicenter reexamination of patients with blunt multiple injuries, the general outcome was usually fair or good. Both the complaints and the objective results of specific extremity areas demonstrated that most limitations were because of injuries below the knee. These results were adequately reflected by a comprehensive scoring system, combining self-report and provider report (HASPOC).

Trends in the management of blunt liver trauma

OBJECTIVE

Blunt liver trauma management has changed over the last 2 decades to include non-operative management as one of the standard approaches, particularly to those with minor liver injury. We reviewed the experience at a non-trauma hospital to identify trends in methods of evaluation and management of blunt liver trauma and discuss its outcome.

METHODS

Medical records of 21 patients who sustained blunt liver trauma between June 1992 and July 1999 were retrospectively reviewed at King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia.

RESULTS

Thirty-three percent received non-operative management and recovered without complications. The rest received an operative management but in comparison had more severe liver injury scales, higher incidence of associated injuries, significantly greater blood transfusion requirements, longer hospital stay and a mortality rate of 67%.

CONCLUSION

Non-operative management of blunt liver trauma is a valid effective option. It requires less blood transfusion and shorter hospital stay and is associated with a low complication rate. Severe liver injury can be associated with high mortality. Outcome can be significantly affected by both the severity of liver trauma and associated injuries particularly severe head injury. Management of the severely injured is expected to have a better outcome in a trauma centre.

[Rehabilitation after anterior cruciate ligament reconstruction: inpatient or outpatient rehabilitation? A series of 103 patients]

PURPOSE OF THE STUDY

The goal of this work was to evaluate outpatient rehabilitation after anterior curciate ligament reconstruction using the bone-tendon technique.

MATERIAL AND METHODS

This was a prospective non-randomized study of 103 consecutive patients participating in the same rehabilitation program, excepting for the first month. During the first postoperative month, 55 patients (group A) attended a physical therapy outpatient clinic near their home and 48 patients (group B) followed the same rehabilitation protocol at an inpatient facility of their choice. We recorded preoperative data for age, sex, weight, height and function (sports, occupational activities). Surgery data concerned delay between severe sprain and surgery, and the exact surgical procedure used (meniscal tear, associated procedure). Clinical assessment (mobility, effusion, clinical and radiological laxity) and functional scores (Tegner, Lysholm, Arpege, IKDC) as well as delay to recovery of gait and to renewed physical activity were recorded at 3 and 6 weeks and 4, 6 and 12 months postoperatively. Two isokinetic tests were done 4 and 6 months postoperatively.

RESULTS

There was no statistical difference for the pre and peroperative data between the two groups, with the exception of meniscal tears that were more frequent in group A (p<0.05). Postoperative outcome and complications were not significantly different between the 2 groups except for greater flexion at 3 weeks in group B (related to difference in measurement date). Fifteen complications were observed in each group: 4 reflex dystrophies and 2 cyclope syndromes in each group, 5 patellar syndromes in group A and 1 in group B; 3 painful surgical wound sites in group A and 8 in group B (including one requiring revision). In group A there was one early failure due to a surgical error requiring revision. At 1 year, there were 2 cases of persistent femoropatellar syndromes, one of which occurred after reflex dystrophy. A high percentage of the patients were lost to follow-up (45% in group A and 50% in group B) and lack of randomization should also be considered when interpreting the results.

DISCUSSION

This is the first report comparing inpatient and outpatient rehabilitation protocols after anterior cruciate ligament reconstruction. The only reports in the literature have compared different ambulatory rehabilitation programs that appear to be internationally accepted as the routine procedure. The current trend towards short hospital stays for surgery is compatible with outpatient rehabilitation programs if dependent patients receive proper support from an ambulatory medical unit, a physical therapist or a home assistant. Our study demonstrated that the bone-tendon technique for anterior cruciate ligament reconstruction is compatible with an outpatient rehabilitation program if quality medical and surgical follow-up is ensured. This type of rehabilitation program gives results comparable with those obtained after inpatient programs conducted in a rehabilitation facility during the first postoperative month.

Neurological rehabilitation of severely disabled cardiac arrest survivors. Part I. Course of post-acute inpatient treatment

BACKGROUND

Some survivors of out-of-hospital cardiac arrest (CA) sustain anoxic brain injury. The aim of this study was to offer these patients a new treatment approach, to describe the course and outcome of rehabilitation, and to judge whether rehabilitation provided benefit.

METHODS

Twenty severely disabled patients (mean age 47.6 years, 17 M:3 F) were admitted for inpatient rehabilitation after sustaining anoxic brain damage secondary to CA. The multidisciplinary treatment approach aimed at orientation, communication, mobility, and self care. Function was assessed using Barthel index (BI) score. On discharge, placement and global outcome was noted. Medical charts of consecutive patients were reviewed retrospectively.

RESULTS

Inpatient rehabilitation lasted on for average 12 weeks. Improvement in function was slow with a median increase of 1.88 BI score per week. Patients achieved clinically significant functional improvement as measured by pre-post comparison of BI (P<0.001). On discharge, overall disability was mild in 2 (10%), moderate in 7 (35%), and severe in 11 (55%) patients.

CONCLUSION

Rehabilitation of selected CA survivors is appropriate, reducing the subsequent burden of care. Although in 55%, only minor dependence on care persisted, on a group level, the potential for rehabilitation was modest, and recovery curve was flat. Before admission, families should be given realistic information about the possible outcome, because independence was rarely achieved.

Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome,

BACKGROUND/PURPOSE

Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author's experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome.

METHODS

Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion.

RESULTS

Mean age of the study children was 10.7 +/- 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.

CONCLUSIONS

Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning.

A longitudinal examination of athletes' emotional and cognitive responses to anterior cruciate ligament injury

OBJECTIVE

To determine the emotional and cognitive impact of injury and surgery on physical recovery in injured athletes.

DESIGN

A prospective longitudinal study comparing the psychosocial and physical recovery of competitive and recreational athletes.

SETTING

Tertiary-care sports medicine center.

PARTICIPANTS

Twenty-seven athletes (15 men and 12 women) who required anterior cruciate ligament (ACL) reconstruction surgery.

INTERVENTIONS

A repeated-measures design used to compare the psychosocial and physical changes for 6 months after ACL surgery.

MAIN OUTCOME MEASURES

Emotional (mood) and cognitive (coping) functions and physical recovery (range of motion, physician-rated level of recovery, and physician permission to return to sport).

RESULTS

There was a significant time-effect difference in mood, with a greater mood disturbance and recovery rate for competitive athletes than recreational athletes. Differences in mood and pain coping were significant at 2 weeks and 2 months after surgery.

CONCLUSION

Athletes experience significant mood changes throughout rehabilitation, which may hinder rehabilitation early in the process. Longer-term rehabilitation was not impacted by mood or pain coping. Future studies might focus on examining the process over a longer time period (1-2 years after surgery). Physicians should be aware of these findings and appropriately counsel and motivate athletes toward more favorable positive psychological and physical outcomes.

Recovery of arm function in patients with paresis after traumatic brain injury

OBJECTIVE

To characterize the frequency of recovery of arm paresis in patients with traumatic brain injury (TBI) admitted to rehabilitation.

DESIGN

Retrospective review identifying a cohort of patients with moderate or severe arm paresis after TBI followed at least 6 months postinjury.

SETTING

Freestanding acute rehabilitation hospital TBI unit.

PATIENTS AND METHODS

Forty-four patients with moderate to severe arm paresis were selected from 264 consecutive admissions and characterized by injury pathology subtype, injury severity (duration of unconsciousness [loss of consciousness, LOC] and posttraumatic amnesia [PTA]), age, and level of paresis according to Brunnstrom Stages of Recovery (BS 1 to 6). Patient groups with and without arm paresis were compared according to these variables (t tests and chi(2)).

MAIN OUTCOME MEASURES

Recovery of arm paresis to isolated motor function (BS 5 or 6) and time to achieve recovery. Recovered and nonrecovered patients were compared (Mann-Whitney, t tests, and chi(2)) on injury severity, initial level of paresis, age, time to rehabilitation admission, and pathology subtype. Time to recovery was compared for patients at different levels of initial paresis, ranges of LOC, and pathology subtypes (Mann-Whitney and Kruskal-Wallis tests).

RESULTS

Forty-four patients (17%) had moderate (BS 3 to 4) or severe (BS 1 to 2) paresis at rehabilitation admission. They were more severely injured than nonparetic patients based on longer LOC (p < .002) and PTA (p < .009). Thirty-six patients (82%) recovered by 6 months; 72% of these recovered by 2 months. If still paretic at 2 months, only 56% recovered. Mean recovery time was 6.9 weeks (SD, 6.1) from injury. Time to recovery was best predicted by initial level of paresis and injury severity (r2 = .48), but not age. Patients with diffuse injury tended towards a more protracted recovery (7.9 weeks, SD 6.5) than patients with focal injury (4.2 weeks, SD 3.9) (p = .08) and only those with diffuse injury showed further recovery after 3 months.

CONCLUSIONS

Arm paresis after TBI is relatively infrequent. Most patients recover by 2 months but later recovery is possible, especially in patients with primarily diffuse brain damage. Recovery is highly related to initial impairment, injury severity, and distribution of brain injury.

Time course of changes in bilateral arm power of swimmers during recovery from injury using a swim bench

OBJECTIVES

There has been little research on the time course of recovery from injury in athletes. This is especially the case for recovery in arm power in injured swimmers. The purpose of this study was to compare the power output of the injured and non-injured arms of swimmers during recovery from injury by use of a maximal exercise test on a computer interfaced isokinetic swim bench.

METHODS

Thirteen swimmers (five men and eight women; age 18.8 (3.2) years; stature 1.76 (0.05) m; body mass 61.7 (5.9) kg; mean (SD)) gave written informed consent and were recruited to this study throughout a three year period. All subjects had experienced non-aquatic soft tissue injury to their dominant-side shoulder or upper arm in the three months before participation, but had been allowed to return to swimming training. All of the subjects had injured their dominant arm and the mean time for absence from training was 3.7 (1.1) weeks. At return to training and at four, eight, and twelve weeks thereafter, subjects performed two all-out 30 second tests on the swim bench by simulating the swimming arm action. From these tests, peak power output (PPO), mean power output (MPO), and power decay (PD) for each arm during the 30 seconds of exercise could be determined by averaging the two tests. The differences between return to training and the four, eight, and twelve week periods were analysed using repeated measures analysis of variance with Tukey b post hoc test.

RESULTS

The repeated testing showed 95% confidence intervals of +/- 11.4 W for PPO, +/- 9.5 W for MPO and +/- 0.5 for PD. When the swimmers returned to training the results showed that PPO was 179 (21.9) v 111 (18.1) W (P = 0.02), MPO was 122 (9.8) v 101 (8.8) W (P = 0.01), and PD was 2.5 (0.6) v 5.2 (1.9) (P = 0.001) for non-injured and injured arms respectively (all values mean (SEM)). There were similar differences at four weeks which disappeared after eight weeks, except for that of PPO which was still evident (187.3 (21.9) v 156.8 (18.1) W; P = 0.01). At 12 weeks there were no differences between the non-injured and injured arm on any of the indices of arm power (P > 0.05).

CONCLUSIONS

These results suggest that, using the swim bench power test, differences in bilateral arm power output after injury persist for at least eight weeks after return to swimming training. These findings support the need for prolonged rehabilitation after such injury. This would best include physiotherapy and a training programme within which special consideration is given to the recuperation process.

Functional outcome after violence related traumatic brain injury

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Student's t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Functional outcomes of older adults with traumatic brain injury: a prospective, multicenter analysis

OBJECTIVE

To investigate improvement rates and medical services costs in older brain injured adults relative to younger patients.

DESIGN

Descriptive statistics were computed in a prospective comparative study of 50 patients 55 years and older and 50 patients 18 to 54 years old matched for gender and injury severity (number of days in coma, admission Glasgow Coma Score, intracranial pressure). Independent t tests were performed to examine differences between the two samples on specific variables.

SETTING

Five medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.

PARTICIPANTS

Patients were selected from a national database of 531 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury between 1989 and 1994.

MAIN OUTCOME MEASURES

Disability Rating Scale, Functional Independence Measure, Rancho Los Amigos Levels of Cognitive Functioning Scale, length of stay, acute care and rehabilitation charges, and discharge disposition.

RESULTS

Older persons averaged a significantly longer rehabilitation length of stay, higher total rehabilitation charges, and a lower rate of change on functional measures. No significant differences between groups were found for acute care length of stay, daily rehabilitation charges, acute care charges (daily or total), or discharge disposition.

CONCLUSIONS

Although older persons demonstrated functional changes, the cost of change was substantially higher than for younger patients, coincident with longer lengths of stay. These higher overall charges and slower rates of change may effect changes in referral and management patterns.

Rehabilitation and follow-up of children with severe traumatic brain injury

We studied the outcome of 25 patients [12 girls and 13 boys; mean age 13.7 (SD 3.9 years)] with severe traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) score 6 h after the injury was (mean) 4.5 (SD 2.7), and the mean duration of unconsciousness was 15.8 (SD 10.6) days. Being the most severely brain-injured children in the health care region, they were all referred to its only regional pediatric rehabilitation center during 1986-1990. At discharge, 1 patient was healthy, 1 was in a vegetative state and 18 had multiple impairments. Motor problems were present in 22, epilepsy in 7 and speech impairment in 14. It was not possible to assess cognition in 3 of the children, and 15 of the remaining 22 fell in the normal range. At follow up 2-6 years after trauma, all 23 survivors reported at least one sequela, and 21 had multiple sequelae. As many as two-thirds had normal I.Q. and only 3 were non-ambulatory, but behavioral and personality disturbances were so disabling that none of the patients in this group had been able to readjust to a normal life in society after the trauma.

[The use of physical factors in the combined treatment of traumatic damages to the nerve trunks of the extremities]

Traumatic impairment of peripheral nerves in the limbs requires multimodality treatment including physiotherapy, chemotherapy, orthopedic methods, massage, manual therapy. The above complex produced responses in the majority of patients treated.

Magnetic resonance imaging of acute tendon injury in the finger

Accurate assessment of flexor tendon function in a digit with an acute, non-penetrating injury is difficult. MR imaging can negate the need for surgical exploration and the associated morbidity.

Resuscitation of the injured child

Unintentional injury is the leading cause of death for children less than 14 years of age. Optimal injury control includes prevention, acute care, and rehabilitation. When prevention efforts fail, a dedicated well-trained team must be prepared to resuscitate and treat the injured child. This article presents an approach to resuscitation that emphasizes the primary and secondary survey. Early and aggressive airway control with cervical spine protection is stressed, followed by a rapid assessment of ventilatory mechanics and circulatory status. Clinical indicators of inadequate tissue perfusion are described, with priorities concerning intravenous access highlighted. Initial resuscitation steps, complemented by laboratory and radiological assessment, occur before the secondary survey. The secondary survey completes the early resuscitation phase and consists of a systematic and complete physical examination. Resuscitation priorities specific to the multiply-injured child are also discussed. Finally, the importance of rehabilitation and prevention efforts are included.

Second toe-to-finger transfer in hand mutilations

A series of 68 second toe-to-long finger transfers in 55 patients, including 52 transfers in 41 patients with mutilating injuries and 16 transfers in 14 patients with congenital deformities, was reviewed. Mean followup was 6.7 years. The failure rate was 6%, and secondary procedures were done in 18% of the patients. In the group with traumatic injuries, mean flexion was 36 degrees, with a mean extension lag of 33 degrees. Two-point discrimination was an average of 11 mm. Grasp was 47% of that for the normal contralateral side, and pinch was 38%. Of the manual workers, 62.5% returned to the same job. Analysis of the congenital series was more difficult. Although mobility was not significantly better in these patients, discrimination was a mean 5 mm (10 patients were tested). Growth plates remained open in 86% of the patients. All patients were able to use their finger to pinch.

Non-penetrating corneal foreign body injuries: factors affecting delay in rehabilitation of patients

A review of 783 patients with non-penetrating, superficial corneal foreign bodies (FBs), indicated that delay in rehabilitation was related to two factors: (1) the size of the abrasion following removal of the FB, larger abrasions requiring longer duration of antibiotic ointment, and (2) inadequate removal of corneal rust. Allergy to chloramphenicol 1% ointment (5.5 in 1000), commonly used in the management of corneal abrasions, is unpredictable and can also impair rapid rehabilitation.

Functional outcome in children with traumatic brain injury. Agreement between clinical judgment and the functional independence measure

As improvements in the delivery of trauma care have increased survival from injury, it has become essential to assess the resulting morbidity to plan for medical and psychosocial services, particularly for children whose needs may be wide and long term. This paper focuses on the assessment of disability of 598 children, age 8 to 19 yr, hospitalized for traumatic brain injury with or without injury to other body regions, exclusive of spinal cord injury. The disability was measured at discharge from acute care in nine areas of functional activities and a recovery time assigned by a clinician. For the study, children were divided into three groups: those whose recovery was expected in less than 7 months (Group A: n = 463), in 7 to 24 months (Group B: n = 66) and in greater than 2 yr (Group C: n = 69). The clinician's expectation of recovery time significantly (P less than 0.01) reflected the injury severity as measured by the Glasgow Coma Scale and the Injury Severity Score. By the Glasgow Coma Scale, 16.4% were comatose on admission in Group A, 51.5% in Group B and 58% in Group C. The Injury Severity Score was significantly different with 25.5% severely injured in Group A, 68.2% in Group B and 84% in Group C. At discharge, 15% in Group A had four or more areas of impairments, 61% in Group B and 84% in Group C. The Functional Independence Measure confirmed the clinician's assessment of compromise with significantly (P less than 0.01) different average values of 110, 80 and 58 for Groups A, B and C, respectively.

Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury

OBJECTIVE

To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury.

DESIGN

A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center.

SETTING

A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons.

RESULTS

Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950.

CONCLUSIONS

In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.

Severely injured geriatric patients return to independent living: a study of factors influencing function and independence

Our previous work demonstrated that geriatric trauma patients (age greater than 65 years) consume disproportionate amounts of health care resources. In the past we hypothesized that late mortality is high, long-term outcome is poor, and return to independence is low in a severely injured geriatric population. Of 6,480 trauma admissions over 5 years, geriatric patients (n = 495) with blunt trauma injury (n = 421) and an ISS greater than 16 (n = 105) who survived until discharge (n = 61) underwent long-term follow-up (mean = 2.82 years). We surveyed 20 measures of functional ability; 10 measures of independence; availability and use of rehabilitation resources; employment history; alcohol use; support systems; and nursing home requirements. Of the 105 patients, 7 were subsequently lost to follow-up. Among the remaining 98, 44 (44.9%) died in hospital and 54 (55.1%) were discharged and interviewed. The mean age of the contacted patients was 72.6; their mean ISS was 23.3. Forty eight of 54 (88.9%) were alive at the time of interview, while 6/54 (11.1%) had died. Although only 8/48 patients regained their preinjury level of function, 32/48 (67%) returned to independent living. The 32 independent patients, those with "acceptable" outcome, were compared with an "unacceptable" outcome group composed of the 44 in-hospital deaths, the 6 late deaths, and the 16 dependent patients. Factors associated with poor outcome include a GCS score less than or equal to (p = 0.001), age greater than or equal to 75 (p = 0.004), shock upon admission (p = 0.014), presence of head injury (p = 0.03), and sepsis (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Differential reading recovery in patients with severe to moderate closed head injury

A differential recovery was seen when alternate forms of a nationally standardized test of Reading Vocabulary, Literal Reading Comprehension and Inferential Reading Comprehension was administered serially to 10 consecutive closed head injury admissions to a university rehabilitation hospital. Inferential Reading Comprehension was the most impaired and had the fastest recovery rate. Subtle cognitive deficits in Inferential Reading Comprehension were detected when Reading Vocabulary was at or better than a twelfth grade level. Maximal recovery of all three reading functions occurred within 4 months after trauma, with most occurring in the first 3 months. The reading recovery pattern parallels the recovery of intelligence scores in the literature.

Bilateral femoral nerve neuropathy following blunt trauma. Case report

A unique case of bilateral compressive injury of the femoral nerves is reported in a 19-year-old man. Traumatic femoral nerve neuropathy following operative injury, penetrating injury, anticoagulant therapy with hemorrhage, and stretch injury has been described previously, and the literature concerning this unusual clinical problem is reviewed. Bilateral traumatic femoral nerve neuropathy resulting from compressive injury has not been previously reported.

A model of orthopaedic dysfunction for clinical decision making in physical therapy practice

This model serves as a framework for the critical analysis of current practice concepts. The analysis obtained from using this model should be integrated with other physiological systems of the body during examination and treatment processes. Currently used as a basis for graduate study in orthopaedic physical therapy, the model helps students identify fundamental research questions, compare various examination and treatment philosophies, and comprehend generic treatment goals and strategies.

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion

We reviewed 144 consecutive patients with flail chest and/or pulmonary contusion between 1979 and 1984. The purpose was to analyze the factors adversely affecting morbidity and mortality. There were 97 males and 47 females, with an average age of 40 years +/- 18 S.D. (range, 2-83). Seventy-five per cent of the injuries were caused by motor vehicle accidents, with the remainder due to falls (17%), cardiopulmonary resuscitation (4%), altercations (2%), or falling objects (2%). The Injury Severity Score (ISS) averaged 32 +/- 14 S.D. in all survivors versus 60 +/- 14 S.D. in those who died. Eighty-three patients (58%) required mechanical ventilation. Thirty-six patients died (25%). Isolated pulmonary contusion or flail chest had a mortality of 16% each. However, the mortality more than doubled when there was a combined pulmonary contusion and flail chest (42%). More than half of all deaths were directly attributed to central nervous system injuries with another third due to massive hemorrhage. Factors that were associated with a higher morbidity and mortality included severe associated thoracic injuries, a high ISS, the presence of shock, falls from heights, and the combination of pulmonary contusion and flail chest.

Aggressive trauma care benefits the elderly

Few past studies have examined the long-term functional outcome of geriatric patients who survive trauma. To evaluate factors that determine the long-term potential for recovery in this population, we studied 63 survivors of blunt trauma over age 65 years between 9 and 38 months after hospital discharge. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8 +/- 1.1. Thirty-nine patients (62%) had two or more body regions injured. Forty-five patients (71%) had pre-existing cardiopulmonary disease. Surgery was required in half of the patients, one third experienced complications, and nine (14%) required ventilatory support for 5 or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing-home care (NH). NH patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 NH patients (63%) returned home 3.1 +/- 0.9 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Ultimately, 56 patients (89%) returned home after trauma. These patients were younger, had a shorter hospital stay, and experienced fewer complications than patients who required permanent NH care. Among 12 patients 80 years old and over, eight patients eventually returned home. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified, since few patients require permanent NH care and the majority return to independent living after trauma.

Successful vascular reconstruction. Determinants of disability

Improvements in limb salvage during the last decade are a reflection of advances in angiography, antibiotics and technique. We report a 100 per cent success rate with vascular repair and a 100 per cent disability outcome in extremity injuries. Ten male patients, with a mean age of 27.3 (range 18 to 41) years, sustained trauma to the extremity with vascular injury. The etiology of injury was gunshot wounds (5), blunt trauma (4), and stab wounds (1). Time from injury to vascular repair was a mean of 186 (range 60 to 360) min. Vessels injured included popliteal artery and vein (4), tibial artery and vein (2), subclavian artery and vein (2), and axillary artery (1). Six of the injuries were associated with fracture of the adjacent bone and treated with external skeletal fixation. All patients had an associated nerve injury. Five patients underwent fasciotomy; nine were treated with 500 ml Dextran-40 for 48 hr (each day for 2 days). All patients received cephalosporin antibiotics pre-, intra-, and post-operatively. All patients had successful vascular repair, as identified by Doppler ultrasound (10 patients) and intra-/post-operative arteriography (5 patients). The median follow-up period was 22 (range 18 to 30) months. There were no primary amputations (within 30 days); there were four late amputations (2, no function and foot ulcer; 2, causalgia). The five popliteal/tibial injuries had no dorsiflexion and foot drop, two had no function and leg ulcers; two patients had femoral and sciatic nerve injury at the thigh; and three patients had injuries to the brachial plexus.(ABSTRACT TRUNCATED AT 250 WORDS)

Late outcome of very severe blunt head trauma: a 10-15 year second follow-up

Forty patients with very severe blunt head trauma (post-traumatic amnesia greater than or equal to 1 month) were initially examined at an average of 4.5 months after the injury. The patients were visited in their homes 2.5 years and 10-15 years after the accident and questionnaires were presented to patients, relatives and/or staff. Though physical impairment, dysarthria and defects of memory remained severe in many cases, the psychosocial sequelae presented the most serious problems. Permanent changes in personality and emotion were reported in two thirds and were especially frequent among the youngest patients. The worse overall outcome was seen in cases with severe brainstem involvement or anterior lesions or both. In spite of the great frequency of deficits long-term improvement of functional state was common and several regained at least some work capacity.

Computerized tomography head scans as predictors of rehabilitation outcome

This study explored the relationship between rehabilitation functional outcome, demographic characteristics, and predicted goal achievement for 30 patients with closed head injury according to characteristics of their computerized tomography (CT) head scans performed within 10 days of injury. Goals and outcome were measured according to levels of independent/dependent function at discharge from an interdisciplinary inpatient rehabilitation program by means of the Patient Evaluation Conference System (PECS). Patients were classified into the three following major subgroups according to CT findings: (1) normal; (2) 1 hemisphere lesion; and (3) bilateral lesion. Marked differences in patient outcome and in the team's ability to accurately predict outcome were found to match the subgroups so classified. The need to incorporate CT scan data into early team planning and goal setting is stressed.