Pressure ulcer risk factors in persons with SCI: Part I: Acute and rehabilitation stages

BACKGROUND

Pressure ulcers (PUs) are a common complication following a spinal-cord injury (SCI). Good prevention requires identifying the individuals at risk for developing PUs. Risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed to design an SCI-specific assessment tool. The first results seem quite disappointing, probably because of the level of evidence of the risk factors used.

OBJECTIVE

To determine PU risk factors correlated to the patients with SCI, medical care management during the acute as well as in the rehabilitation and chronic stages. This first part focuses on identifying the risk factors during the acute and rehabilitation stages.

MATERIALS AND METHODS

Systematic review of the literature.

RESULTS

Six studies met our inclusion criteria. The risk factors during the acute stage of an SCI are essentially linked to care management and treatment modalities. There is insufficient evidence to make a recommendation on medical risk factors, except for low blood pressure on admission to the Emergency Room, with a moderate level of evidence. Regarding the rehabilitation stage, no study was deemed relevant.

DISCUSSION AND CONCLUSIONS

Additional observational studies are needed, for both the acute and rehabilitation stages, to improve this level of evidence. However, this systematic review unveiled the need for a carefully assessed t care management and the related practices, especially during the acute stage of an SCI.

[Bickerstaff's syndrome presenting with coma, tetraplegia and blindness]

INTRODUCTION

Bickerstaff brainstem encephalitis is characterized by the occurrence of ataxia, ophthalmoplegia, motor weakness with areflexia and central nervous system symptoms, with drowsiness, pyramidal syndrome and sensorial symptoms. Diagnosis is based on MR findings and GQ1b antibodies. Treatment is not well known.

OBSERVATION

We report a patient aged 39 years native of Laos who presented weakness, loss of reflexes, and drowsiness. Brain MR showed hyperintense signals in the brain stem. GQ1b antibodies were positive. The course was characterized by decrease of the weakness, normalization of MR and negativity of GQ1b antibodies.

DISCUSSION

This observation underlines common features of Bickerstaff brainstem encephalitis, Miller Fisher syndrome and Guillain Barre syndrome. A favorable course and GQ1b antibodies are shared by these syndromes.

Influence des poussées sur la survenue d’un handicap au long cours dans la sclérose en plaques de forme rémittente : étude observationnelle de 99 patients

INTRODUCTION

Rate of relapse occurring during the first 5 years of MS-RR is a prognosis factor of occurrence of disability or secondary progressive (SP) phase. Progressive phase, related to chronic axonal loss, is mainly considered as the principal factor of disability progression. Influence of acute relapses during the relapsing-remitting phase on disability development is not known as a prognosis factor.

OBJECTIVES

To determine the influence of the exacerbations among patients with RR-MS after the second clinical event on the disability occurrence.

METHODS

Diagnosis of multiple sclerosis was established according to Poser's classification. Disability measurement was made with the use of the Expanded Disability Status Scale (EDSS). The patients included in the study were classified as clinically definite RR-MS, with an EDSS score<or=3.5. The progressive phase was defined as the steady worsening of symptoms and signs for at least 6 months (Schumacher et al., 1965; Lublin and Reingold, 1996). The exacerbations were quoted and evaluated by a neurologist and the residual disability lasting at least 6 months after an acute event was measured with the EDSS. A score of 4.0 corresponds to limited walking ability, but without aid or rest for>500 m. The study began at the time of the second clinical event and ended when an EDSS score of 4.0 was reached or when a SP phase was beginning or at the last follow-up visit date if these two stages were not reached. The primary outcome measure was the comparison of the risk and the average time to reach an EDSS>or=4.0 or a SP form according to the annual exacerbation rate (AER) using Kaplan-Meier survival curve.

RESULTS

Among the 238 ms patients of the database, 136 patients were classified as having a definite RR-MS. Among these 136 patients, 99 patients could be included in the study according to the inclusion criteria. The median follow up of the patients since the first clinical event was 9.8 years (range 4 to 44). The average EDSS score was 0.7 at the beginning of the study and 2.3 at the end. 20.2p.cent of patients (n=20) reached an EDSS score of 4.0 or a SP-MS. The median AER was 0.4 and the average 0.62 (range 0 to 6.1). The time to reach the primary end point for 25p.cent of the population was 17.8 years in group with an AER<0.4 (group A) and 6.9 years in group with an AER>0.4 (group B) (logrank; p<0.0001). The relative risk for patients of the group B compared to group A to reach an EDSS of 4.0 or a SP form was 8.01 (IC-95p.cent: 2.74-23.46; p=0.0001).

CONCLUSIONS

In spite of a limited number of patients, this study gives evidence that a high rate of acute exacerbations in RR-MS patients after the second clinical event may be an independent predictive factor of long-term residual disability progression. High relapse rate leads to a more frequent and faster SP or EDSS>4.0 occurrence.

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit]

OBJECTIVES

To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department.

METHODS

An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge.

RESULTS

Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs.

CONCLUSIONS

Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

[Assessment of idiopathic Parkinson's disease in physical medicine and rehabilitation]

Parkinson's disease (PD) is a chronic disease associated with motor impairments (bradykinesia, rigidity, tremor and postural disorders), cognitive disorders and dysautonomia. Most symptoms are greatly improved by dopatherapy during the first stages, then signs of treatment ineffectiveness or intolerance occur that signal the beginning of motor and cognitive decline. This evolution signified the need to develop an effective tool to measure the effectiveness of drugs or surgery in PD and has had the Movement Disorder Society to propose 20 years ago a tool to assess such patients: the Unified Parkinson's Disease Rating Scale (UPDRS). This scale has a good internal consistency and a good interrater reliability. Yet, some impairments, especially of cognitive origin, are evaluated too succinctly and need complementary scales. As well, other disorders such as bladder disorders are not included, nor is quality of life studied despite the impact of PD on daily life. Specific scales have been proposed. UPDRS may be well-adapted to PD follow-up in the physical medicine and rehabilitation context by measuring treatment effectiveness, detecting Dopa ineffectiveness or complications and assessing patients' handicap in daily activities. The evolution of UPDRS will improve the qualities of the scale and contribute to better determining the various stages of the disease.

Hémorragie intracrânienne et phéochromocytome

INTRODUCTION

Pheochromocytoma is rarely disclosed by intracranial hemorrhage. We report two cases.

OBSERVATION

The first 26-year-old patient developed subarachnoid hemorrhage due to a ruptured aneurysm of the middle cerebral artery. The second patient, aged 44 years, had a temporal hematoma. Diagnosis was suggested in both patients by hypertension and elevated urinary catecholamines and confirmed by imaging and MIBG scintigraphy. Adrenal gland tumors, on both glands in the first patient and on the right gland in the second were successfully removed; cranial hypertension totally regressed. Von Hippel Lindau disease was diagnosed by molecular genetics in the first patient. Paroxysmal hypertension could explain the brain hemorrhage in the first patient and may have favored aneurysmal rupture in the second.

CONCLUSION

The relationships between pheochromocytoma and cerebral aneurysm are discussed.

[Pediatric mechanical circulatory assistance. Biventricular assistance for fulminant myocarditis in a 5 year old child]

The authors report the case of a 5 years old infant with cardiogenic shock due to a fulminant myocarditis. The severity of the shock which was refractory to conventional therapies necessitated to require to a cardiopulmonary bypass on emergency, followed by an external pneumatic bi-ventricular assistance. After 10 days (3 days with cardioplumonary bypass and 7 days of bi-ventricular assistance), the patient had been able to be disconnected of any mechanical circulatory supply with total recovery of the cardiac function.

Évaluation de la qualité de l'information concernant l'incontinence urinaire féminine sur le web francophone

OBJECTIVES

An increasing number of patients look for medical information on Internet, and find hardly accurate answers to their questions. The objective of this study was to assess the quality of information about urinary incontinence on free access Web-sites.

MATERIAL AND METHODS

A search using the most used search engines in French speaking countries and key words given by patients located 24 Web-sites on female urinary incontinence to review. A general description of each site was done. Then a specially designed assessment scale, whose criteria were extracted from a literature review and from practice guidelines for the management of female urinary incontinence, was used by two reviewers to assess each Web-site content.

RESULTS

Three key terms (urinary incontinence, urine loss, urine leak) were used on three search engine (Google, Yahoo, Voila) and the first 10 Web-sites located for each search were analyzed. The mean score was low (7.92 (+/-3.1) range 0-24, maximum 24) and only four sites received the "highly recommended" mention.

CONCLUSIONS

This study using medical evidence-based criteria to assess the quality content of French speaking Web-sites about female urinary incontinence highlights the poor quality of information available for Internet "typical users". Doctors should play a greater role in evaluating these sites and/or developing their quality.

[Alcohol neurolytic blocks for pain and muscle spasticity]

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

[The shoulder-hand syndrome after stroke: clinical factors of severity and value of prognostic score of Perrigot]

PURPOSE

The purposes of this study were to evaluate the prognostical factors of reflex sympathetic dystrophy in stroke patients in attempt to improve the Perrigot prognostical score.

MATERIAL AND METHOD

This prospective study included 28 stroke patients with reflex sympathetic dystrophy. An initial clinical assessment including Perrigot score was made at the time of admission (before the end of the first month) and a second evaluation of reflex sympathetic dystrophy at the end of the third month. Patients were assessed using Motricity Index, Ashworth scale, de Bats grading (for glenohumeral alignment), Labrousse criteria (for reflex sympathetic dystrophy severity), and MADRS depression scale. Sensory deficit and unilateral neglect were noted.

RESULTS

The length of stay in acute ward was 16 days. The Perrigot score was correlated with the reflex sympathetic dystrophy severity (r = 0.7, p < 0.0001). It predicted the result of therapy. A significant correlation was found between reflex sympathetic dystrophy severity and motor deficit (r = -0.591, p = 0.0007) and spasticity (p < 0.05). No relation was found with stroke side, unilateral neglect, depression or shoulder subluxation. It wasn't possible to improve the Perrigot prognostical score.

CONCLUSION

Perrigot score predict reflex sympathetic dystrophy severity and the result of therapy. The shoulder subluxation which is not included in this score appears to be not predictive. Shoulder subluxation is simply a marker of a severe paresis.

[Effect of traumatic brain injury on control and suppression of inhibition processes]

Recent hypotheses have renewed discussion on the mechanisms linking executive functions and working memory in patients with traumatic brain injury. In this context, we studied the control and suppression functions of inhibition processes. Results obtained with a suppression paradigm showed that the traumatic brain injury patient makes a number of suppression errors and that suppression responses imply an important temporal loss in this population.

Assessment of hand after brain damage with the aim of functional surgery

The semiology of the hand after brain damage is really rich. Its clinical evaluation remains quite difficult and must be integrated in the neuro-orthopedic and cognitive context. Deficiency, neuropsychological, analytic and functional status, must be assessed before any surgical decision aiming the improvement of prehension. Neuropsychological evaluation precise the hemispheric specialization: right hemisphere lesions conduct to unilateral spatial neglect while left hemispherical lesions determine language troubles and gesture impairment (apraxia). The analytical evaluation describes motor and sensitive function and assesses spasticity and pain. Concerning the functional assessment, the Enjalbert's score seems to be the most adapted to the upper limb. The assessment of hand deficiency and its origin is necessary to orientate the surgical decision and includes the Zancolli classification for the fingers and wrist and the House classification for the thumb. These classification used for cerebral palsy seems to be insufficient for all the different situations occurring after brain damage. A new classification is proposed based on 3 parameters: fingers extension, thumb abduction and supination. Surgical decision should be examined only after an adapted rehabilitation program.

[Epidemiology and cost of pressure sores in the aged]

PREVALENCE

The prevalence of pressure sores reaches 10-20% in hospitalized elderly subjects. Higher rates are observed in units providing mid-term nursing. Rates recorded in long-term units are inversely lower. The prevalence of pressure sores in the elderly population living at home is poorly known.

FAVORING FACTORS

Very old age is a favoring factor due to associated diseases. Insufficient mobility, incontinence, undernutrition, mental disorders, and skin fragility increase the risk. All these factors must be taken into consideration when using risk scales to adapt preventive measures. NATURAL HISTORY: Pressure sores generally develop in the hospital, generally within one week of admission. For patients who do not die shortly thereafter, healing is generally achieved within 3 to 5 months. Pressure sores are a source of pain and infection. They also prolong the hospital stay. Overmortality is associated with pressure sores, basically resulting from the effect of comorbid states. COST: The economic impact of pressure sores is considerable but it is quite difficult to extract the individual cost of prevention, or treatment, from the overall cost of care due to the associated deficiencies and incapacities. It would be advisable to apply evidence-based protocols to reduce the incidence of pressure sores and also reduce the economic cost, both in terms of prevention and treatment.

Management of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) is currently defined as CRPS type I (complex regional pain syndrome). Due to the lack of comprehensive understanding of underlying pathophysiological mechanisms, a wide variety of therapeutic approaches are proposed, all of them being of unpredictable and variable efficacy. This is also due to the lack of controlled studies and randomized therapeutic trials. Most of the so-called "efficient" treatments are in fact based on anecdotal case reports and/or uncontrolled studies with small number of cases. Sympathetic blocks and active physiotherapy are, for many authors, the cornerstones of the efficient management. The role of prevention must be strongly emphasized, focusing, if RSD occurs following surgery, on the importance of pre- and postoperative efficient analgesia.

Neurological complications in insufficiency fractures of the sacrum. Three case-reports

Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.

[Somesthetic evoked potentials of the spinal cord and cervico-brachial neuralgia]

Thirty patients with active cervico-brachial neuralgia were investigated by detection of the sensory action potential of the nerve, the spinal somaesthetic evoked potential and the cerebral somaesthetic evoked potential. Stimulation is applied to the affected side and symmetrically to the healthy side, at the finger and at the wrist. The digital stimulation recruits a more specific root territory (2nd finger C6-C7, 5th finger C8-T1). These results were compared to those obtained in a population of 14 controls. In cases of active cervico-brachial neuralgia, the spinal somaesthetic evoked potential from digital stimulation (N16) was always abolished in the painful territory; it was also abolished on the pain free side in 75% of cases, while it was present in 96% of the controls. The spinal somaesthetic evoked potential from stimulation of the wrist was only abolished on the painful side in 29% of cases, but the mean amplitude of N13 was reduced. In contrast, the cerebral somaesthetic evoked potential and the sensory action potential of the nerve were only minimally altered. These changes regress after clinical cure. There is a correlation between the severity of the clinical course and the electrophysiological findings. Isolated abolition of the spinal somaesthetic evoked potential from digital stimulation is a constant feature of benign cervico-brachial neuralgia, while abolition of the spinal somaesthetic evoked potential by stimulation of the finger and of the wrist, bilaterally, corresponds to the most severe forms.