Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study

Background

Pressure ulcers are common in acute and long-term care. However, critically ill patients usually have multiple risk factors for pressure ulcers.

Objectives

The study was conducted to assess pressure ulcer incidence in intensive care patients, the factors related to pressure ulcer incidence and the course of pressure ulcers after the admission to an intensive care unit.

Design

A longitudinal design.

Setting

This study was carried out in cardiological and surgical intensive care of a general hospital and in a nephrological intensive care of a university hospital.

Participants

All patients admitted to intensive care wards during the period from April until October 2006 were invited to take a part in the study. One hundred and twenty-one patients were involved in the study. The inclusion criteria were adult intensive care patients, males and females, all diagnosis were included. The exclusion criterion was patients whose age less than 18 years.

Method

Each patient was assessed twice; first, upon admission and second upon discharge or death, or after 2 weeks if the patient was still in intensive care. The assessed data included pressure ulcer preventive measures, risk factors using Braden score, pressure ulcer characteristics and treatment. Additionally, incontinence supplies (urine/bowel) if used and the severity of illness using Acute Physiology and Chronic Health Evaluation (APACHE II score) were assessd.

Results

This study revealed a total incidence of 3.3% (4.5% in nephrological patients and 2.9% in surgical patients). Sixteen patients with a total of 21 pressure ulcers were admitted to the intensive care units. During the patients’ stay at the intensive care units six pressure ulcers developed newly and five pressure ulcers healed. The mean of the APACHE II score of patients with new pressure ulcers (16.6) were higher than in patients without new pressure ulcers (11.5).

Conclusion

Pressure ulcer incidence is low in this study compared to other studies. Pressure ulcers can be healed in intensive care patients. Using some preventive measures such as foam and alternating air pressure mattresses may help to decrease pressure ulcer development. Hydrocolloid dressing may help to increase the healing rate of pressure ulcers.     

Pressure ulcers: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP)

Background

Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking.

Aims and objectives

Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP).

Design

Prospective psychometric instrument validation study.

Methods

A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008.

Results

A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC = 0.88 (95% CI = 0.84-0.91, P < 0.001)]. For the total instrument, the internal consistency (Cronbachs α) was 0.79.

Conclusion

The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored.     

Impact of sitting time on seat-interface pressure and on pressure mapping with multiple sclerosis patients

Crawford SA, Stinson MD, Walsh DM, Porter-Armstrong AP. Impact of sitting time on seat-interface pressure and on pressure mapping with multiple sclerosis patients. Arch Phys Med Rehabil 2005;86:1221-5.

Objective

To examine changes in seat-interface pressure with multiple sclerosis (MS) patients.

Design

Case series.

Setting

Multiple Sclerosis Society’s Resource Centre and community.

Participants

Convenience sample of 15 MS wheelchair users and 12 MS non-wheelchair users.

Intervention

Interface pressure was measured for 8 minutes using the Force Sensing Array pressure mapping system.

Main Outcome Measures

Number of activated sensors, standard deviation, average and maximum pressures.

Results

With the wheelchair users, significant decreases were found in the standard deviation and average and maximum pressures during 0 to 2 minutes of sitting (P<.01). Average pressure was the only parameter to show a significant decrease in the non-wheelchair users (P<.01) during 0 to 2 minutes. Significant increases were found in all output parameters during 2 to 4 minutes with both groups (P<.05). Non-wheelchair users showed no significant changes in the output parameters after 4 minutes, but wheelchair users showed significant continued increases in the output parameters from 4 to 8 minutes (P<.05).

Conclusions

Because no significant changes in interface pressure occurred after 4 minutes of sitting with the non-wheelchair users, 4 minutes may be a reasonable sitting time before interface pressure is recorded with this group. Significant changes in interface pressure continued up to 8 minutes with the wheelchair users, therefore 8 minutes or beyond may be a reasonable sitting time before recording with this group.     

Frequency of pressure ulcers in the paediatric population: A literature review and new empirical data

Background

Published pressure ulcer incidence and prevalence figures in the paediatric population vary widely. The frequency of pressure ulcers in the German paediatric population is unknown. Currently, a systematic synthesis of PU incidence and prevalence studies in paediatric settings is missing.

Objectives

To determine the prevalence and incidence of pressure ulcers in the paediatric population and the anatomic sites that are most often affected; and whether pressure ulcer occurrence in German paediatric hospital samples is comparable to international figures.

Design

A systematic literature review and a secondary data analysis were conducted.

Methods

The MEDLINE und CINAHL databases were searched. Methodological quality of relevant studies was systematically evaluated, relevant data extracted and synthesised. Data from five German-wide pressure ulcer prevalence studies were analysed.

Results

In total, 19 studies were identified containing any information about pressure ulcer frequency in the paediatric population. Methodological quality of many studies was low. Taking only higher quality studies into account, pressure ulcer incidence was approximately 7% in the total paediatric population and 26% in the ICU setting. Prevalence estimates varied between 2% and 28%. Excluding grade 1 pressure ulcers, prevalence ranged from 1% to 5%. Especially in newborns and infants, the head was most often affected by pressure injuries. Many pressure ulcers were caused by medical devices. In Germany, pressure ulcer prevalence grade 1-4 in the general paediatric population was 2.3% (95% CI 1.4-3.6%). Excluding grade 1 pressure ulcer, prevalence was 0.8% (95% CI 0.4-1.8%).

Conclusions

Due to considerable methodological limitations and insufficient reporting there is a dearth of sound empirical evidence about pressure ulcer frequency in the paediatric population. Conducting and reporting of future studies must be improved. Pressure ulcer prevalence in German hospital samples was comparable to international figures. Newborns, infants, and small children are at higher risk to develop pressure ulcers at the occipital region as compared to other anatomic locations. The likelihood of developing sacral and heel pressure ulcers increases with increasing age and growth.     

Wavelet-based spectrum analysis of sacral skin blood flow response to alternating pressure

Jan Y-K, Brienza DM, Geyer MJ, Karg P. Wavelet-based spectrum analysis of sacral skin blood flow response to alternating pressure.

Objectives

To provide insight into the physiologic mechanisms associated with alternating pressure, using wavelet analysis of skin blood flow (SBF) oscillations, and to determine whether the application of alternating pressure induces myogenic responses, thereby enhancing SBF as compared with constant loading.

Design

Repeated-measures design.

Setting

University research laboratory.

Participants

Healthy, young adults (N=10; 5 men, 5 women; mean age ± standard deviation, 30.0±3.1y).

Intervention

Alternating pressure for 20 minutes (four 5-min cycles with either 60mmHg or 3mmHg) and constant loading for 20 minutes at 30mmHg on the skin over the sacrum.

Main Outcome Measures

A laser Doppler flowmeter was used to measure sacral SBF response to both alternating pressure and constant loading. Wavelet-based spectrum analysis of SBF oscillations was used to assess underlying physiologic mechanisms including endothelium-related metabolic (.008-.02Hz), neurogenic (.02-.05Hz), and myogenic (.05-.15Hz) controls.

Results

Alternating pressure stimulated an increase in sacral SBF of compressed soft tissues as compared with constant loading (P<.01). SBF during the high-pressure phase of 4 alternating pressure cycles showed an increasing trend. An increase in power in metabolic frequency range and a decrease in power in the myogenic frequency range during alternating pressure were observed compared with SBF prior to loading. Power increased in the myogenic frequency range during the low-pressure phase of alternating pressure and decreased during the high-pressure phase.

Conclusions

SBF control mechanisms, as assessed by the characteristic frequencies embedded in SBF oscillations, show different responses to 2 loading pressures with the same average pressure but different patterns. Our study suggests that optimization of operating parameters and configurations of alternating pressure support surfaces to compensate for impaired SBF control mechanisms in pathologic populations may be possible using wavelet analysis of blood flow oscillations.     

Dynamic aspect of functional recovery after stroke using a multistate model

Pan SL, Lien IN, Yen MF, Lee TK, Chen THH. Dynamic aspect of functional recovery after stroke using a multistate model.

Objective

To estimate time to functional recovery and quantify the effects of significant prognostic factors affecting the dynamic change of 3-state functional outcome after stroke.

Design

Modeling of clinical predictions.

Setting

Referral center.

Participants

One hundred eleven patients with first-time ischemic stroke.

Interventions

Not applicable.

Main Outcome Measure

Serial Barthel Index scores at onset, 2 weeks, and 1, 2, 4, and 6 months poststroke. The severity of disability was classified into 3 functional states: poor functional state (PFS) for Barthel Index scores from 0 to 40, moderate functional state (MFS) for scores from 45 to 80, and good functional state (GFS) for scores greater than 80. A 3-state Markov regression model together with Bayesian acyclic graphic underpinning was used to estimate transition parameters and mean time to functional recovery between states and to predict the probability of functional recovery by using Gibbs sampling technique.

Results

The mean total recovery time was 3.1 months for patients with PFS at baseline and 1.3 months for patients with MFS at baseline. The mean recovery times to different functional states were also estimated. Age predominantly affected the probabilities of MFS to GFS transitions, younger patients had faster transition rates (rate ratio, 4.51; 95% confidence interval [CI], 2.72−7.40); but age had only borderline effects on PFS to MFS transitions. In contrast, infarct size exerted substantial effects on PFS to MFS transitions: small-size infarct correlated with a higher transition rate (rate ratio, 10.17; 95% CI, 5.25−20.13), whereas only a borderline effect on MFS to GFS transitions was found. The baseline functional state significantly affected the MFS to GFS transitions.

Conclusions

By using a multistate model, overall and patient-specific mean time to functional recovery to different functional states can be estimated and the effect of clinical predictors on functional transitions can be precisely quantified to predict patient-specific probability of functional recovery.     

Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study

Objective

To evaluate the effectiveness and cost-effectiveness of new incentive system for pressure ulcer management, which focused on skilled nurse staffing in terms of rate of healing and medical costs.

Design, setting and participants

A prospective cohort study included two types of groups: 39 institutions, which introduced the new incentive system, and 20 non-introduced groups (control). Sixty-seven patients suffering from severe pressure ulcers in the introduced group and 38 patients in the non-introduced group were included. Wound healing and medical costs were monitored weekly for three weeks by their skilled nurses in charge.

Main outcome measures

Healing status and related medical costs.

Results

The introduced group showed significantly higher rate of healing compared with the control group at each weekly assessment. Multiple regression analysis revealed that the introduction of the new incentive system was independently associated with the faster healing rate (β = 3.44, P < .001). The budget impact analysis demonstrated that introducing this system could reduce cost of treating severe pressure ulcers by 1.776 billion yen per year.

Conclusions

The new incentive system for the management of pressure ulcers, which focused on staffing with skilled nurses can improve healing rate with reduced medical cost.     

Electrical Stimulation Therapy Increases Rate of Healing of Pressure Ulcers in Community-Dwelling People With Spinal Cord Injury

Houghton PE, Campbell KE, Fraser CH, Harris C, Keast DH, Potter PJ, Hayes KC, Woodbury MG. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury.

Objective

To investigate whether electric stimulation therapy (EST) administered as part of a community-based, interdisciplinary wound care program accelerates healing of pressure ulcers in people with spinal cord injury (SCI).

Design

Single-blind, parallel-group, randomized, controlled, clinical trial.

Setting

Community-based home care setting, Ontario, Canada.

Participants

Adults (N=34; mean age ± SD, 51±14y) with SCI and stage II to IV pressure ulcers.

Interventions

Subjects were stratified based on wound severity and duration and randomly assigned to receive either a customized, community-based standard wound care (SWC) program that included pressure management or the wound care program plus high-voltage pulsed current applied to the wound bed (EST+SWC).

Main Outcome Measures

Wound healing measured by reduction in wound size and improvement in wound appearance at 3 months of treatment with EST+SWC or SWC.

Results

The percentage decrease in wound surface area (WSA) at the end of the intervention period was significantly greater in the EST+SWC group (mean ± SD, 70±25%) than in the SWC group (36±61%; P=.048). The proportion of stage III, IV, or X pressure ulcers improving by at least 50% WSA was significantly greater in the EST+SWC group than in the SWC group (P=.02). Wound appearance assessed using the photographic wound assessment tool was improved in wounds treated with EST+SWC but not SWC alone.

Conclusions

These results demonstrate that EST can stimulate healing of pressure ulcers of people with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community.     

The effect of surface electric stimulation of the gluteal muscles on the interface pressure in seated people with spinal cord injury

van Londen A, Herwegh M, van der Zee CH, Daffertshofer A, Smit CA, Niezen A, Janssen TW. The effect of surface electric stimulation of the gluteal muscles on the interface pressure in seated people with spinal cord injury.

Objective

To study effects of surface electric stimulation of the gluteal muscles on the interface pressure in seated persons with spinal cord injury (SCI).

Design

One session in which alternating and simultaneous surface electric stimulation protocols were applied in random order.

Setting

Research laboratory of a rehabilitation center.

Participants

Thirteen subjects with SCI.

Intervention

Surface electric stimulation of the gluteal muscles.

Main Outcome Measures

Interface pressure, maximum pressure, pressure spread, and pressure gradient for the stimulation measurement. Variables were compared using 2-tailed paired t tests.

Results

Alternating and simultaneous stimulation protocol caused a significant (P<.01) decrease in interface pressure (-17±12mmHg, -19±14mmHg) and pressure gradient (-12±11mmHg, -14±12mmHg) during stimulation periods compared with rest periods. There was no significant difference in effects between the 2 protocols.

Conclusions

Surface electric stimulation of the gluteal muscles in persons with SCI causes a decrease in interface pressure. This might restore blood flow in compressed tissue and help prevent pressure ulcers.     

A Systematic Review of Therapeutic Interventions for Pressure Ulcers After Spinal Cord Injury

Regan MA, Teasell RW, Wolfe DL, Keast D, Mortenson WB, Aubut JL, for the Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury.

Objective

To systematically review evidence on the prevention and treatment of pressure ulcers in those with a spinal cord injury (SCI).

Data Sources

For this evidence-based review, the following data sources were used: MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO.

Study Selection

To be selected for inclusion in the current review, there had to have been an intervention, studies had to have 3 or more subjects, and 50% or more of the participating group had to have an SCI.

Data Extraction

Data extracted included study design, subject demographics, inclusion and exclusion criteria, study type, sample size, outcome measures used, and study results.

Data Synthesis

Articles selected for this review were organized into 1 of 2 categories: prevention or treatment. Within each broad category, several smaller ones were created, and articles were grouped according to the prevention (direct or indirect) or treatment intervention discussed.

Conclusions

Of the 26 articles selected for inclusion in the systematic review, 7 were randomized controlled trials (RCTs) that dealt with treatment for pressure ulcers, and there was 1 RCT on prevention. Despite the cost-effectiveness of prevention, little research exists on preventative interventions, and what does exist is mostly level 4 evidence. More research is needed for both prevention and treatment, but especially the former.     

The impact of limitations in physical, executive, and emotional function on health-related quality of life among adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

Ness KK, Gurney JG, Zeltzer LK, Leisenring W, Mulrooney DA, Nathan PC, Robison LL, Mertens AC. The impact of limitations in physical, executive, and emotional function on health-related quality of life among adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.

Objective

To examine associations between limitations in physical performance, executive function, and emotional health (activity domains) and either social role attainment or health-related quality of life (HRQOL) in adult survivors of childhood cancer.

Design

Cross-sectional analysis.

Setting

Cancer survivors living in the community; previously treated for childhood cancer at one of 26 institutions.

Participants

Subjects included 7147 (76.8%) of 9307 eligible adult members of the Childhood Cancer Survivor Study who completed a follow-up questionnaire between 2002 and 2004.

Interventions

Not applicable.

Main Outcome Measures

Demographic information was used to classify social roles and the Medical Outcomes Survey 36-Item Short-Form Health Survey to ascertain HRQOL. Questions from the National Health Interview Survey were used to represent physical performance; from the Brief Symptom Inventory to classify emotional health; and from the Behavioral Rating of Executive Function to describe executive function. Multivariate logistic regression was used to examine the association between limitations in activity domains, role attainment, and HRQOL.

Results

In this cohort, 18.1% reported deficits in physical performance, 10.5% in emotional health, and 14.0% in executive function. In adjusted models, when compared with survivors who reported no limitations, those with physical performance, executive function, or emotional health deficits were less likely to be employed, married, or have incomes greater than $20,000 a year. Limitations in executive function or emotional health were associated with no health insurance. Limitations in any activity domain were associated with poor HRQOL. Emotional health limitations had the most impact, with odds ratios from 3.18 (physical performance summary) to 25.81 (mental health).

Conclusions

The results of these analyses show the need for development and testing of interventions to remediate limitations in activity domains, because they negatively impact role attainment and HRQOL.     

Time course analysis of the effects of botulinum toxin type a on elbow spasticity based on biomechanic and electromyographic parameters

Lee H-M, Chen J-JJ, Wu Y-N, Wang Y-L, Huang S-C, Piotrkiewicz M. Time course analysis of the effects of botulinum toxin type A on elbow spasticity based on biomechanic and electromyographic parameters.

Objective

To quantify changes of elbow spasticity over time after botulinum toxin type A (BTX-A) injection in the upper extremity of stroke patients.

Design

Before-after trial in which the therapeutic effects were followed up at 2, 6, and 9 weeks after the BTX-A injection (Botox).

Setting

Hospital.

Participants

Chronic stroke patients (N=8) with upper-limb spasticity.

Intervention

BTX-A was injected in upper-limb muscles, including the biceps brachii.

Main Outcome Measures

Treatment effects were quantified as the changes in the velocity and the length dependence of hyperexcitable stretch reflexes. Manual sinusoid stretches of the elbow joint at 4 frequencies (1/3, 1/2, 1, 3/2Hz) over a movement range of 60° were performed on patients by using a portable device. The Modified Ashworth Scale (MAS), biomechanic viscosity, and the reflexive electromyography threshold (RET) of the biceps brachii were used to evaluate the degree of hypertonia.

Results

The statistical analyses of the MAS score, biomechanic viscosity, and RET revealed a significant decrease in spasticity after the injection (all P<.05). Moreover, our quantitative parameters (biomechanic viscosity, RET) revealed small changes in spasticity after the BTX-A injection that could not be observed from clinical MAS evaluations. Five of 8 subjects showed a maximal reduction in spasticity (in terms of biomechanic viscosity value) within 6 weeks after the injection, whereas it was notable that all subjects exhibited peak RET values at either 2 or 6 weeks after the injection with variable degrees of relapse of spasticity.

Conclusions

Early relapse of spasticity (within 9 weeks of the injection) can be detected from biomechanic and neurophysiologic assessments in a clinical setup. These quantitative indices provide valuable information for clinicians when making decisions to perform additional rehabilitation interventions or another BTX-A injection in the early stages of treatment.     

Measurement properties of the pressure biofeedback unit in the evaluation of transversus abdominis muscle activity: a systematic review

Background

Measurements from pressure biofeedback units (PBUs) can be used to evaluate the activity of the transversus abdominis (TrA) muscle indirectly. These measurements can classify patients or monitor the progress of treatment programmes for people with low back pain.

Objective

To systematically review studies on the measurement properties of PBUs for the assessment of TrA activity.

Data sources

Eligible studies were identified through searches of PUBMED, CINAHL and BIREME (1990 to 2009). In addition, hand searches of journals and citation tracking were performed.

Study selection

Full-text studies involving any type of clinimetric tests of PBU measurement for the assessment of TrA activity were selected.

Data extraction

Two independent reviewers selected the studies, extracted the data and assessed methodological quality.

Data synthesis

Due to the heterogeneity of study designs and statistical analysis, it was not possible to pool the data for a meta-analysis.

Results

Six studies met the inclusion criteria. These studies were typically of low quality and recruited healthy subjects rather than patients with low back pain. The studies found moderate to good reproducibility (intra-class correlation coefficients from 0.47 to 0.82) and acceptable construct validity (intra-class correlation coefficients from 0.48 to 0.90).

Conclusions

The current evidence about the measurement properties of PBUs for the assessment of TrA activity is mainly based on studies with suboptimal designs, and the findings from these studies are likely to be overly optimistic. The most important clinical questions about the measurement properties of PBUs for the assessment of TrA activity are yet to be answered.     

Interpreting patients as a means of clinical practice: Introducing nursing hermeneutics

Background

The increased reference to hermeneutics from nursing scientists, researchers and academics has emphasized that interpretation has traditionally been a fundamental part of nursing practice. In nursing research a propensity for acquiring knowledge and understanding by using, multiple modalities has been demonstrated. In recent years, the use of hermeneutic phenomenology, has featured amongst these modalities. Hermeneutic phenomenology is an inquiry arm of, philosophical hermeneutics.

Objectives

To explore the hypotheses that the patient can be considered as “text” and as such to be, interpreted in order to gain information for decision-making in clinical practice.

Design

A qualitative approach (hermeneutic phenomenological) to nursing clinical practice.

Settings

The clinical case of a patient suffering from cancer is described in the paper who was treated, in an Oncology Centre in Cyprus.

Methods

A hermeneutical model of clinical decision-making in nursing is implemented in practice. The, model was initially used in medical practice; however it finds applications to nursing as well. According, to the model, a patient is perceived as a literary text which may be interpreted on four levels: (1) the, literal facts of the patient's body and the literal story told by the patient, (2) the nursing diagnostic, meaning of the literal data, (3) the praxis (the nursing interventions) emanating from the nursing, diagnosis, and (4) the change effected by the clinical encounter in both the patient's and nurse's lifeworlds.

Results

Nursing interventions were successfully informed by the interpretation process.     

Relatives' Criticism Influences Adjustment and Outcome After Traumatic Brain Injury

Weddell RA. Relatives' criticism influences adjustment and outcome after traumatic brain injury.

Objectives

To apply some of the methods developed to study the effects of relatives' expressed emotion (EE) on psychiatric relapse rates and to test the prediction that relatives' criticism and psychiatric distress would be associated with outcome and emotional distress after traumatic brain injury (TBI).

Design

Retrospective cohort design with correlational analyses of quantitative and qualitative measures of TBI outcomes.

Setting

The author interviewed participants in the hospital. The research assistant interviewed close relatives at home.

Participants

Participants and relatives (N=78) were interviewed 34.3±15.2 months (mean ± SD) after a severe TBI.

Interventions

None.

Main Outcome Measures

Dependent variables in a series of hierarchical linear regression models were participants' scores on the Zung Depression Scale, Spielberger Trait Anxiety Inventory, State-Trait Anger Expression Inventory, an Anger Towards Relative questionnaire constructed for this study, and Extended Glasgow Outcome Scores. Participant-independent variables were social class, posttraumatic amnesia, Wechsler Memory Scale-Delayed Recall score, WAIS-R intelligence quotient, and a short version of the Smell Identification Test. Relative independent variables were the number of critical comments directed toward participants in the interview and psychiatric distress as measured by the General Health Questionnaire.

Results

The contributions of variance associated with relative independent variables (predominantly criticism) were significant in stage 2 of most hierarchical regression analyses after the adjustments for variance associated with participant independent variables made in stage 1.

Conclusions

Future application of EE research methods is warranted. If the present results are replicated, then evidence-based family interventions developed by EE researchers to reduce criticism might also improve TBI outcomes.     

Relationship Between Age and Spasticity in Children With Diplegic Cerebral Palsy

Pierce SR, Prosser LA, Lauer RT. Relationship between age and spasticity in children with diplegic cerebral palsy.

Objective

To examine the relationship between passive torque, reflex activity, co-contraction, and age during the assessment of spasticity of knee flexors and extensors in children with spastic diplegic cerebral palsy (CP).

Design

Retrospective.

Setting

Pediatric orthopedic hospital.

Participants

Children (N=36) with spastic diplegic CP.

Interventions

Not applicable.

Main Outcome Measures

Spasticity of the knee flexors and knee extensors (as measured by peak passive torque, mean passive torque, reflex activity of the medial hamstrings, reflex activity of vastus lateralis, and co-contraction) was assessed during passive movements completed using an isokinetic dynamometer with concurrent electromyography.

Results

A significant positive relationship was found between age and mean knee flexor passive torque (P<.05), while a significant negative relationship was found between age and mean percentage of the range of motion with co-contraction (P<.05).

Conclusions

Our results suggest that passive stiffness may play a larger role in spasticity than reflex activity as children with spastic diplegic CP age. Additional research is needed to determine whether subject age could influence the effectiveness of interventions, such as serial casting or botulinum toxin, for spasticity in children with spastic diplegic CP.