Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke

Celnik P, Hummel F, Harris-Love M, Wolk R, Cohen LG. Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke.

Objective

To test the hypothesis that somatosensory stimulation would enhance the effects of training functional hand tasks immediately after practice and 1 day later in chronic subcortical stroke patients.

Design

Single-blinded and randomized, crossover study.

Setting

Human research laboratory.

Participants

Nine chronic subcortical stroke patients.

Interventions

Three separate sessions of motor training preceded by (1) synchronous peripheral nerve stimulation (PNS), (2) no stimulation, or (3) asynchronous PNS.

Main Outcome Measures

Time to complete the Jebsen-Taylor Hand Function Test (JTHFT time) and corticomotor excitability tested with transcranial magnetic stimulation.

Results

After familiarization practice, during which all patients reached a performance plateau, training under the effects of PNS reduced JTHFT time by 10% beyond the post-familiarization plateau. This behavioral gain was accompanied by a specific reduction in GABAergically mediated intracortical inhibition in the motor cortex. These findings were not observed after similar practice under the influence of no stimulation or asynchronous PNS sessions.

Conclusions

Somatosensory stimulation may enhance the training of functional hand tasks in patients with chronic stroke, possibly through modulation of intracortical GABAergic pathways.     

Functional Status of Patients With Cerebral Palsy According to the International Classification of Functioning, Disability and Health Model: A 20-Year Follow-Up Study After Selective Dorsal Rhizotomy

Langerak NG, Lamberts RP, Fieggen AG, Peter JC, Peacock WJ, Vaughan CL. Functional status of patients with cerebral palsy according to the International Classification of Functioning, Disability and Health Model: a 20-year follow-up study after selective dorsal rhizotomy.

Objective

To determine functional status of patients with cerebral palsy 20 years after they received selective dorsal rhizotomy (SDR).

Design

A prospective 20-year follow-up study.

Setting

Red Cross Children's Hospital (SDR operation and 1-year follow-up assessment) and at institutional or private locations nearby patients' homes (20-year follow-up assessment).

Participants

Referred sample of 14 patients with spastic diplegia (6 women, 8 men; mean age, 27y; range, 22-33y) who were preoperatively ambulant and fulfilled strict selection criteria for SDR operation in 1985.

Interventions

Patients were assessed before and 1 and 20 years after SDR.

Main Outcome Measures

Standardized assessments of function according to 2 dimensions of the International Classification of Functioning, Disability and Health (ICF) model: (1) body structure and function (muscle tone, joint stiffness, voluntary movement) and (2) activity (rolling, sitting, kneeling, crawling, standing, walking, transitions) were obtained. In addition, based on assessments and questionnaires, Gross Motor Function Classification System (GMFCS) levels were determined before and at 1 year after SDR retrospectively and currently at 20 years after SDR.

Results

One year after SDR, functional outcomes based on the 2 dimensions of the ICF model improved significantly, and these improvements were maintained at 20 years after surgery. Patients showed a shift in their GMFCS levels 1 and 20 years after SDR.

Conclusions

In line with our 20-year follow-up study with gait parameters as outcome measures, patients with spastic diplegia still show improvements in their functional status 20 years after SDR. We acknowledge the presence of possible confounding factors and a small sample size, but we argue that the improvements found in this study were caused mainly by SDR. Finally, changes in GMFCS levels suggest a possible role for this tool to detect changes after an intervention.     

A Preliminary Assessment of the Benefits of the Addition of Botulinum Toxin A to a Conventional Therapy Program on the Function of People With Longstanding Stroke

Meythaler JM, Vogtle L, Brunner RC. A preliminary assessment of the benefits of the addition of botulinum toxin A to a conventional therapy program on the function of people with longstanding stroke.

Objective

To determine if botulinum toxin type A (BTX-A) combined with therapy can facilitate improved upper-extremity (UE) functional status versus therapy alone.

Design

Double-blind randomized crossover trial.

Setting

Tertiary care outpatient rehabilitation center.

Participants

Convenience sample of 21 men and women (ages 19-80y) with stroke more than 6 months after insult who had tone greater than 3 on the Ashworth Scale for 2 joints in the involved UE.

Intervention

Subjects were consecutively recruited and randomized to a double-blind crossover trial. Subjects received either BTX-A combined with a defined therapy program or placebo injection combined with a therapy program in two 12-week sessions.

Main Outcome Measures

The primary functional outcome measure was the Motor Activity Log (MAL). Subjects were also assessed on physiologic measures including tone (Ashworth Scale), range of motion, and motor strength.

Results

Improvements were noted in the functional status of the subjects in both arms of the study as measured by the MAL. All subjects had a significant change in functional status on MAL with therapy (P<.05). The use of BTX-A combined with therapy as compared with therapy only improved the functional status of the subjects on the MAL Quality of Movement subscale (P=.0180, t test) and showed a trend toward significance in the Amount of Use subscale (P=.0605, analysis of variance). Six weeks after treatment, the BTX-A combined with therapy decreased the Ashworth score statistically (P=.0271), but the therapy alone group decreased a similar amount at 6 weeks (P=.0117), indicating that most of the physiologic tone change could be attributed to therapy. After each 12-week period, tone had largely returned to baseline (P>.05).

Conclusion

A focused therapy program showed the most improvement in function in this defined stroke population. BTX-A combined with a focused traditional therapy program slightly enhanced the functional status of stroke subjects beyond that obtained with therapy alone 12 weeks after injection.     

Higher Muscle Passive Stiffness in Parkinson's Disease Patients Than in Controls Measured by Myotonometry

Marusiak J, Kisiel-Sajewicz K, Jaskólska A, Jaskólski A. Higher muscle passive stiffness in Parkinson's disease patients than in controls measured by myotonometry.

Objective

To assess muscle passive stiffness in medicated Parkinson's disease patients using myotonometry.

Design

Case-control study.

Setting

Kinesiology laboratory.

Participants

Women with Parkinson's disease (PD) (n=8) and healthy matched elderly women (controls) (n=10) (mean age: PD, 77±3y; controls, 77±4y).

Interventions

Not applicable.

Main Outcome Measures

Passive stiffness of relaxed biceps brachii (BB) muscle was measured using myotonometry. Additionally, surface electromyographic and mechanomyographic signals were recorded from the muscle at rest, and amplitude of those signals was analyzed offline.

Results

The values of BB muscle passive stiffness were significantly (P=.004) higher in PD than in the controls, with a statistically significant influence of parkinsonian rigidity score (Unified Parkinson's Disease Rating Scale) on intergroup differences (P<.001). The Spearman correlation coefficient ρ value showed a significant (P=.005) positive relationship (ρ=.866) between the parkinsonian rigidity score and passive stiffness values of BB in PD. The groups did not differ significantly in the electromyogram amplitude (P=.631) and mechanomyogram amplitude (P=.593) of the BB muscle, and values of these parameters did not correlate significantly with rigidity score (P=.555, P=.745, respectively) in the patients.

Conclusions

Myotonometer is a sensitive enough tool to show that PD patients have higher muscle passive stiffness than healthy controls.     

The effectiveness of a multidisciplinary pain management programme managing chronic pain on pain perceptions, health-related quality of life and stages of change—A non-randomized controlled study

Background

Cognitive behavioural therapy (CBT) has been useful in the treatment of chronic pain conditions for many years. Given the increasing number of persons with chronic pain and associated psychosocial problems, the development and implementation of effective interventions based on CBT is warranted.

Objectives

The aim of this study is to evaluate the effects of a multidisciplinary pain management programme on health-related quality of life (HRQL), as measured by the Short Form Health Survey (SF-36), pain perception as measured by the Brief Pain Inventory (BPI), and readiness-to-change as measured by the Pain Stages of Change Questionnaire (PSOCQ).

Design

A pretest-post-test quasi-experimental design, with waiting list controls and baseline and post-test measures, was used.

Setting

The study was conducted in the rehabilitation unit of a university hospital.

Participants

Of 117 people suffering from chronic pain, 113 completed the 8-week multidisciplinary pain management programme. The patients were consecutive referrals. Inclusion criteria were: adults (18-67 years), pain lasting over 6 months, motivation and no ongoing litigation. Exclusion criteria were affected by major mental disorders or major medical conditions requiring treatment.

Methods

The intervention was based on a cognitive behavioural approach. Therapeutic dialogues and training, combined with physical activity, were provided to a fixed plan, including homework. The programme has several features that directly address psychosocial aspects of chronic pain. Statistical and clinical significance are considered.

Results

The findings suggest that this programme has the potential to improve HRQL, reduce pain intensity and interference, and contribute to improvement in readiness-to-change. Statistically significant results are supplemented by results showing their clinical significance.

Conclusions

Improvements in HRQL, pain-related disability, and readiness-to-change suggest that the vicious cycle of chronic pain may be alleviated by our programme. As we see it, effective treatment results are about identifying and addressing the important and changeable influences maintaining pain problems such as acceptance, understanding the mind-body connection and self-management. Although further research is needed to evaluate the effectiveness of this work, such group approaches appear to represent a feasible treatment option for many patients with chronic pain.     

Stand up and be counted: measuring time spent upright after hip fracture and comparison with community dwelling older people

Objectives

Following hip fracture, the amount of time an individual spends on their feet (‘uptime’) may be an important marker of recovery. Using an automated device that measured uptime (Uptimer), we aimed to: (1) compare hip fracture patients’ uptime with age- and gender-matched community dwelling older people; (2) identify whether uptime changed during the transition from hospital to home; and (3) examine the relationship between uptime and existing functional measures.

Design

Prospective, observational study.

Setting

Rehabilitation hospital and community.

Participants

Patients undergoing rehabilitation after hip fracture surgery who aimed to return home at the end of rehabilitation, and age- and gender-matched community dwellers.

Interventions

Patients received standard care.

Main outcome measures

Uptime over 24 hours was measured on three occasions in hip fracture patients: 1 week before, 1 day before and 1 week after discharge home. Uptime over 24 hours was measured once in age- and gender-matched community dwelling older people. Functional mobility, self-reported activity, pain, mood and endurance were also assessed.

Results

Thirteen hip fracture patients (mean age 80.4 years) and 13 community dwelling participants completed testing. Once home, hip fracture patients spent 3.4 hours/day (25th, 75th percentiles 2.8, 5.2) upright, while community dwelling healthy older people were upright for 6.5 hours/day (6.1, 8.7). A trend for uptime to increase between hospital and home was observed. Hip fracture uptime at home correlated significantly with self-reported activity, functional mobility and gait endurance (P < 0.05).

Conclusions

This study highlighted uptime limitations of hip fracture patients at home. We discuss possible future directions for research using the Uptimer.     

Psychometric Properties of the Community Integration Questionnaire Adjusted for People With Aphasia

Dalemans RJ, de Witte LP, Beurskens AJ, van den Heuvel WJ, Wade DT. Psychometric properties of the community integration questionnaire adjusted for people with aphasia.

Objectives

To describe the feasibility of the Community Integration Questionnaire (CIQ) adjusted for use in people with aphasia and to report its psychometric properties in people with aphasia (internal consistency, factor analysis, test-retest reliability, convergent validity).

Design

A cross-sectional, interview-based psychometric study. Test-retest reliability was evaluated in 20 people (minimal to severe aphasia) by 2 different interviewers within a 2-week period.

Setting

Community.

Participants

In total 490 stroke survivors with (minimal to severe) aphasia were approached, of which 165 (34%) participants returned the answering letter. Participants (N=150) agreed to take part and were interviewed using a structured interview format.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire (CIQ), Frenchay Aphasia Screening Test, Barthel Index, Dartmouth Coop Functional Health Assessment Charts (COOP)-World Organisation of Family Doctors (WONCA) Charts, Life Satisfaction Questionnaire.

Results

A total of 150 stroke survivors with aphasia completed the CIQ adjusted for people with aphasia. The CIQ adjusted for people with aphasia was a feasible instrument. Results showed good internal consistency for the CIQ total (standardized Cronbach α=.75), excellent test-retest reliability (intraclass correlation coefficient=.96), moderate correlations with the Barthel Index, the COOP-WONCA, and the Life Satisfaction Questionnaire with regard to construct validity. Significant relations were found with regard to age and aphasia severity.

Conclusions

The CIQ adjusted for people with aphasia seems to be an adequate instrument to assess participation in people with aphasia.     

Long-Term Pain, Fatigue, and Impairment in Neuralgic Amyotrophy

van Alfen N, van der Werf SP, van Engelen BG. Long-term pain, fatigue, and impairment in neuralgic amyotrophy.

Objectives

Recently, it has become clear that neuralgic amyotrophy (NA; idiopathic and hereditary brachial plexus neuropathy) has a less optimistic prognosis than usually assumed. To optimize treatment and management of these patients, one needs to know the residual symptoms and impairments they suffer. Therefore, the objective of this study was to describe the prevalence of pain, psychologic symptoms, fatigue, functional status, and quality of life in patients with NA.

Setting

Neurology outpatient department of an academic teaching hospital.

Participants

NA patients (N=89) were studied, and clinical details were recorded. Self-report data were on average collected 2 years after the onset of the last NA episode.

Main Outcome Measures

Pain was assessed with the McGill Pain Questionnaire, fatigue with the Checklist Individual Strength, and psychologic distress with the Symptom Checklist 90. Functional status and handicap were assessed with the modified Rankin Scale and Medical Outcomes Study 36-Item Short-Form Health Survey.

Results

Pain was usually localized in the right shoulder and upper arm, matching the clinical predilection site for paresis in NA. About a quarter to a third of the patients reported significant long-term pain and fatigue, and half to two thirds still experienced impairments in daily life. Over one third of the individual patients suffered from severe fatigue. The group did not fulfill the criteria of chronic fatigue or major psychologic distress. There was no correlation of pain or fatigue with the level of residual paresis on a Medical Research Council scale, but patients with a comorbid condition fared worse than patients without.

Conclusions

A significant number of NA patients suffer from persistent pain and fatigue, leading to impairment. Symptoms were not correlated with psychologic distress. This makes it likely that they are caused by residual shoulder or arm dysfunction but not as part of a chronic pain or fatigue syndrome in these patients.     

Test position and hip strength in healthy adults and people with chronic stroke

Barbic S, Brouwer B. Test position and hip strength in healthy adults and people with chronic stroke.

Objective

To determine if peak torques generated by the hip flexors and extensors are dependent on test position in healthy adults and in people with chronic stroke.

Design

Cross-sectional study.

Setting

Motor performance laboratory.

Participants

Volunteers were 10 young (20.7±1.5y), 10 older adults (62.1±7y), and 10 stroke survivors (60.6±10y) who were an average of 5 years poststroke.

Interventions

Not applicable.

Main Outcome Measures

Isokinetic (60°/s) peak concentric hip flexor and extensor torques (in Nm/kg) generated in supine and standing positions.

Results

Peak flexor torques measured in standing were generally higher than in supine (P=.018); a pattern evident in all groups, but significant only in stroke. An interaction between test position and group for hip extensor strength (P=.016) reflected 2 distinct patterns in which torques were highest in standing among the young subjects and highest in supine after stroke.

Conclusions

Isokinetic hip flexor and extensor strength measured in standing and supine are comparable in young and older healthy people. In chronic stroke, the test position may over or underestimate maximum peak torque depending on the muscle group tested, particularly on the side ipsilateral to the lesion. These findings may have implications for predicting functional ability from strength measurements.     

Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Bandura's exercise self-efficacy scale: Validation in an Australian cardiac rehabilitation setting

Background

Despite the established benefits of cardiac rehabilitation (CR) in improving health outcomes for people with cardiovascular disease, adherence to regular physical activity at recommended levels remains suboptimal. Self-efficacy has been shown to be an important mediator of health behaviour, including exercise.

Objectives

To assess the psychometric properties of Bandura's exercise self-efficacy (ESE) scale in an Australian CR setting.

Design

Validation study.

Setting

Cardiac rehabilitation.

Participants

One hundred and ten patients (Mean: 60.11, S.D.: 10.57 years).

Methods

Participants completed a six-minute walk test (6MWT) and Bandura's exercise self-efficacy scale at enrolment and on completion of a 6-week CR program.

Results

Bandura's ESE scale had a single factor structure with high internal consistency (0.95), and demonstrated no floor or ceiling effects. A comparison of ESE scores by distance walked on 6MWT indicated those who recorded more than 500 m at baseline had significantly higher ESE scores (Mean: 116.26, S.D.: 32.02 m) than those patients who only achieved up to 400 m on the 6MWT at baseline (Mean: 89.94, S.D.: 29.47 m) (p = 0.044). A positive and significant correlation between the change in scores on the ESE scale and the change in the 6MWT distance (r = 0.28, p = 0.035) was seen.

Conclusions

The ESE scale was a robust measure of exercise self-efficacy over the range of patients attending this outpatient cardiac rehabilitation program. Interventions to improve self-efficacy may increase CR patient's efficacy for regular physical activity.     

Changes in Ankle Mechanical Stability in Those With Knee Osteoarthritis

Hubbard TJ, Hicks-Little C, Cordova M. Changes in ankle mechanical stability in those with knee osteoarthritis.

Objective

To examine ankle joint mechanical stability in patients who had mild to moderate knee osteoarthritis (OA).

Design

Case control study.

Setting

Biodynamics research laboratory.

Participants

Subjects with knee OA (n=15; 5 men and 10 women; mean age ± SD, 60.3±10.2y; mean mass ± SD, 93.9±18.3kg; mean height ± SD, 167.23±9.5cm) were matched to healthy controls (n=15; 5 men and 10 women; mean age ± SD, 59.6±12.6y; mean mass ± SD, 83.5±19.2kg; mean height ± SD, 169.7±12.6cm).

Interventions

Not applicable.

Main Outcome Measures

Mechanical ankle-subtalar joint stability was assessed with an instrumented arthrometer where ankle-subtalar joint motion for anterior/posterior displacement and inversion/eversion rotation was measured. Separate 2 × 2 mixed model analyses of variance were performed.

Results

Significant group × side interactions were observed for anterior and posterior displacement (P<.05) where patients with knee OA had significantly less anterior and posterior ankle displacement compared with the control group, as well as compared with their unaffected extremity. Additionally, patients with knee OA had significantly (P<.05) less inversion/eversion rotation than their respective controls.

Conclusions

These data suggest that altered ankle joint mechanics may be the result of deviations in ankle joint alignment secondary to the structural changes at the knee. Compensatory changes in ankle joint mechanics must also be considered when addressing lower extremity functional deficits in patients with knee OA.     

A comparison between self-reported and observed activity limitations in adults with neuromuscular disorders

Vandervelde L, Dispa D, Van den Bergh PY, Thonnard J-L. A comparison between self-reported and observed activity limitations in adults with neuromuscular disorders.

Objective

To investigate the agreement between the self-reported and examiner-reported difficulties of patients with neuromuscular disorders (NMDs) in performing daily activities at home.

Design

A comparison between 2 methods of administering a measurement instrument.

Setting

Neuromuscular reference center in a university hospital.

Participants

Adult patients (N=57) with diagnosed NMDs living at home.

Interventions

Not applicable.

Main Outcome Measure

The ACTIVLIM questionnaire.

Results

The intraclass correlation coefficient, model 2,1 (ICC_2,1), between the measures was very good (ICC_2,1=.87), indicating a good agreement between self-perceived and observed measures.

Conclusions

The use of ACTIVLIM as a self-reporting questionnaire is a valid method for assessing activity limitations in patients with NMD.     

Relationship Among Shoulder Proprioception, Kinematics, and Pain After Stroke

Niessen MH, Veeger DH, Meskers CG, Koppe PA, Konijnenbelt MH, Janssen TW. Relationship among shoulder proprioception, kinematics, and pain after stroke.

Objective

To identify a possible relationship among chronic poststroke shoulder pain (PSSP), scapular resting pose, and shoulder proprioception.

Design

Case-control study.

Setting

Rehabilitation center.

Participants

A total of 21 inpatients with stroke and 10 healthy control subjects.

Interventions

Not applicable.

Main Outcome Measures

Orientations of both the contralateral and ipsilateral (ie, paretic and nonparetic) shoulders during rest in degrees, angular displacement (degrees) for threshold to detection of passive motion (TDPM) tests, and absolute error (degrees) for passive reproduction of joint position (PRJP) tests.

Results

The contralateral shoulder of patients with PSSP showed more scapular lateral rotation and larger TDPM and PRJP scores than both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation than control subjects, whereas their ipsilateral shoulder showed more scapular lateral rotation than both control subjects and patients with good proprioception.

Conclusions

A clear relation among affected shoulder kinematics, affected proprioception, and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateral (ie, nonparetic) shoulder because it could be used in determining the risk of developing PSSP in the contralateral (ie, paretic) shoulder.     

Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation

Horn SD, Deutscher D, Smout RJ, DeJong G, Putman K. Black-white differences in patient characteristics, treatments, and outcomes in inpatient stroke rehabilitation.

Objective

To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation.

Design

Multicenter prospective observational cohort study of poststroke rehabilitation.

Setting

Six U.S. inpatient rehabilitation facilities.

Participants

Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335).

Interventions

Not applicable.

Main Outcome Measure

FIM.

Results

Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found.

Conclusions

Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes.     

Reliability of Rehabilitative Ultrasound Imaging of the Transversus Abdominis and Lumbar Multifidus Muscles

Koppenhaver SL, Hebert JJ, Fritz JM, Parent EC, Teyhen DS, Magel JS. Reliability of rehabilitative ultrasound imaging of the transversus abdominis and lumbar multifidus muscles.

Objectives

To evaluate the intraexaminer and interexaminer reliability of rehabilitative ultrasound imaging (RUSI) in obtaining thickness measurements of the transversus abdominis (TrA) and lumbar multifidus muscles at rest and during contractions.

Design

Single-group repeated-measures reliability study.

Setting

University and orthopedic physical therapy clinic.

Participants

A volunteer sample of adults (N=30) with current nonspecific low back pain (LBP) was examined by 2 clinicians with minimal RUSI experience.

Interventions

Not applicable.

Main Outcome Measures

Thickness measurements of the TrA and lumbar multifidus muscles at rest and during contractions were obtained by using RUSI during 2 sessions 1 to 3 days apart. Percent thickness change was calculated as thickness_contracted-thickness_rest/thickness_rest. Intraclass correlation coefficients (ICC) were used to estimate reliability.

Results

By using the mean of 2 measures, intraexaminer reliability point estimates (ICC_3,2) ranged from 0.96 to 0.99 for same-day comparisons and from 0.87 to 0.98 for between-day comparisons. Interexaminer reliability estimates (ICC_2,2) ranged from 0.88 to 0.94 for within-day comparisons and from 0.80 to 0.92 for between-day comparisons. Reliability estimates comparing measurements by the 2 examiners of the same image (ICC_2,2) ranged from 0.96 to 0.98. Reliability estimates were lower for percent thickness change measures than the corresponding single thickness measures for all conditions.

Conclusions

RUSI thickness measurements of the TrA and lumbar multifidus muscles in patients with LBP, when based on the mean of 2 measures, are highly reliable when taken by a single examiner and adequately reliable when taken by different examiners.     

Impact of Mental Disorders on Cost and Reimbursement for Patients in Inpatient Rehabilitation Facilities

Dobrez D, Heinemann AW, Deutsch A, Durkin EM, Almagor O. Impact of mental disorders on cost and reimbursement for patients in inpatient rehabilitation facilities.

Objective

To determine whether comorbid mental disorders affect inpatient rehabilitation facility (IRF) costs and to examine the extent to which Medicare's prospective payment system reimbursement sufficiently covers those costs.

Design

Secondary analysis of Medicare IRF Patient Assessment Instrument files and Medicare Provider and Review files. Payment was compared with costs for patients with and without reported mood, major depression, substance use, or anxiety disorders. The relationships among payment group assignment, comorbidity-related adjustments in payment, and the presence of mental disorders were estimated.

Setting

IRFs (N=1334) in the United States.

Participants

Medicare fee-for-service beneficiaries (N=1,146,799) discharged from IRFs from 2002 to 2004.

Interventions

Not applicable.

Main Outcome Measure

IRF costs.

Results

Mental disorders were reported for 13% of the Medicare fee-for-service beneficiaries. After controlling for payment group and comorbidity classifications, patients with mood, major depression, or anxiety disorders had significantly greater costs of $433, $1642, and $247 compared with patients without these disorders. The higher cost for patients with major depression (14.9% higher) is sufficient to justify a tier 2 comorbidity classification.

Conclusions

A reimbursement adjustment for the presence of a major depressive disorder would bring Medicare reimbursement in line with facility costs. The failure to compensate facilities directly for providing care to patients with major depression may result in reduced access to care for these patients. It also may create a disincentive to meet mental health treatment needs during the rehabilitative episode. Further work is needed to compare costs between patients with and without confirmed mental health disorders, given concerns about the accurate reporting of mental health disorders.     

Ultrasound as a Screening Tool for Proceeding With Caudal Epidural Injections

Chen CP, Wong AM, Hsu C-C, Tsai W-C, Chang C-N, Lin S-C, Huang Y-C, Chang C-H, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections.

Objective

To study the anatomical structure of the sacral hiatus using ultrasound. Based on the sonographic images of the sacral hiatus, the feasibility of caudal epidural injection can then be assessed.

Design

Case-controlled study.

Setting

Rehabilitation outpatient clinic in a tertiary medical center.

Participants

Patients (N=47; 20 women, 27 men) with low back pain and sciatica who were to receive caudal epidural injection treatments were recruited into this study.

Interventions

Sonographic images of the sacral hiatus were obtained from all the patients. An ultrasound machine capable of examining musculoskeletal tissues with real-time linear-array ultrasound transducer was used to measure the distance between the anterior wall and posterior wall of the sacral hiatus (diameter of the sacral hiatus) and the distance between bilateral cornua.

Main Outcome Measures

Diameter of the sacral canal and distance between bilateral cornua measured in millimeters.

Results

The mean diameter of the sacral canal was measured to be 5.3±2.0mm in our recruited patients. The mean distance between bilateral cornua was measured to be 9.7±1.9mm. Caudal epidural injections failed in 7 patients. In these 7 patients, 4 had very small diameter of the sacral canal (1.6, 1.2, 1.4, and 1.5mm). In 1 man, sonographic images revealed a closed sacral hiatus (no sacral canal diameter can be measured). Two patients revealed flow of fresh blood into the syringe while checking for the escape of cerebrospinal fluid after the needles were inserted into the sacral canal. For safety reasons, steroid injections were not performed in these 2 patients.

Conclusions

Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound. Sonographic images indicating a closed sacral canal and sacral diameters ranging from 1.2 to 1.6mm may suggest a higher failure rate in caudal epidural injection.     

Cognitive and Affective Predictors of Rehabilitation Participation After Stroke

Skidmore ER, Whyte EM, Holm MB, Becker JT, Butters MA, Dew MA, Munin MC, Lenze EJ. Cognitive and affective predictors of rehabilitation participation after stroke.

Objective

To examine associations between cognitive and affective impairments and rehabilitation participation during stroke rehabilitation.

Design

Secondary analyses of stroke patients who received acetylcholinesterase inhibitors during inpatient rehabilitation.

Setting

University-affiliated inpatient rehabilitation facilities.

Participants

Patients (N=44) admitted to inpatient stroke rehabilitation with impairment in attention, memory, or executive functions.

Interventions

Secondary analysis of patients receiving inpatient stroke rehabilitation care plus random assignment to one of two acetylcholinesterase inhibitors or no drug at rehabilitation admission.

Main Outcome Measures

Correlations between measures of cognitive (Digit Span, Hopkins Verbal Learning Test, Executive Interview) and affective impairments (Hamilton Rating Scale for Depression, Apathy Evaluation Scale) and participation (Pittsburgh Rehabilitation and Participation Scale) were examined. Significant correlates of participation were examined in a linear multiple regression model.

Results

Executive functions and depressive symptoms were significant correlates of participation. After controlling for baseline disability, executive functions predicted participation, but depressive symptoms did not (F_4,32=9.35; R²=.54, P<.001).

Conclusions

These findings are an important first step toward understanding potentially modifiable clinical factors that contribute to rehabilitation participation and overall functional status after rehabilitation. A better understanding of cognitive impairment and rehabilitation participation may be used to develop strategies for improving functional outcomes after stroke.