Percutaneous Radiologic Gastrostomy in Patients With Amyotrophic Lateral Sclerosis on Noninvasive Ventilation

Park JH, Kang S-W. Percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis on noninvasive ventilation.

Objective

To determine the safety and feasibility of percutaneous radiologic gastrostomy (PRG) tube placement in patients with amyotrophic lateral sclerosis (ALS) with too low a vital capacity to be weaned off noninvasive positive pressure ventilation (NPPV).

Design

Five-year follow-up cohort study.

Setting

Inpatient pulmonary rehabilitation hospital.

Participants

Patients with ALS (N=25) with dysphagia on NPPV.

Interventions

PRG tube placement was performed. During the procedure, all subjects used NPPV via nasal masks. No sedatives or narcotics were administered for premedication.

Main Outcome Measures

Success and complication rates after PRG tube placement, and mean survival after the procedure.

Results

For the 25 patients enrolled, mean percent forced vital capacity (FVC) was 33.3±17.8% seated (n=19) and 25.3±12.0% supine (n=18). FVCs could not be measured in patients who could not tolerate being off NPPV. PRG placement was 100% successful technically. Mean survival for the 25 patients was 32.1 months.

Conclusions

The application of NPPV during PRG was found to be a successful, safe means of providing nutritional care for patients with ALS with too low an FVC to be off NPPV. We advocate that PRG be considered the treatment of choice for nutritional care in patients with ALS on NPPV.     

Patient experience of neurologic rehabilitation: a qualitative investigation

Wain HR, Kneebone II, Billings J. Patient experience of neurologic rehabilitation: a qualitative investigation.

Objective

To understand the experiences of patients who had undergone neurologic rehabilitation.

Design

An interpretative phenomenological analysis of semistructured interviews.

Setting

Neurologic rehabilitation unit.

Participants

A purposive convenience sample of 8 past patients.

Interventions

Not applicable.

Main Outcome Measure

Participants' reports of neurologic rehabilitation obtained via in-depth semistructured interviews.

Results

Participants predominantly described positive experiences of rehabilitation. The superordinate theme person-centeredness was developed, which included 4 key themes: ownership, personal value, holistic approach, and therapeutic atmosphere. These reflected patients' perceptions of choice and control and feelings of personal respect and self-worth. These appeared to be promoted through the multidimensional benefits of the unit (eg, the understanding and friendly nature of staff and other patients, physical improvements, psychologic gains) as well as the unit's informal, relaxed environment. When present, these factors created a positive rehabilitation experience; when absent, a negative experience.

Conclusions

These findings support those from other literature, which has identified person-centered care as a core element of successful rehabilitation and linked its absence to dissatisfaction with health care. This research has increased our understanding of patients' experience of neurologic rehabilitation, and could inform the development of a patient-centered assessment instrument for neurologic rehabilitation.     

Effects of vision and arm position on amplitude of arm postural tremor in patients with multiple sclerosis

Feys P, Helsen WF, Liu X, Lavrysen A, Nuttin B, Ketelaer P. Effects of vision and arm position on amplitude of arm postural tremor in patients with multiple sclerosis. Arch Phys Med Rehabil 2004;85:1031-3.

Objectives

To quantify the effects of vision and arm position on arm postural tremor, comparisons were made between flexed and extended arm positions performed with the eyes open and closed.

Design

Case-control study.

Setting

National multiple sclerosis (MS) center in Belgium.

Participants

Sixteen patients (32 arms) with MS who had intention tremor and 16 healthy controls (32 arms).

Interventions

Not applicable.

Main outcome measure

The amplitude of postural tremor was assessed by a magnetic position sensor attached to the index finger.

Results

The amplitude of postural tremor was not influenced by changes in visual condition or different arm positions. Both healthy controls and MS patients made more directional changes in the flexed, compared with the extended arm position.

Conclusions

The amplitude of the arm postural tremor in MS is independent of vision and arm position. Selecting 1 arm position is sufficient to assess postural tremor amplitude.     

Impact of using the ICF framework as an assessment tool for students in paediatric physiotherapy: a preliminary study

Objective

To determine if clinical assessment of children with neurological conditions by physiotherapy students was improved through the overt use of the International Classification of Functioning, Disability and Health (ICF).

Design and participants

A retrospective, pragmatic audit of practice using written patient assessments completed by third-year physiotherapy students. Assessments completed by third-year students in 2008 were compared with assessments completed by third-year students in 2009. The assessment format used in 2008 was very loosely based on the ICF model, while the 2009 assessments made rigorous use of the ICF approach.

Setting

Two schools for children with special needs to which physiotherapy students from the Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, Division of Physiotherapy, University of Cape Town are sent for clinical exposure.

Method

A score sheet was drawn up to evaluate specific criteria in each assessment, using a five-point marking scheme. The mark sheet was tested for reliability. All assessments were evaluated independently using the score sheet by two external physiotherapists who were blind to the purpose of the exercise.

Results

There was a significant difference between the scores obtained on the score sheet for the 2008 group and the 2009 group. The 2009 group obtained a median score of 60, compared with a median score of 50 for the 2008 group (median difference between groups 9.2, 95% confidence interval 4.2 to 14.1). The overall impression mark given to the 2009 group was also higher than that given to the 2008 group, with a median difference between the groups of 5.9 (95% confidence interval 3.2 to 12.7). It would appear that the 2009 students, using the ICF framework for assessing patients, were able to include more function-related information in their assessments, resulting in a more holistic assessment.

Conclusion

Teaching students to use the ICF framework when assessing paediatric patients encourages clinical reasoning and an improved holistic approach to identifying the patient's problems in context. This, in turn, enables the student to plan a more appropriate intervention treatment, to the patient's benefit.     

A Systematic Review of the Management of Orthostatic Hypotension After Spinal Cord Injury

Krassioukov A, Eng JJ, Warburton DE, Teasell R, Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of orthostatic hypotension after spinal cord injury.

Objective

To review systematically the evidence for the management of orthostatic hypotension (OH) in patients with spinal cord injuries (SCIs).

Data Sources

A key word literature search was conducted of original and review articles as well as practice guidelines using Medline, CINAHL, EMBASE, and PsycInfo, and manual searches of retrieved articles from 1950 to July 2008, to identify literature evaluating the effectiveness of currently used treatments for OH.

Study Selection

Included randomized controlled trials (RCTs), prospective cohort studies, case-control studies, pre-post studies, and case reports that assessed pharmacologic and nonpharmacologic intervention for the management of OH in patients with SCI.

Data Extraction

Two independent reviewers evaluated the quality of each study, using the Physiotherapy Evidence Database score for RCTs and the Downs and Black scale for all other studies. Study results were tabulated and levels of evidence assigned.

Data Synthesis

A total of 8 pharmacologic and 21 nonpharmacologic studies were identified that met the criteria. Of these 26 studies (some include both pharmacologic and nonpharmacologic interventions), only 1 pharmacologic RCT was identified (low-quality RCT producing level 2 evidence), in which midodrine was found to be effective in the management of OH after SCI. Functional electrical stimulation was one of the only nonpharmacologic interventions with some evidence (level 2) to support its utility.

Conclusions

Although a wide array of physical and pharmacologic measures are recommended for the management of OH in the general population, very few have been evaluated for use in SCI. Further research needs to quantify the efficacy of treatment for OH in subjects with SCI, especially of the many other pharmacologic interventions that have been shown to be effective in non-SCI conditions.     

Factor structure of the Maslach burnout inventory: An analysis of data from large scale cross-sectional surveys of nurses from eight countries

Background

Job burnout is an important predictor of nurse retention. Reliable and valid measures are required to monitor this phenomenon internationally.

Objective

To evaluate the applicability of the Maslach burnout inventory (MBI) in international nursing research.

Design

Secondary analysis of cross-sectional hospital nurse survey data from eight countries.

Settings

Hospitals in the U.S., Canada, the U.K., Germany, New Zealand, Japan, Russia and Armenia.

Participants

54,738 direct care professional nurses from 646 hospitals in eight countries.

Methods

Confirmatory and exploratory factor analysis were undertaken to identify the factor structure of the MBI. The internal consistencies of the subscales were investigated.

Results

Exploratory factor analysis revealed three factors being extracted from the 22-item Maslach burnout inventory. In nearly all countries the two items (6 and 16) related to the “stress” and “strain” involved in working with people loaded on the depersonalization subscale rather than the emotional exhaustion subscale to which they were initially assigned. The three subscales exhibited high reliability with Cronbach alphas exceeding the critical value of 0.70. The correlation coefficients for the emotional exhaustion and depersonalization subscales were strong and positive.

Conclusions

The 22-item Maslach burnout inventory has a similar factor structure and, with minor modifications, performed similarly across countries. The predictive validity of the emotional exhaustion and depersonalization subscales might be improved by moving the two items related to stress and strain from the emotional exhaustion to the depersonalization subscale. Nevertheless, the MBI can be used with confidence as a burnout measure among nurses internationally to determine the effectiveness of burnout reduction measures generated by institutional and national policies.     

Validation of the Multidimensional Outcome Expectations for Exercise Scale in Ambulatory, Symptom-Free Persons With Multiple Sclerosis

McAuley E, Motl RW, White SM, Wójcicki TR. Validation of the Multidimensional Outcome Expectations for Exercise Scale in ambulatory, symptom-free persons with multiple sclerosis.

Objective

To determine the psychometric properties of the 3-factor Multidimensional Outcome Expectations for Exercise Scale in a sample of ambulatory, symptom-free persons with multiple sclerosis (MS).

Design

Cross-sectional validation study.

Setting

Midwestern university.

Participants

Community-dwelling adults (N=242) with an established definite diagnosis of MS, as corroborated by the participant's neurologist, who were relapse free for the last 30 days and ambulatory with minimal assistance.

Interventions

Not applicable.

Main Outcome Measures

Multidimensional Outcome Expectations for Exercise Scale, physical activity, self-efficacy, and physical health status. Confirmatory factor analyses using covariance modeling and correlational analyses were used to establish factorial and construct validity.

Results

Analyses showed excellent factorial validity for the hypothesized factor structure reflecting physical, social, and self-evaluative outcome expectations. All 3 subscales were internally consistent. Theoretically, relevant correlations between outcome expectations and self-efficacy, physical activity, and physical health status were all supported.

Conclusions

The Multidimensional Outcome Expectations for Exercise Scale appears to be a reliable and valid measure of outcome expectations for exercise in this limited sample of community-dwelling adults with MS. Further validation in clinical samples is warranted.     

Reproducibility of maximal quadriceps strength and its relationship to maximal voluntary activation in postpoliomyelitis syndrome

Horemans HL, Beelen A, Nollet F, Jones DA, Lankhorst GJ. Reproducibility of maximal quadriceps strength and its relationship to maximal voluntary activation in postpoliomyelitis syndrome. Arch Phys Med Rehabil 2004;85:1273-8.

Objectives

To determine what changes in maximal isometric strength can be detected in a symptomatic quadriceps muscle in patients with postpoliomyelitis syndrome (PPS) and to investigate the association between the variability in maximal strength and maximal voluntary activation (MVA).

Design

Repeated-measures over a 3-week interval.

Setting

University hospital.

Patients

Convenience sample of 65 patients with PPS.

Intervention

Dynamometer testing.

Main outcome measures

Maximal voluntary contraction (MVC) torque of the quadriceps was measured with a Kin-Com dynamometer and MVA was determined by twitch interpolation.

Results

The mean difference between the 2 consecutive measurements was −0.7±12.8Nm (95% confidence interval [CI], −3.9 to 2.5). The test-retest reliability was excellent for MVC torque (intraclass correlation coefficient [ICC]=.96; 95% CI, .93-.98) and moderate for MVA (ICC=.73; 95% CI, .56-.85). The smallest detectable change in MVC torque was 25% for an individual. The variability in MVA explained 18% of the variability in maximal strength.

Conclusions

Variability in maximal quadriceps strength, measured with a fixed dynamometer, was large and partly related to variability in MVA. This implies that even with optimally standardized strength testing, a follow-up of many years is required to objectify progression of quadriceps weakness in an individual patient with PPS. To demonstrate changes in strength in groups of patients in follow-up or intervention studies, feasible sample sizes are required.     

The contribution of cognition and spasticity to driving performance in multiple sclerosis

Marcotte TD, Rosenthal TJ, Roberts E, Lampinen S, Scott JC, Allen RW, Corey-Bloom J. The contribution of cognition and spasticity to driving performance in multiple sclerosis.

Objective

To examine the independent and combined impact of cognitive dysfunction and spasticity on driving tasks involving high cognitive workload and lower-limb mobility in persons with multiple sclerosis (MS).

Design

Single-visit cohort study.

Setting

Clinical research center.

Participants

Participants included 17 drivers with MS and 14 referent controls. The group with MS exhibited a broad range of cognitive functioning and disability. Of the 17 patients with MS, 8 had significant spasticity in the knee used to manipulate the accelerator and brake pedals (based on the Modified Ashworth Scale).

Interventions

Not applicable.

Main Outcome Measures

A brief neuropsychologic test battery and 2 driving simulations. Simulation 1 required participants to maintain a constant speed and lane position while attending to a secondary task. Simulation 2 required participants to adjust their speed to accelerations and decelerations of a lead car in front of them.

Results

Patients with MS showed greater variability in lane position (effect size, g=1.30), greater difficulty in maintaining a constant speed (g=1.25), and less ability to respond to lead car speed changes (g=1.85) compared with controls. Within the MS group, in a multivariate model that included neuropsychologic and spasticity measures, cognitive functioning was the strongest predictor of difficulty in maintaining lane position during the divided attention task and poor response time to lead car speed changes, whereas spasticity was associated with reductions in accuracy of tracking the lead car movements and speed maintenance.

Conclusions

In this preliminary study, cognitive and physical impairments associated with MS were related to deficits in specific components of simulated driving. Assessment of these factors may help guide the clinician regarding the types of driving behaviors that would put patients with MS at an increased risk for an automobile crash.     

A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function

Hart DL, Wang Y-C, Stratford PW, Mioduski JE. A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function.

Objectives

To describe the use of a computerized adaptive test (CAT) in routine clinical practice and evaluate content coverage and construct validity, sensitivity to change, and responsiveness of hip CAT functional status (FS) measures.

Design

Longitudinal, prospective observational cohort study.

Setting

Two hundred fifty-seven outpatient rehabilitation clinics in 31 states (United States).

Participants

Two samples were examined: intake and discharge rehabilitation FS data from patients (N=8714) treated for hip impairments between January 2005 and June 2007 and data from patients (N=444) used to develop the hip CAT were examined for comparison (2002-2004).

Interventions

Not applicable.

Main Outcome Measures

Hip functional status and global rating of change.

Results

The CAT used on average 7 items to produce precise estimates of FS that adequately covered the content range with negligible floor and slight ceiling effects. Test information functions and SEs supported FS measure precision. FS measures discriminated patients in clinically logical ways. Sixty-one percent of patients obtained discharge FS measures greater than or equal to minimal detectable change (95% confidence intervals). Change of 6 FS units (scale: 0-100) represented minimal clinically important improvement, which 64% of patients obtained.

Conclusions

The hip CAT was efficient; produced valid, responsive measures of FS for patients receiving therapy for hip impairments; and functioned well in routine clinical application but would benefit from more difficult items.     

Spinal Epidural Abscess: A 5-Year Case-Controlled Review of Neurologic Outcomes After Rehabilitation

Koo DW, Townson AF, Dvorak MF, Fisher CG. Spinal epidural abscess: a 5-year case-controlled review of neurologic outcomes after rehabilitation.

Objective

To describe the neurologic outcomes of 29 spinal epidural abscess (SEA) patients after rehabilitation compared with a case-controlled traumatic spinal cord injury (TSCI) cohort.

Design

Five-year retrospective chart review.

Setting

University-affiliated surgical spine unit and inpatient rehabilitation program.

Participants

Patients (n=29; 19 men, 10 women) requiring inpatient rehabilitation after SEA and TSCI case controls (n=29) matched by level of injury, American Spinal Injury Association (ASIA) Impairment Scale (AIS), ASIA motor score (AMS), sex, and age.

Main Outcome Measure

The primary outcome was a change in AMS from acute admission to discharge from inpatient rehabilitation.

Results

Despite having lower admission motor scores, there was a significant trend toward greater neurologic recovery in the SEA group (P=.047). In contrast to what is known regarding recovery from complete TSCI, this study shows potential for dramatic recovery in SEA subjects presenting with AIS grade A deficit with a 73% conversion rate to incomplete status; out of 11 SEA subjects with initial AIS grade A, 2 improved to AIS grade B, 1 to AIS grade C, and 5 to AIS grade D.

Conclusions

This study shows the potential for a significant improvement in neurologic deficits related to SEA. Based on the results of our study, it is clearly inappropriate to generalize recovery patterns seen in the TSCI patient population to SEA-associated myelopathy because the latter appears to have more favorable outcomes.     

The Health and Quality of Life Outcomes Among Youth and Young Adults With Cerebral Palsy

Young NL, Rochon TG, McCormick A, Law M, Wedge JH, Fehlings D. The health and quality of life outcomes among youth and young adults with cerebral palsy.

Objectives

To describe the health and quality of life (QoL) of youth and young adults who have cerebral palsy (CP), and to assess the impact of 3 key factors (severity, age, and sex) on these outcomes.

Design

Cross-sectional survey.

Setting

Participants were identified from 6 children's treatment centers in Ontario.

Participants

The sample of participants (N=199) included youth (n=129; age, 13-17y) and adults (n=70; age, 23-33y) with a broad range of severity: 35% mild, 19% moderate, and 47% severe.

Intervention

Not applicable.

Main Outcome Measures

Health Utilities Index (HUI₃), Assessment of Quality of Life (AQoL), and Self-Rated Health (SRH).

Results

SRH was reported to be excellent or very good by 57% of youth and 46% of adults. Mean HUI₃ scores were .30 for youth and .31 for adults. Mean AQoL scores were .28 for youth and adults. Severity of CP in childhood predicted 55% of the variance in HUI₃ scores and 45% of the variance in AQoL scores. Age and sex were not significant predictors of health or QoL.

Conclusions

The observed health and QoL scores were much lower than those previously reported in the literature. This is likely a result of the inclusion of those with severe CP. The scores for youth were similar to those for adults and suggest that health and QoL outcomes were relatively stable across the transition to adulthood. Youth and adults with CP have limited health status and will require health care support throughout their lives to help them optimize their well being. Longitudinal follow-up studies are essential to understand better the patterns of health in this population over time.     

A Prospective Outcome Study on the Effects of Facet Joint Radiofrequency Denervation on Pain, Analgesic Intake, Disability, Satisfaction, Cost, and Employment

Burnham RS, Holitski S, Dinu I. A prospective outcome study on the effects of facet joint radiofrequency denervation on pain, analgesic intake, disability, satisfaction, cost, and employment.

Objective

To assess the effect of radiofrequency denervation (RFD) on patients with chronic low back pain (LBP) of facet joint origin.

Design

Prospective cohort study.

Setting

Interventional pain management program.

Participants

Consecutive subjects (N=44; 101 facet joints) over 2 years with chronic refractory mechanical LBP of facet origin established by 2 local anesthetic blocks (medial branch ± intra-articular) resulting in more than 50% pain relief.

Intervention

RFD of the symptomatic lumbar facet joints.

Main Outcome Measures

Self-reported pain intensity, frequency, bothersomeness, analgesic intake, satisfaction, disability, back pain-related costs, and employment twice prior to and at 1, 3, 6, 9, and 12 months post-RFD.

Results

Post-RFD, significant improvements in pain, analgesic requirement, satisfaction, disability, and direct costs occurred. They peaked at 3 to 6 months and gradually diminished thereafter. Satisfaction with medical care and living with current symptoms improved similarly. Overall, satisfaction with the RFD procedure was high, and no complications were reported.

Conclusions

RFD provides safe and significant short-term improvement in pain, analgesic requirements, function, satisfaction, and direct costs in patients with chronic LBP of facet origin.     

Inter- and intrarater reliability of the Waterlow pressure sore risk scale: a systematic review

Background

The Waterlow scale is one of the pressure ulcer risk assessment scales which are frequently criticised for their low reliability. It is widely used in the United Kingdom, Europe and all over the world.

Objectives

The study objectives were to systematically review and evaluate inter- and intrarater reliability and/or agreement of the whole Waterlow scale and its single items. The overall aim was to find out if the Waterlow scale is applicable to daily clinical practice.

Design

Systematic review.

Data sources

MEDLINE (1985-June 2008), EMBASE (1985-June 2008), CINAHL (1985-June 2008) and World Wide Web.

Review methods

Selections of relevant studies, data extractions, recalculations of reliability and agreement coefficients, and study quality assessments were independently conducted by two researchers. Designs, methods and results of relevant studies were systematically described, compared and interpreted.

Results

Eight research reports were identified containing the results of nine inter- and intrarater reliability and agreement studies. Only three studies were considered as high quality studies. The Waterlow scale in clinical practice was examined in four studies. Interrater agreement for the total score varied between 0% and 57%. Taking into account any differences of up to two points the total score agreement increased to up to 86%. Median ranges of differences among raters scoring single items were high for ‘poor nutrition’, ‘skin type’, and ‘mobility’. Recalculated intrarater reliability for one researcher was ICC(2, 1) = 0.97 (95% C.I. 0.94-0.98).

Conclusions

Empirical evidence is rare regarding reliability and agreement among nurses when using the Waterlow scale in clinical practice. Interrater agreement for the total score is comparable to other pressure ulcer risk assessment scales. The interrater reliability has never been examined. Therefore, evaluation of reliability and agreement and evaluation of the applicability of the Waterlow scale to clinical practice are limited. It is very likely that the items ‘poor nutrition’, ‘mobility’, and ‘skin type’ are the most difficult items to rate.     

A Comparison of Functional Electrical and Magnetic Stimulation for Propelled Cycling of Paretic Patients

Szecsi J, Schiller M, Straube A, Gerling D. A comparison of functional electrical and magnetic stimulation for propelled cycling of paretic patients.

Objective

To compare isometric torque and cycling power, smoothness and symmetry using repetitive functional magnetic stimulation (FMS) and functional electrical stimulation (FES) in patients with paretic legs with preserved sensibility and in patients without sensibility.

Design

Repeated-measures design.

Setting

Laboratory setting.

Participants

Eleven subjects with complete spinal cord injury (SCI) and 29 subjects with chronic hemiparesis (16.6±5.5mo poststroke) volunteered.

Interventions

Using a tricycle testbed, participants were exposed to isometric measurements and ergometric cycling experiments, performed during both 20Hz FMS and FES stimulation. Subjects with hemiparesis and with complete SCI were stimulated at maximally tolerable level and maximal intensity, respectively.

Main Outcome Measures

Maximal isometric pedaling torque and mean ergometric power, smoothness, and symmetry were recorded for voluntary, FES, and FMS conditions.

Results

Two different patterns of the efficacy of FMS were identified. (1) Patients with complete SCI did not benefit (less torque and power was evoked with FMS than with FES, P<.003 and 10⁻⁴ respectively). (2) Patients with hemiplegia and preserved sensibility could improve their torque output (P<.05), smoothness, and symmetry of pedaling (P<.05) with FMS more than with FES.

Conclusions

FMS is a potential alternative to surface FES of the large thigh musculature in stimulation-supported cycling of patients with partially or completely preserved sensibility.     

Evaluation of consultation training in hypertension care

Background

Nurses in hypertension care play an important role in minimising the risk factors for cardiovascular diseases, but this care can be improved.

Aim

To evaluate the content of nurses' consultations with hypertensive patients before and after consultation training.

Methods

Nineteen nurses from a randomised study of nurse-led hypertension clinics at health centres received three days of residential training in patient-centred counselling and cardiovascular prevention. To assess the result, two consultations with hypertensive patients in clinical practice before and after the training were audio-recorded. Content analysis was used for the analysis.

Results

Diet and exercise were the most frequent topics in the consultations both before and after the training. Discussions about alcohol and the patient's responsibility for treatment increased after the training. The time spent talking about various issues, other health problems, history and appointment scheduling decreased in the consultations after the training.

Conclusion

After the consultation training, the nurses succeeded in emphasising important issues for risk factor control to a greater extent.