The physically disabled medical student

Aims and objectives: The aim of this paper is to explore the stroke literature, with particular emphasis on the management of psycho-social issues during and in the aftermath of stroke rehabilitation. Within the literature, there are a number of studies that indicate that the present 'medical physical' approach to stroke rehabilitation may not be achieving desirable long-term psycho-social outcomes and these are considered. The studies highlight the potential effect of the human emotional and social aspects of having a stroke upon the physical and mental well-being of the person. For the person living with stroke, the ability to maintain a positive sense of direction in life as well as hold onto their, or develop a new, identity is crucial in terms of adapting to change. Holding onto one's self-worth and unity with the past and anticipating the future enhances the ability to cope and adapt in the aftermath of stroke rehabilitation. This links with the investigation into rehabilitation counselling as a potential strategy for the management of long-term psycho-social functional status following stroke. Conclusion: It is suggested that the medical model of stroke rehabilitation places undue emphasis on clinical diagnosis and treatment. By default, measurement of physical independence or disability that is compressed into standardized scales has arguably led to the neglect of the emotional and social consequences of stroke and a partial or inhibited view of the person. It is proposed that there is a need to develop and evaluate the effectiveness of rehabilitation counselling from short-term stroke rehabilitation through to long-term psycho-social adaptation,for this client group to provide clear evidence for service provision.     

Managing symptoms in chronic disease: Some dimensions of patients' experience

This paper is a review of strategics that patients use to manage their symptoms in chronic conditions, with particular reference to multiple sclerosis. It emphasizes the complex and socially conditioned process through which symptoms come to be recognized and managed by patients. This process is compared and contrasted with that of medical recognition of symptoms. A range of patient-based strategies and their implications is then discussed.     

Rehabilitation and resettlement of the working adult in the U.K.

This article presents data on 259 physicians and medical students with a wide range of physical disabilities and specialty training. Three out of four were in active medical practice despite their disability, most often in the specialties of internal medicine, family practice, or psychiatry. Neurological disorders accounted for over half the sample, with spinal cord injury, multiple sclerosis, stroke, and post-polio weakness being the most commonly encountered diagnoses. These data indicate that physically disabled physicians are more numerous than the previous literature would suggest that they are capable of practising in many professional specialties.     

The concept of consequences of disease in patients with low back pain

This paper is based on 212 patients operated on 1 year earlier for lumbar disc herniation. We should have liked to find severity scales for impairment in the ICIDH. The severity scale for disability was not practical for use with low back pain patients. Assignment to the different scale categories of occupation handicap was relatively easy. As a theoretical model of the process of an individual's illness we found it helpful to use that proposed by Purola. The ICIDH concepts seem like a bridge between the medical (internal system) and social connexions (external system) of illness.

Résumé Ce document se fonde sur 212 patients ayant été opérés l an avant d'une hernie discale lombaire. Nous aurions aimé trouver des échelles de gravité de la déficience dans l'ICIDH. L'échelle de gravité de l'incapacité n'est pas d'application pratique pour les patients souffrant de douleurs du bas du dos. L'affectation aux différentes catégories d'échelle de handicap professionnel est relativement facile. Comme modèle théorique du processus de maladie d'un individu, nous avons trouvé utile le modèle proposé par Purola. Les concepts ICIDH semblent représenter une sorte de pont entre connections médicales (système interne) et sociales (système externe) d'une maladie.

Zusammenfassung Diese Untersuchung beruht auf 212 Patienten, die um 1 Jahr früher wegen Lumbalbandscheibenvorfall operiert wurden. Wir waren bestrebt, schwierige Fälle für Verschlechterung in der ICIDH zu finden. Der Grad der Behinderung eignete sich nicht bei Patienten mit Kreuzschmerzen. Die Unterteilung der verschiedenen, berufsbedingten Behinderungen war relativ einfach. Das theoretische Modell von Purola war besonders nützlich für die Krankheitsentwicklung eines Patienten. Das ICIDH-Konzept erscheint wie eine Brücke zwischen medizinischen (internes System) und sozialen (externes System) Zusammenhängen von Krankheiten.

Resumen Esta comunicación está basada sobre 212 pacientes operados l año antes de prolapso de disco lumbar. Nos hubiera agradado encontrar escalas de gravedad de impedimento en ICIDH. La escala de gravedad para incapacitación no se consideró práctica para su uso con personas que padecen de dolor lumbar. La asignación a las distintas categorías de la escala de minusvalidez ocupacional resultó relativamente fácil. Encontramos de utilidad el empleo como modelo teórico del proceso de la enfermedad de un individuo el propuesto por Purola. Los conceptos del ICIDH parecen servir de puente entre las conexiones médicas (sistema interno) y las sociales (sistcma externo) de la enfermedad.     

The physically disabled in the Netherlands -evaluation of the 1971/1972 survey

This article describes a survey to collect information on the physically disabled in the Netherlands, carried out in 1971/1972. Definitions, objectives, and methods are described. Estimated numbers of disabled people in the Netherlands are given, together with their main characteristics in terms of age, sex, kind of functional disorder, and underlying cause. Impaired people are also compared with non-impaired persons in the population, so as to reveal measures of deprivation. The overall results of the survey are then assessed, in terms both of the extent to which the original objectives were attained and of disadvantages encountered. The paper concludes with a discussion of more recent developments, including the introduction of the International Classification of Impairments, Disabilities, and Handicaps, a study of factors determining needs, and a catalogue of requirements for updating, completing, and enlarging the data.     

Preliminary experiences with WHO's ICIDH; a user's report

A simple feasibility study of the ICIDH was conducted: 1148 patients were classified by their physician, the opinion of the physicians about the feasibility of the ICIDH was recorded, and finally 21 patients were classified twice to assess reliability. The results suggest that the I code is feasible for patients with locomotor disorders. The use of the D code presented several problems. It is very time-consuming and reliability of D code assignments seems to be low. The feasibility of the D code can probably be improved if the numerical framework is reshaped. The H code seems to allow for simple meaningful scorings, although we tended to use it as a substitute for the impractical D code, rather than as an indicator of handicap.     

Handicap in stroke survivors

Background and purpose: As survival following stroke improves, individuals are more likely to live with the aftermath of stroke rather than immediately die from it. The purpose of this study was to examine the consequences of stroke on the life activities of survivors in the social realm (stroke handicap) using the framework of the World Health Organization's International Classification of Impairments, Disabilities and Handicaps. Methods: Multivariate analysis of variance was applied to cross-sectional data from a clinical study to investigate the correlates of handicap in a cohort of hemispheric stroke survivors at 3 months (n= 145) and at 1 year (n= 135) after stroke onset. Handicap was assessed with the Reintegration to Normal Living Index, impairment by the Adams' Hemispheric Stroke Scale and Zung Depression Scale, and disability by the Functional Independence Measure. Environmental variables in the model included marital status and receipt of rehabilitation therapy. Results: Physical disability and post-stroke depressive symptoms were associated with handicap at both follow-up periods (p<0.05). Cognitive disability and impairments from a previous stroke were also associated with handicap (p<0.01), but only at 1 year. The presence of a spouse was found to benefit male survivors at 1 year. Conclusions: Disability and depressive symptoms restrict the meaningful life activities of stroke survivors in the first year of recovery. Social supports may be influential in reducing their impact.     

The experience of being disabled and obese

Purpose. This qualitative study was designed to explore the experiences of disabled and severely obese people living in the community. The challenges that their size and disabilities posed within their homes and in accessing community facilities were explored, with particular reference to the provision and use of assistive technologies.

Methods. The study comprised in-depth interviews with a sample of six severely obese, disabled people using a grounded theory approach.

Results. Three key themes emerged: the experience of daily life; accessing services; and responses to challenges. The study participants found that their home and community environments were seldom adequate for their size. Difficulties were identified in relation to accessing and using NHS services and negative attitudes and treatment from staff. Assessments and quality of assistive devices and housing adaptations received were criticised by some. Participants identified a range of responses to these challenges.

Conclusion. The challenges that obesity bring are compounded by disability, including the need for higher levels of care and the higher costs of assistive devices for this client group. The study suggests there may be a need for training for professionals who work with obese, disabled people to ensure their needs are met in appropriate and cost-effective ways.     

The experience of being disabled and obese

Purpose. This qualitative study was designed to explore the experiences of disabled and severely obese people living in the community. The challenges that their size and disabilities posed within their homes and in accessing community facilities were explored, with particular reference to the provision and use of assistive technologies.

Methods. The study comprised in-depth interviews with a sample of six severely obese, disabled people using a grounded theory approach.

Results. Three key themes emerged: the experience of daily life; accessing services; and responses to challenges. The study participants found that their home and community environments were seldom adequate for their size. Difficulties were identified in relation to accessing and using NHS services and negative attitudes and treatment from staff. Assessments and quality of assistive devices and housing adaptations received were criticised by some. Participants identified a range of responses to these challenges.

Conclusion. The challenges that obesity bring are compounded by disability, including the need for higher levels of care and the higher costs of assistive devices for this client group. The study suggests there may be a need for training for professionals who work with obese, disabled people to ensure their needs are met in appropriate and cost-effective ways.     

The assessment of physical independence handicap: experience in a community disablement survey

Two approaches to the ascertainment of physical independence handicap have been explored using data from a survey of disablement in the population. The survey used a two-stage methodology with an initial postal sift to ascertain those with selected disabilities, a stratified random sample of whom were followed-up with an in-depth interview. The first approach to handicap was direct ascertainment of the scale categories by means of a question in the interview schedule. The second approach was to synthesize the scale categories from the answers to interview questions about disabilities in activities of daily living and other relevant factors. The final synthesized algorithm gave a 75% match within one scale point with the direct question and 85% agreement with receipt of attendance allowance, a state benefit paid to those meeting certain criteria for dependence on others. The lessons learned from the work have been incorporated in a revised and expanded scale, which is suggested as a starting point for revision of physical independence dimension of handicap.     

Work profile and functional capacity of formwork carpenters at construction sites

Purpose :This study established a work profile and functional capacity for formwork carpenters (FCs) working at construction sites. Method : Thirty male FCs aged 19-45 were recruited by convenient sampling from the construction training centres. All FCs participated in an interview/questionnaire and a standardized functional capacity evaluation (FCE) using the Baltimore Therapeutic Equipment Primus (BTE Primus) and Valpar Component Work Sample (VALPAR19). Thirty male adults (office workers) aged 19-45 participated in the exact FCE for comparison. Results : The results of the questionnaire indicated that the job demands of formwork carpenters were frequent lifting (46.7%), carrying (50.0%) and handling (60.0%). Significantly higher lifting and carrying capacities were revealed among the FCs, but not in their isometric strengths and the endurance of the upper limbs ( x 2 = 6.48, df = 2, p < 0.05). Conclusions : The dynamic and repetitive sub-maximal nature of the work of formwork carpentry induced an elevation of jobspecific lifting and carrying capacities among the FCs. The job and functional capacity profiles would be useful for formulating guidelines for the rehabilitation of injured workers and the training of new workers in the trade.     

Cervical necrotizing fasciitis: 10 years' experience at a single institution

Objective: To evaluate clinical and microbiologic characteristics, modalities of treatment and outcome of patients with cervical necrotizing fasciitis admitted to our institution. Design: Retrospective clinical investigation. Patients and methods: We reviewed the charts of 20 consecutive patients hospitalized in our Intensive Care Unit between January 1987 and June 1998 with the diagnosis of cervical necrotizing fasciitis. Results: All the patients required mechanical ventilation. Four of them had mediastinal involvement. The organisms most commonly implicated included Streptococcus, Prevotella, and Peptostreptococcus species. Patients with adequate surgery had a better outcome than those with inadequate surgical procedures. Because no evidence-based recommendations exist in the field of head and neck infections, hyperbaric oxygen was not used as adjunctive therapy. Of the 20 patients, 3 (15 %) died. Conclusion: The main finding of this study is that prompt, rather than delayed, surgical débridement correlates with a decrease in morbidity and mortality. However, no definite conclusion is justified due to the relatively small number of patients. Immediate radical débridement, and early redébridement if needed, appropriate antibiotics and intensive care support are critical in controlling these life-threatening infections. Received: 25 November 1998 Final revision received: 7 April 1999 Accepted: 1 June 1999     

Transfusion-associated GVHD: 10 years' experience at the American University of Beirut-Medical Center

BACKGROUND: Although rare, transfusion-associated GVHD (TA-GVHD) is a fatal complication of blood transfusion in which active lymphocytes from the donor attack and destroy recipient organs and tissues. STUDY DESIGN AND METHODS: A search of patient records was carried out at the American University of Beirut-Medical Center, looking for patients who developed TA-GVHD over a 10-year period extending from 1991 to 2001. Relevant information was collected and analyzed. RESULTS: A total of 10 records were found as a result of this search. All were immunocompetent and received fresh nonleukoreduced, nonirradiated blood. The majority received the transfusion at outside periphery hospitals. They received different treatment modalities. The mortality rate was 100 percent. CONCLUSION: TA-GVHD is a serious complication with very high mortality. Effective prevention guidelines should be established in Lebanon including irradiation and the creation of a central blood bank.     

The 1981 Philip Nichols Memorial Lecture

The level of functional achievement gained during a rehabilitation programme provides the basis for supplying aids and requesting community services on discharge. In a study of follow up regimes for patients with rheumatoid arthritis a comparison was made between functional assessments in hospital before discharge and at home shortly after discharge. A small number of the activities assessed showed a significant change at home and these changes were all towards a lower level of independence.     

Splenic artery aneurysms encountered in the ED: 10 years' experience

Objective

Our objective was to report 7 cases of splenic artery aneurysm (SAA) encountered in the emergency department (ED).

Methods

A retrospective survey of our ED database revealed 7 cases of SAA (6 men, 1 woman; mean age, 56 years) of 651 347 ED visits over the last decade. Their clinical and imaging features, management, and outcomes were evaluated.

Results

Splenic artery aneurysm in the ED was rare (prevalence, 0.011%). Common presentations included acute abdomen (n = 5) and shock (n = 2). Five cases had liver cirrhosis and portal hypertension. Abdominal radiographs (n = 7) revealed 2 atherosclerotic patients with SAA. Abdominal computed tomography (n = 7) depicted all SAAs (size, 1.5-8 cm; mean, 3.8 cm). Four ruptured SAAs were successfully managed with coils embolization. Among them, 1 patient with ruptured mycotic SAA also received surgery, but the patient died of Klebsiella sepsis 3 months later.

Conclusions

In the ED, ruptured SAA should be included as a rare differential consideration of acute abdomen, especially in middle-aged men with liver cirrhosis and portal hypertension. Although SAA may be an unexpected computed tomographic finding, once diagnosed, endovascular treatment is recommended.     

The sexual behaviour of physically disabled adolescents

Introduction.?Risky sexual behaviour is a major factor contributing to the increasing prevalence of HIV/AIDS in South Africa. A large national survey of adolescent's sexual behaviour was undertaken in 2002, however adolescents with disabilities were excluded from this study. The aim of this study is to compare the sexual behaviours of adolescents with physical disabilities to those of their non-disabled peers.

Methodology.?A cross-sectional sample was drawn from learners with physical disabilities between grades 8 and 9 in Cape Town. Data were collected using the South African youth risk behaviour survey adapted by the medical research council of South Africa.

Results.?There were responses from 91 participants, of which 56% were males. Approximately, one quarter of the special school sample reported sexual activity compared with one third of the national sample; the difference approached significance. As with the national sample, relatively few adolescents thought they were likely to contract HIV in their lifetime (12%). Fifty percent of the sample claimed that they were able to protect themselves against contracting HIV compared with 66% of the adolescents without disability. The percentage reporting two or more sexual partners in the special schools (27%) was about half that of the national sample (53%). There was little difference in the percentages reporting substance abuse related to sexual activity (14% compared with 15%) and the national sample reported more regularly use of condoms (Special school 18% compared with 25%).

Discussion.?Disabled adolescents are indulging in risky sexual behaviours, and are at equal risk as their non-disabled peers of developing HIV.

Conclusion.?Adolescents with disability must not be excluded from main stream research and health promotion activities specifically related to sex education.     

The Parkinsonian and driving

A survey of 15 members of branches of the Parkinson's Disease Society was undertaken by a medical student as part of a course in social medicine. Most of the individuals had given up driving a car but only a third of the group had notified the Driving and Vehicle Licensing Centre of their disorder, which they are required to do; similarly, most had neglected to inform their insurance companies of the diagnosis. Four people admitted that Parkinson's disease had been a contributory factor in an accident involving another vehicle, and anxiety over being a hazard was admitted by most of the group. Giving up driving exacerbated the premature social ageing encountered in Parkinson's disease, and those afflicted should be encouraged to liaise more closely with arrangements for re-education in methods of safe driving.     

Impairment,disability, and the ICIDH model I: The relationship between impairment and disability

The conceptual scheme put forward in the International Classification of Impairments, Disabilities, and Handicaps suggests that impairment should be related to disability. This paper examines the proposition that disability should be related to impairment in terms of parts of the body involved, both in the physical requirements to carry out a given activity and as regards the site and types of functional limitation, by secondary analysis of data collected in a survey of disabled people in Great Britain. Factor analysis of data on functional limitations showed that these impairments could be considered in four groups representing manual dexterity, movements of the arm, strength, and lower limb function. These were found to be correlated with ability in self-care activities depending on the part of the body involved in the activity.