Nerve and muscle disorders and their sequelae.

A number of diseases of the nervous system, especially upper neuron lesions, produce ankle and foot deformities. Such deformities can be the single most important reason why some patients become nonambulatory. This article reviews the impact of upper motor neuron lesions such as traumatic brain injury, stroke, multiple sclerosis, neurodegenerative disorders, and low motor neuron lesions such as peripheral nerve injury, neuropathy, entrapment syndromes, and muscle diseases. This article also reviews diagnostic tests including EMG and nonsurgical management.

A computerized technique for analyzing lateral bending behavior of subjects with normal and impaired lumbar spine. A pilot study.

STUDY DESIGN: A computerized technique, employing a motion analysis system and a force platform, was developed to analyze lateral bending behavior of subjects with normal and painful spines. METHODS: Lateral bending was quantified using motion (angle and speed of rotation), force (ground reaction kinetics), and biomechanical behavior ("compliance" and "transfer mobility") characteristics of four discrete spinal segments measured during standing, range of bending, and bending at normal and maximum speeds. RESULTS: For subjects with pain, there were reductions in the range of lateral bend (43%) and speed of rotation (39%). Ground reaction moment about the medial-lateral axis was greater (58%), whereas that about the anterior-posterior axis was less (28%). "Compliance" was less (25%), whereas "transfer mobility" was greater (24%). CONCLUSIONS: The findings suggest that the characteristics of lateral bending, rather than range of motion, is most affected in subjects with pain.

Seating and wheeled mobility in the disabled elderly population.

Elderly persons constitute the largest among the populations regularly using wheelchairs. This is a review of the few studies specifically concerned with seating for the elderly; it identifies current problems, particularly in the seating for aged people who are in long-term care facilities. This review describes ways of matching currently available seating technology with the needs of disabled elderly persons. Two major barriers to greater use of newer seating technology are (1) the high cost of durable medical equipment and (2) the failure of most clinicians and institutional administrators to recognize the importance of posture and comfort to provide functional independence in wheelchair users. This review discusses seating for four groups of elderly persons: (1) the nonmobile, dependents who may be safety risks and are without energy or ability to wheel or walk by themselves; (2) mobile nonambulatory; and (3) ambulatory, but with special wheelchair needs. Research is needed in wheeled mobility in a number of areas: better matching of mobility to function, cheaper and more effective cushions, more modular seating systems, and better lifting and transfer devices. The American National Standards Institute in cooperation with Rehabilitation Engineering Society of North America has recently recommended standards for wheelchair performance that may be legislated in the next few years.

Prevención de caídas en personas de edad avanzada

Las caídas constituyen los accidentes más frecuentes en la población geriátrica y en muchos casos dichos accidentes son fatales o, cuando menos, severamente incapacitantes. El proceso de envejecimiento con lleva disminución paulatina de innumerables funciones vitales, específicamente y en primer lugar de funciones motoras, sensoriales y de autorregulación cuya alteración hace que las personas de edad avanzada tengan un mayor riesgo de sufrir accidentes como consecuencia de su menor capacidad de reacción cuando fuerzas externas o su propio peso los lleva a perder el equilibrio. En este artículo se revisan las causas principales del mayor número de caídas en los pacientes de edad avanzada y la manera de prevenirlas.

Nonarticular complication of heterotopic ossification: a clinical review.

Heterotopic ossification (HO) is a complication in neurologic lesions such as head injury and spinal cord injury. Limitation of range of motion and ankylosis as results of HO are well documented. In this report, ten instances of nonarticular complications after development of HO are described. There were three instances of vascular compression, five instances of ulnar nerve compression at the elbow, and two instances of suspected lymphedema. Clinical findings and radiographic evidence of these complications are described. Clinicians should be aware of these complications when HO is diagnosed. In addition, HO should be considered in the differential diagnosis of deep venous thrombosis in spinal cord injured and head injured patients.

Dystonia musculorum deformans: three cases treated on a rehabilitation unit.

Dystonia musculorum deformans is a rare involuntary movement disorder of unknown etiology. We treated three brothers in one family on our rehabilitation unit, resulting in definite improvement in their ability to walk and control the dystonic movements, and in their speech and swallowing. All three benefited from orthoses to prevent equinovarus and maintain ankle stability. Intense concentration, such as needlepoint, seemed to reduce the amount of extra motion. Performing another activity during dystonic movements, such as pointing to a communication board, also seemed to give some relief. A special seating system using a collapsible wheelchair, a low center of gravity, and antitip wheels reduced one brother's frequency of falling. Swallowing finely cut foods was not a problem with any of our patients, although one had to be instructed in a special technique. An electronic communication board was very helpful. Our success in these cases should encourage others working in rehabilitation to consider such patients and to apply the principles of rehabilitation, particularly the total team approach, in their care.

Transient locked-in syndrome and phenobarbital.

Locked-in syndrome is a rare syndrome characterized by quadriplegia, intact consciousness, mutism, and communication using vertical eye movements. We report the case history of a patient with transient locked-in syndrome following repeated shunt procedures for idiopathic aqueductal stenosis. Communication was with lateral eye movements. Although she eventually recovered and regained functional independence, high doses of phenobarbital, given to prevent seizures, sedated her and obscured her mental status during her rehabilitation. We urge the careful monitoring of all centrally acting agents in patients with locked-in syndrome.

Effects of alcohol on bone, muscle and nerve.

The acute and chronic effects of alcohol on bone, muscle and peripheral nerves are not well appreciated. Bone complications include traumatic fractures, osteoporosis and osteonecrosis. In muscle, a sustained bout of heavy drinking may cause rhabdomyolysis, while chronic alcohol abuse may produce proximal myopathy. In peripheral nerves, acute alcohol intoxication may lead to pressure neuropathy and chronic abuse may cause peripheral neuropathy.

Spinal cord injuries following electrical accidents.

Injuries from high tension electrical current result in approximately 1000 deaths per year and account for 3% of all major thermal injuries in the United States. Even though the complications from electrical injury can affect almost every organ system in the body, a neurological complication is perhaps the most common non-lethal one. 116 cases of electrical accidents among 1206 burn patients admitted to Kansas University Medical Center were reviewed. There were 5 cases of spinal cord injury which were detected from a few days up to four weeks from the injury. All had incomplete lesions. Two of them had quadriparesis, and 3 paraparesis. Clinical manifestations included motor and sensory involvement, predominantly motor. Possible mechanisms for the spinal cord damage include heating effect, electrogenic changes and vascular damage. Spinal cord injury following an electrical accident is more frequently encountered than is generally recognized.

Management of the diabetic foot.

Foot disease in diabetics is caused by peripheral neuropathy and peripheral vascular disease. Initial evaluation involves repeated physical examinations, including careful inspection for infection, and Doppler analysis of perfusion. A tracing of the ulceration should be obtained so that healing can be monitored. Properly fitting shoes are imperative for prophylactic care. Shoe modification is possible using moldable plastics and metatarsal bars. Patient and family education are also important elements of management.

Evaluation of Moto-Stand a new vehicle for upright ambulation in paraplegics.

The Moto-Stand is a motorised vehicle to propel paraplegics in the upright position. It safely allows handicapped persons a wide range of working capabilities and extends mobility far beyond the limits of a wheelchair. Twenty adults with spinal lesions were evaluated for using the Moto-Stand. The levels of lesion ranged from C6 to L1. The tetraplegics studied had incomplete lesions and they could get on the Moto-Stand but needed some assistance. All the paraplegics studied were able to use the Moto-Stand independently. The Moto-Stand was found to be superior for kitchen activities, especially when handling hot objects and reaching objects at different levels. As it turns in its own space it offers superior maneuverability in the limited space of a kitchen, workshop or even a trailer home. Subjects with moderate to severe spasticity appear to have difficulty in using the Moto-Stand, It was found to be safe and comfortable by the majority of subjects studied.

Experience of a seating clinic.

Patients who cannot walk, particularly those with orthopaedic deformities, need more than a simple wheelchair; they require a special seating system. Since the early 1970's many different systems have been introduced to the field of orthotics and prescribed through "Seating Clinics" in many centres in North America and around the world. Our experience in the Seating Clinic at the University of Kansas Medical centre is presented. Most patients were children (70%) with 69% male and 31% female. Various seating systems were prescribed, including the Safety Travel Chair, the Moulded Plastic Insert, the Orthopaedic Body Support (foam on plywood), the Spinal Support System, the Moulded Seat Total Contact Shell (sitting support orthosis) and the DESEMO support system. The majority of patients had cerebral palsy (58%) and muscular dystrophy (33%). Other conditions included spinal cord injury, spina bifida and multiple orthopaedic deformities. Sixty five percent of the custom made seating systems prescribed were the Orthopaedic Body Support. Unilateral dislocation of the hip presents a major problem in seating because of pelvic obliquity.

Rehabilitation of hip fractures in the elderly.

Hip fractures in the elderly carry a high rate of morbidity and mortality. Most hip fractures require immediate surgical intervention. An intensive period of rehabilitation helps reduce complications. Management of the whole patient--including treatment of any preexisting medical conditions, attention to nutrition and conditioning exercises--is essential for a good outcome. Success depends more on careful follow-up during rehabilitation than on the nature of the surgical repair.

Hydrogen peroxide: potential for prophylaxis against bacteriuria.

The effect of dilute solutions of hydrogen peroxide, povidone-iodine, and acetic acid on a chronic Staphylococcus epidermidis bacteriuria was studied to determine whether direct bladder instillation of the antimicrobial solutions would reduce or eliminate the bacterial count. In vivo instillation of volumes ranging from 50 to 400ml and retained for 30 seconds to 48 hours was evaluated. The effect of the antimicrobial solution on bacterial survival in urine was also measured in vitro through quantitative analysis of the mixture at various times over 24 hours. Instillation of the antimicrobial solutions into the bladder had no measurable effect on the established bacteriuria. Symptoms of discomfort related to such a manipulation were least evident with hydrogen peroxide. In vitro, hydrogen peroxide had an antimicrobial effect as reflected by the reduction of the number of surviving organisms. Despite inefficacy in a case of already established bacteriuria, hydrogen peroxide appears worthy of study as a prophylactic agent against a variety of organisms because it exhibits in vitro efficacy and minimal in vivo symptoms.

The therapeutic effects of a playground apparatus on children with behavioral problems.

The " Moonwalk ," an apparatus consisting of an air-filled trampoline, was evaluated as a reward for children with emotional and behavioral problems. Two age groups of hospitalized children, 23 aged 5 to 12 and 12 aged 13 to 18, were evaluated utilizing (a) a 26-item teacher's rating scale; (b) a 4-item, 5-point scale to assign ratings to the students before and after the Moonwalk activity; and (c) the students' response to a 7-item consumer questionnaire. Teacher observers found the younger age group showed improvement in behavior at school after the Moonwalk was offered as a reward. The Moonwalk , as a reinforcement, offered a simple method to improve emotional or behavioral problems in an institutional setting.

Transcutaneous nerve stimulation in rheumatoid arthritis.

This study of the effects of transcutaneous nerve stimulation (TNS) on 20 wrists of 11 men with rheumatoid arthritis was designd to make an objective assessment of pain and also to evaluate placebo effects. Following determinations of the length of time each wrist could support a small weight before pain began or increased (loading time), a 3-part test was conducted using the same weight in each case. (1) Each wrist was treated by TNS for 15 minutes and then, with the stimulator still on, loading time was determined (TNS-1). (2) With the stimulator working on the same wrist as for TNS-1, the loading time of the opposite wrist was determined (TNS-2). (3) To study placebo effect, loading time was again determined with the same adjustment on the stimulator but with the battery removed (TNS-3). If the loading time doubled or more, the pain relief was considered to be 100%. From the results (70% of the TNS-1 wrists had 50 to 100% pain relief; 10% of the TNS-2 and 15% of the TNS-3 wrists had some improvement), TNS appears to reduce joint pain and to offer a supplement to antiinflammatory drugs.

Standing balance in healthy boys and in children with Duchenne muscular dystrophy.

Balance in double stance was measured on a force platform with an X-Y Plotter (stabilograph) in 57 healthy boys aged 5 to 10 years and in 13 children with Duchenne muscular dystrophy (DMD), aged 6 to 15 years. Horizontal excursions of the center of gravity were measured in the anteroposterior (AP) and right-left (RL) planes. Measurements superimposed upon foot position tracings were compared with a potential excursion defined by the outer margin of foot position. Balancing ability was expressed as a ratio of measured excursion to potential maximal excursion. The objective was to determine whether a quantitative functional measure relating to muscle weakness and standing could be obtained. The mean ratio of AP excursions for healthy children was 0.5 (range 0.29 to 0.7); for dystrophic children 0.29 (range 0.07 to 0.57). The mean ratio of RL excursions for healthy children was 0.57 (range 0.23 to 0.77); for dystrophic children 0.36 (range 0.1 to 0.63). These ratios tended to increase with age in healthy children but decreased in those with dystrophy. DMD children have less ability to move the horizontal center of gravity within the base of support on double stance than their healthy peers of comparable age. Stabilography may be useful not only for assessing balance and documenting its deterioration but also for evaluating the effectiveness of treatment in DMD.

Physiatrists: career development and professional interests.

A total of 1,080 physiatrists were asked to respond to a questionnaire which covered various aspects of career development and vocational interests in Physical Medicine and Rehabilitation (PM&R). The data from the 486 usable responses were analyzed on the basis of several factors including nationality, mode of entry into the specialty, time distribution between graduation and entry into specialty, and professional interests. A large majority (98.8%) expressed good job satisfaction and optimism about the specialty's future. Of the 486 responders. 68 (14%) were women and 481 (98.2%) were MDs of whom 170 (35%) were foreign trained. Nearly 78.4% of the sample had left another medical field in favor of PM&R. As compared with a similar study in 1968, the present study showed a threefold increase in physiatrists going into private practice, a twofold increase in participation in a purely rehabilitation setting, and a decline in the percentage of physiatrists in academic and research areas.

Rehabilitation of the elderly stroke patient.

Early organization of a coordinated effort is essential in rehabilitating the stroke victim. The basic team, in addition to the attending physician, usually consists of a physical therapist, an occupational therapist and a rehabilitation nurse. A speech pathologist, a social worker, a dietitian or an orthotist may also be needed. Contractures, decubitus ulcers, thrombophlebitis and urinary tract infections can be avoided by vigorous attention to nursing details immediately after the stroke.