Effect of penetrating trunk trauma on the recovery of adult survivors: a pilot study.

Gunshot and/or stab wounds to the trunk are injuries seen in South African hospitals. Patients are managed in the intensive care unit. Prolonged mechanical ventilation with immobilization results in some degree of muscle dysfunction. Our goal was to determine if patients recover adequately spontaneously following critical illness. No formal rehabilitation programmes exist in South Africa for these patients following discharge. A prospective, observational study was conducted. Patients were recruited from three ICUs in Johannesburg. Lung function tests, dynamometry, quality of life, 6-minute-walk, and oxygen uptake tests were performed over 6 months following discharge from the hospital. The control group consisted of existing data for healthy volunteers. Distance walked during 6-minute-walk test was significantly reduced for the study group compared to the control group (1 month [p = 0.00251]; 6 months [p = 0.0355]). At 1 month there was a significant reduction in quadriceps and triceps strength for the study group compared to the control group (p = 0.0089; p = 0.0246, respectively). Quadriceps strength remained significantly reduced for the study group (3 months [p = 0.0489]). No difference in muscle strength was detected between the groups at 6 months. Actual and predicted residual volumes differed significantly for the study group (1 month [p = 0.0034]; 6 months [p = 0.0157]). A trend of muscle weakness (to 3 months), poor exercise capacity, and abnormal lung volumes was identified. A formal rehabilitation programme may be needed to address these disabilities.

Adherence to cardiovascular risk factor modification in patients with hypertension.

AIM: The effectiveness of the support of a healthcare practitioner and a family member in producing changes in cardiovascular risk factor modification was tested in a randomised, controlled trial in patients with hypertension. METHODS: The primary outcome measured after the 24-week intervention was blood pressure change. Secondary outcomes included patients' adherence to the programme, their knowledge about hypertension, exercise capacity, body weight, self-reported ability to control stress, adherence to medication and salt restriction, as well as symptoms. RESULTS: There were no marked improvements in blood pressure regulation in either group. The differences between the experimental and control groups were 3 mmHg (CI -6.18-12.18) for systolic blood pressure and 4 mmHg (CI -1.48-9.48) for diastolic blood pressure. The estimated blood pressure effects were small increases in both diastolic and systolic blood pressure, due to larger changes in the control group. These small changes were of no clinical significance. This intervention was not successful in reducing blood pressure of hypertensive patients who participated in a lifestyle programme. Secondary outcomes did show positive changes as a result of the given intervention. The absolute difference in improvement between the two groups was significantly greater for the experimental group than for the control group for the following variables: 24% better adherence to the programme (p = 0.007); 10% higher mean percentage score of hypertension knowledge and its management (p = 0.04); 20% more patients could control their stress levels (p = 0.05); 26% more patients could control their salt ingestion (p = 0.02); and 20% had better adherence to their given medication regimen (p = 0.05). The experimental group had a statistically significant weight reduction of 1 (+/- 4) kg relative to the control group (p = 0.03). Both groups increased their exercise capacity during the trial (p = 0.03). On the completion of the intervention, significantly fewer patients in the experimental group than in the control complained of tiredness (p = 0.05). Patients who had a 75% adherence or more to the programme were found to have maintained their knowledge and their exercise capacity, but not their weight loss after a maintenance phase of 12 weeks, during which time there was no intervention. CONCLUSION: Patients in a supported environment such as the one in this study were able to modify their cardiovascular risk factors, even though there were non-significant changes in blood pressure reported in this study.

Predictors of the successful outcome of one-year survivors of coronary artery bypass surgery.

This study was conducted on a South African cohort to establish the actors that may predict the successful outcome of coronary artery bypass surgery when assessed in terms of improved quality of life one year after the surgery. Information was sought on the socio-economic status of patients, their risk-factor profiles and clinical history. From the patient files, information was recorded on left ventricular ejection fraction, number of vessels bypassed, bypass time, and aortic cross-clamp time. The characteristics that were predictive of a successful outcome one year after surgery were identified. Patients in this study represented a high-risk population with multiple risk factors (obese, heavy smokers, hypertensive, hypercholesterolaemic, inactive, family history of heart disease, diabetes, and regular intake of alcohol). Measured medical parameters could not distinguish between the group with an improved quality of life and the group who did not have improved quality of life. One year after CABG all patients with an improved quality of life were men. The additional identified predictor variables for a successful outcome were: being married, patients' height, the knowledge that smoking affects the cardiovascular system, number of years that sporting activities were stopped prior to CABG surgery, a better quality sex life after the operation, acceptance of self-responsibility for rehabilitation, and the spouse knowing the diet the patient should follow. The predictors of a successful outcome at the time of the operation were: being married (OR = 22.6; p = 0.02); taller than 170 cm (OR = 15.5; p = 0.01); stopped all sporting activities for a period less than 20 years prior to their surgery (OR 11.4; p = 0.01). We concluded that the outcome of coronary artery bypass surgery could not be predicted on the basis of a medical model that considers exclusively the extent of the patient's disease and associated co-morbidities. Patients should be carefully selected and an intensive post-operative educational intervention should be provided to patients and their spouses/caregivers.

Effect of exercise versus relaxation on haemoglobin A1C in Black females with type 2 diabetes mellitus.

BACKGROUND: Evidence suggests that populations in Africa develop Type 2 diabetes mellitus (DM) at an increasing rate as they reject their traditional lifestyles. Diabetes is the tenth most common cause for total life years lost in females in South Africa. Physical activity is under-used in the management of type 2 DM in South Africa. AIM: To investigate the efficacy of an exercise intervention programme compared to relaxation exercises to decrease HbA1c over a period of 12 weeks, in type 2 DM female subjects. DESIGN: Single blind, double-intervention randomized trial. METHODS: Clinical measurements were done before and after the 12-week exercise and relaxation interventions. The interventions consisted of education and aerobic exercise for the exercise group, and education and relaxation for the second group. RESULTS: Adjusted baseline HbA1c change from baseline in the exercise group after 12 weeks was -0.39% (95%CI -0.80 to 0.02) and in the relaxation group -0.97% (95%CI -1.38 to 0.55) (p = 0.052). The results for the BMI were -0.07% kg/m2 (95%CI -0.2 to 0.14) in the exercise group versus -0.23 kg/m2 (95%CI -0.44 to 0.02) in the relaxation group (p = 0.28). The difference from baseline in distances covered following the 6 min walk test was statistically significantly greater (p < 0.01) in the exercise group: 46.76 m (95%CI 36.20-57.32) vs the relaxation group 22.7 m (95%CI 12.07-33.33). DISCUSSION: The exercise intervention failed to reduce the HbA1c to a greater extent than in the relaxation control group. Both groups improved significantly from baseline, probably due to the study effect.

Profiling the membership of self-help groups for aphasic people.

We surveyed the membership of aphasia self-help groups in England. We wanted to know what kinds of people become members and the factors associated with taking an active role. So we aimed to describe the membership in terms of age, aphasia severity, physical state, socio-economic status and group roles. We collected data on 135 members and found them relatively less severe but mainly chronically aphasic, living in their own homes and close to the group meeting place, using their own or public transport, with little community or state aid. While hemiplegia was common, few were wheelchair bound. Those taking active roles were younger and less severely aphasic and from more professional and managerial socio-economic groups.

Recovery of walking function in stroke patients after minimal rehabilitation.

BACKGROUND AND PURPOSE: Independent walking function is a highly desired goal amonst stroke victims, and has been well reported in Western literature. However, few studies have investigated the recovery of gait following stroke in Third World countries, where rehabilitation is often minimal or non-existent. METHODS: A descriptive survey, using a structured questionnaire, was conducted on stroke victims, 12-14 weeks post-discharge from the Chris Hani Baragwanath Hospital, Soweto, South Africa. Although the questionnaire included a number of aspects of impairment, disability and handicap, this paper only reports on the recovery of walking function. RESULTS: A total of 361 patients were screened initially. Only 54 fulfilled all inclusion criteria, 38 (70%) were over 50 years of age and 16 (30%) were aged under 50 years. The average length of stay in hospital of the older group was eight days, and in the younger group, 11.5 days. All 54 subjects interviewed were able to walk prior to their stroke. Twelve to fourteen weeks postdischarge, 23 (66%) subjects in the older group and all (100%) of the younger group said they could walk. Half of the older group and nearly all of the younger group could walk outside their homes, unassisted and without appliances. One-third of the subjects experienced knee pain during walking, but only a small percentage said that this pain prevented them from walking. The ability to catch a taxi in Soweto was used as a measurement of the handicap of gait. Twenty (54%) older group subjects and five (31%) of the younger group never caught a taxi. CONCLUSIONS: Although the recovery of gait in these subjects appears to have been good, the results cannot be extrapolated to the stroke population in general due to the stringent selection criteria of the study. Further studies are required to acquire a broader cross-section of the stroke population, including longer follow-up periods to gain insight into the continuation of walking function. This information is necessary in order to plan effective and appropriate rehabilitation services.

Do stroke patients realise that a consequence of hypertension is stroke?

STUDY OBJECTIVE: The specific objectives of the study were to survey residual disability and handicap following stroke. Information on four risk factors, namely hypertension, age, smoking, and alcohol abuse, was obtained. Enquiry was made into the subjects' insight into the causes of their problems. DESIGN: Descriptive survey. SETTING: Baragwanath Hospital and Soweto. PARTICIPANTS: Stroke patients 12-14 weeks post-discharge. OUTCOME MEASURES: Structured questionnaire. RESULTS: A total of 361 patients were initially screened. Only 54 fulfilled all inclusion criteria, 38 (70%) over 50 years of age and 16 (30%) under 50 years. Ninety-three of the 361 died within the first 3 months; 71% of all patients knew that they had suffered a stroke. Only 20% of the total group understood that hypertension had probably caused their stroke, although 76% of the older group and 56% of the younger group had been told at some stage that they were hypertensive. Of the older group 32% knew the name of their medication, 21% could not name their medication and 23% claimed they were on no medication. Similarly in the younger group, 19% could name their medication, 25% could not name their medication, and 12% were on no medication. In addition 16% of the older group and 56% of the younger group admitted to smoking. The abuse of alcohol in both groups was low, but this figure was taken from subjective assessment and may not reflect the true extent of drinking as a risk factor. CONCLUSION: Most patients in this study appear well aware of their hypertension and take medication. However, they seem unaware that their hypertension and stroke are causally linked and their hypertension knowledge is suboptimal. It is also apparent that smoking is increasing as a major risk factor for stroke in the black population of South Africa. Patients need more education regarding hypertension and its consequences.

The exercise capacity of three socio-economic groups of elderly hypertensive patients.

A third of all persons over the age of 65 suffer from hypertension. The incidence in South African blacks is particularly high. Exercise, although effective in lowering blood pressure, has not gained acceptance for its antihypertensive benefits. It would certainly be an inexpensive management option in community-based clinics in South Africa. In this paper, the exercise profiles of a group of elderly hypertensive patients are examined in three different socio-economic settings: a tertiary care hospital (Group 1); an urban community-based clinic (Group 2); and a rural clinic (Group 3). All the patients completed the six-minute walking test and the Duke Activity Status Index (Hlarky et al., 1984). All test values were expressed as means and standard deviations. A p value of < 0.05 was considered significant. Both resting and exercise pulse rates were higher at the urban clinic (p = 0.019). The blood pressure (BP) was higher in the urban clinic, but not significant so. The mean arterial pressure (MAP) of all three groups was high (115 mm HG). The distance covered in the six-minute walking test was surprisingly low at the urban and the rural clinic. Overall, in all three settings patients' hypertension was not well-controlled. The patients were not fit when compared to their age-predicted metabolic equivalent (MET) values. This lack of fitness may indicate that exercise programmes could be of value.

Penetrating stab wounds of the chest--when should chest physiotherapy commence? A comparative study.

In an effort to optimise the physiotherapy management of patients with penetrating stab wounds to the chest, 26 male patients, aged between 18 and 30 years, were randomised to one of two groups on admission to Hillbrow Hospital. The patients in group I received chest physiotherapy immediately after insertion of the intercostal drain, while patients in group II received chest physiotherapy 9-12 hours after insertion of the drain as is currently the normal hospital procedure. Mean duration of intercostal drainage in group I was 40 hours and that in group II 65.92 hours. Patients in group I had significantly shorter intercostal drainage times than patients in group II (P = 0.0001). Patients in group I had a mean hospital stay of 43.96 hours while patients in group II had a mean hospital stay of 77.53 hours (P = 0.0001). There was a significant difference in the duration of hospitalisation between the two groups, this being shorter in group I than in group II. The prevalence of spiking temperatures was also significantly lower in group I than in group II, since only 2 patients in group I but 8 patients in group II developed a spiking temperature (P = 0.0207). This study suggests that an aggressive approach of immediate chest physiotherapy in these patients has definite beneficial results.