Factors influencing decisions about neurogenic bladder and bowel surgeries among veterans and civilians with spinal cord injury.

OBJECTIVE: This study investigated factors influencing surgical decision-making (DM) to treat neurogenic bladder and bowel (NBB) dysfunction for veterans and civilians with spinal cord injury (SCI) in the United States (US). DESIGN: Semi-structured interviews complemented by survey measures. SETTING: Community-dwelling participants who received treatment at a major Midwestern US medical system, a nearby Veterans Affairs (VA) facility, and other VA sites around the US. PARTICIPANTS: Eighteen participants with SCI who underwent surgeries; completed semi-structured interviews and survey measures. INTERVENTIONS: Not applicable. OUTCOMES MEASURES: Semi-structured interviews were coded to reflect factors, DM enactment, and outcomes, including surgery satisfaction and quality of life (QOL). Quantitative measures included COMRADE, Ways of Coping Questionnaire, Bladder and Bowel Treatment Inventory, PROMIS Global Health and Cognitive Abilities scales, and SCI-QOL Bladder and Bowel short form. RESULTS: Themes identified about factors influencing DM included: recurrent symptoms and complications; balancing dissatisfaction with NBB management against surgery risks; achieving independence and life style adjustments; participant's driven solutions; support and guidance and trust in doctors; and access and barriers to DM. DM enactment varied across surgeries and individuals, revealing no clear patterns. Most participants were satisfied with the surgery outcomes. Some differences in demographics were observed between veterans and civilians. CONCLUSIONS: We have attempted to illustrate the process of NBB DM as individuals move from factors to enactment to outcomes. Attending to the complexity of the DM process through careful listening and clear communication will allow clinicians to better assist patients in making surgical decisions about NBB management.

Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial.

OBJECTIVES: To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS). DESIGN: Randomized, single-blinded, multicenter parallel-group trial. METHODS: Patients with SAPS were randomized into the TMEDN group (n = 73) or the NTMEX group (n = 72). Primary outcomes included the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale (GROC) and medication intake. The treatment period was 6 weeks, with follow-ups at 2 weeks, 4 weeks, and 3 months. RESULTS: At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC score of 5 or greater) and stopped taking medication (P<.001). CONCLUSION: Cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling resulted in greater reductions in pain, disability, and medication intake than nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current in patients with SAPS. The effects were maintained at 3 months. J Orthop Sports Phys Ther 2021;51(2):72-81. Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785.

Abnormal orthostatic blood pressure control among subjects with lacunar infarction.

INTRODUCTION: Hypertension is a recognised risk factor for lacunar stroke. However, their association has been evaluated using static blood pressure (BP) assessment in supine or sitting position alone. We hypothesised that impaired dynamic (orthostatic) BP control may associate with lacunar strokes. PATIENTS AND METHODS: Consecutive subjects with mitral regurgitation (MR) confirmed, lacunar strokes were compared with two control groups. Firstly "normal", age and sex matched, population controls (1:3 ratio) and then 'at risk' controls matched for age, sex, hypertension history and antihypertensive medication (1:2 ratio). Orthostatic BP control was assessed by active stand tests with continuous, phasic, beat-to-beat BP measurement. FINDINGS: Thirty-six subjects (mean 69.9 years) were compared with 108 controls in group 1 and 72 in group 2. Prevalence of syncope was higher among those with lacunar stroke (cases: 44.4%, group 1: 17.6%, p = 0.003, group 2: 12.5%, p = 0.0004, Fisher's exact). Mean baseline systolic BP (SBP) was significantly higher in cases (cases: 150 mm Hg, group 1: 140 mm Hg, p = 0.03, group 2: 143 mm Hg, p = 0.1). Ten seconds after standing, SBP dropped significantly less in cases (cases: -14.1 mm Hg, group 1: -31.4 mm Hg, p < 0.0005, group 2: -27.3 mm Hg, p = 0.001, t test). Diastolic BP also fell significantly less in cases. Cases' SBP and DBP recovered to, then persistently overshot baseline levels. DISCUSSION AND CONCLUSION: Subjects with MR-defined lacunar stroke, of likely small vessel aetiology, exhibit orthostatic hypertension compared with population norms.

Actimeter-derived sleep and wake data and nocturnal ambulatory blood pressure estimation in subjects with stroke and transient ischaemic attack.

BACKGROUND/AIMS: Abnormalities in nocturnal blood pressure control identified using ambulatory blood pressure monitoring are associated with adverse cardiovascular outcomes. Sleep and wake episodes during such studies are usually identified by means of sleep diaries but these may be inaccurate in stroke patients. We performed a study to determine whether sleep-wake data obtained using wrist-mounted actimeters would significantly influence the results of routinely performed nocturnal ambulatory blood pressure monitoring when compared with diary-based sleep-wake recording and fixed time-period data. METHODS: Actimetry was performed using a wrist-mounted device during routine ambulatory blood pressure monitoring in subjects who had suffered a transient ischaemic attack or stroke. The mean nocturnal blood pressure readings were calculated using sleep data derived from actimetry and diaries and compared for a fixed time period from 11:00 pm to 8:00 am. RESULTS: Twenty subjects (mean age 68 years, and 13 female) were studied. Patients were found to have slept for a median of six-hours (one- to eight-hours) by diary and five-hours (zero- to eight-hours) by actimeter data. Diary and actimeter data agreed in 69% of recordings. The mean sleeping systolic blood pressure was lower when calculated by actimeter data than by diary data (119·6 mmHg vs. 123·2 mmHg, P=0·049, paired t-test) but there was no significant difference in diastolic blood pressure. The mean nocturnal blood pressure calculated from 11:00 pm to 7:00 am was higher than sleeping blood pressure calculated from diary data. (mean systolic blood pressure: 127·6 mmHg vs. 123·6 mmHg, P=0·065; mean diastolic blood pressure 69·0 vs. 64·0, P=0·028). CONCLUSION: Calculation of nocturnal and sleeping blood pressure is lower in subjects with stroke and transient ischaemic attack when objective actimeter-derived sleep/wake data are used.

Estimated prevalence of fatigue following stroke and transient ischemic attack is dependent on terminology used and patient gender.

INTRODUCTION: The prevalence of fatigue following stroke and Transient Ischaemic Attack (TIA) is disputed, with prevalences ranging from 30% to 72% reported. We hypothesized that methods and descriptors used may substantially affect the prevalence reported. METHODS: Subjects completed validated assessments of fatigue and sleepiness (the Fatigue Severity Scale [FSS] and Epworth Sleepiness Scale [ESS]) as well as 5-point Likert scores on frequency of symptoms using the 5 statements of fatigue derived from patient interviews. RESULTS: Among the 91 subjects, the mean FSS score was 3.8. FSS score correlated more strongly with the statement "I have a lack of energy" (r=0.470; ρ<0.001; Spearman's rho) than with the statement "I feel physical fatigue" (r=0.349; ρ=0.001). The statement "I have a lack of energy" also produced the highest prevalence of severe symptoms, with 37% agreeing that they had the symptom "often" or "always." Agreement between Likert scales was only fair, the best being that for "I have a lack of energy" and "I feel physical fatigue" (κ=0.50). There was a gender difference in simple expression of fatigue, with the statement "I feel physical fatigue" correlating strongly with FSS score in males (r=0.61; ρ<0.001) but not correlating in females (r=0.039; ρ=0.29). Depending on which definition of fatigue was used, the prevalence of fatigue varied between 13% and 63%. FSS score correlated weakly with ESS score (r=0.287; ρ=0.008). Our data indicate significant variation in the prevalence of fatigue among subjects with stroke and transient ischemic attack depending on the descriptors and methods used to define it. CONCLUSION: There is a significant difference between the genders in how fatigue is expressed.