A child with spina bifida, cerebral palsy and juvenile rheumatoid arthritis: rehabilitation challenge.

PURPOSE: A child with spina bifida, cerebral palsy and juvenile rheumatoid arthritis is presented, and strategies to approach a patient with multiple paediatric onset disabling conditions with possible overlaps are discussed. CONCLUSION: The value of multidisciplinary team approach including physiatrist, physical therapist, occupational therapist, rehabilitation nurse, prosthetist-orthotist, psychologist, speech-language pathologist, paediatric rheumatologist, social worker, kinesiotherapist, dietitian, recreation therapist, dentist and other disciplines as required is emphasized.

Roadmap to physical medicine and rehabilitation: answers to medical students' questions about the field.

Medical specialty training has undergone dramatic changes in the last 5 yr. This article was prepared by the Undergraduate Education Committee of the Association of Academic Physiatrists in an attempt to help guide medical students who are considering a career in physical medicine and rehabilitation. This report is an update of two previous articles addressing medical students' questions to assist them in making educated decisions about residency training and medical practice.

Malone antegrade continence enema for adults with neurogenic bowel disease.

PURPOSE: We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS: Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS: Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS: Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.

Primary care for persons with disabilities. The physiatrist's perspective.

It is difficult for many persons with physical disabilities to find and access primary health care. This article discusses this problem from the perspective of a physiatrist. It discusses the components of primary health care and then compares and contrasts the current status of the training, skills, and interest levels of generalist physicians and physiatrists in providing primary medical care for disabled persons. It includes a discussion of the artificiality of the specialist/generalist dichotomy and the concept of specialists providing true primary care to certain patient populations. General and personal strategies are suggested to influence and to change the health care system so disabled persons can find and have improved access to good primary health care.

Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes.

Bowel incontinence is a major social impairment for 90% of patients with spina bifida. This study assess the bowel continence of children and young adults with spina bifida before and after a toileting intervention that emphasized patient/family education and a regular, consistently timed, reflex-triggered bowel evacuation. Bowel continence defined as one or fewer incontinent stools per month, rose from 13% (5/40) to 60% (24/40) following intervention. Twenty-four of the 35 initially incontinent patients were compliant. Seventy-nine percent (19/24) of the compliant subjects achieved continence whereas 0/11 of the noncompliant subjects achieved continence p < 0.0001). Presence of the bulbocavernosus (BC) and anocutaneous (AC) reflexes correlated significantly with achieving continence (either vs none p < .02, AC vs no AC p < .01). Instituting bowel training before age 7 correlated with improved outcomes by means of better compliance. Excluding noncompliant subjects, 83% (24/29) of the original sample of 40 patients satisfied our strict definition of bowel continence after this simple low technology intervention.

Geriatric rehabilitation. 3. Mid- and late-life effects of early-life disabilities.

This self-directed learning module highlights mid- and late-life effects of early-life disabilities. It is part of the chapter on geriatric rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article contains information on how to evaluate, prevent, and manage late complications seen in adults and older adults with cerebral palsy, spina bifida, spinal cord injury, multiple sclerosis, juvenile rheumatoid arthritis, and early-life amputations, including psychosocial and other quality-of-life issues. New advances in post-polio syndrome are also covered.

Geriatric rehabilitation. 2. Diagnosis and management of acquired disabling disorders.

This self-directed learning module highlights the diagnosis and rehabilitation management of acquired disabling disorders. It is part of the chapter on geriatric rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article contains information on the physiology of aging; rehabilitation management of pathologic conditions of the older adult affecting the cardiovascular, pulmonary, skeletal, connective tissue, and neurologic systems; rehabilitation issues relating to psychologic functioning of the older adult; pharmacologic concerns of the older adult; and response to illness with aging.

Geriatric rehabilitation. 4. Assessment, preservation, and enhancement of fitness and function.

This self-directed learning module highlights the assessment, preservation, and enhancement of fitness and function in the older adult. It is part of the chapter on geriatric rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article contains information on functional assessment, deconditioning, exercise testing and physiology, gait disorders and falls, sports injuries, and industrial injuries in the older adult.

Aerobic capacity with two leg work versus one leg plus both arms work in men with peripheral vascular disease.

The purpose of this pilot study was to examine the correlation between ergometry in men with peripheral vascular disease exercising with both legs and with one leg and both arms. Fifteen men with peripheral vascular disease performed three symptom-limited exercise tests on an ergometer that could be operated from a wheelchair with both legs or with one leg and both arms. The three exercise conditions were both legs (arms stabilized), left leg plus both arms, and right leg plus both arms. The exercise parameters compared were maximum oxygen consumption, maximum heart rate, and duration of exercise. Blood pressure was monitored at two-minute intervals and oxygen saturation and electrocardiogram were monitored continuously. The mean VO2 max +/- standard deviation for both legs, right leg plus both arms, and left leg plus both arms were 14.36 +/- 6.15, 14.86 +/- 4.09, 14.01 +/- 4.14 ml O2/kg-min, respectively. The mean duration of exercise +/- standard deviation were 12.01 +/- 5.74, 10.94 +/- 4.68, and 9.81 +/- 4.70 minutes respectively. The mean maximum heart rate +/- standard deviation were 126 +/- 24, 137 +/- 23, 136 +/- 23, respectively for the same exercise conditions. The Pearson Correlation Coefficients for VO2 for both legs versus right leg plus both arms and left leg plus both arms were .639 and .873, respectively. The Pearson Correlation Coefficients for duration of exercise for both legs versus right leg plus both arms and left leg plus both arms were .837 and .877, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Guillain-Barré syndrome in children: evidence of axonal degeneration and long-term follow-up.

A retrospective study was done of 12 children who met the NINCDS clinical criteria for the diagnosis of Guillain-Barré syndrome and who were hospitalized with this diagnosis. Electrodiagnostic testing was sufficiently complete for interpretation of the neuropathophysiology in six children. Long-term outcome was determined through examination by a physician one to eight years after onset in all six children, and was supplemented by telephone follow-up with the children or their parents by the authors five to eight years after onset. Long-term clinical outcome was analyzed for any correlation between poor outcome and axonal degeneration. The electrodiagnostic tests were consistent with primarily axonal neuropathophysiology in three of the six children. Poor clinical outcome appeared to correlate with electrodiagnostic evidence of primarily axonal pathophysiology, or absence of an evoked M-response, or both.

Cortical thumb orthosis for children with spastic hemiplegic cerebral palsy.

An orthosis was developed to control the position of the indwelling "cortical" thumb and improve function of the spastic hand of children with spastic hemiplegic cerebral palsy. A clinical evaluation was made of five children, 20 to 26 months old, with mild to moderate spastic hemiplegic cerebral palsy. All five children exhibited an indwelling thumb at rest and during reaching and grasping activities, using a "raking," ulnar type of prehension pattern. In all five children the orthosis was effective in changing the position of the thumb and improving the prehension pattern to a radial grasp in which objects were held between the thumb and the fingers, usually in a three-jaw chuck or large cylindrical prehension pattern, depending on the size of the object being manipulated. Possible explanations for the improved hand function include placement of the thumb in a more functional position, inhibition of muscle tone in thumb adductors and flexors, and the opportunity for increased sensory input and successful practice using the hand.

Self-directed learning and medical rehabilitation: a comparison.

A comparison is made between medical rehabilitation and continuing medical education (CME). It is hypothesized that such a comparison can help physicians who have little formal training in educational methodology to become more efficient and effective in carrying out their own self-directed learning. This hypothesis is based on the premise that the decision-making processes are similar for managing the medical rehabilitation of a patient and for carrying out self-directed CME.

Electric cart modification for boy with hip extension contractures.

A 7-year-old boy with Schwartz-Jampel syndrome was evaluated for a mobility and seating device. Assessment results indicated reduced upper and lower extremity function due to tight stiff muscles, labored and slow movements, hip extension contractures, asthmatic and restrictive pulmonary disease, and normal intelligence. Due to the combination of severe musculoskeletal and pulmonary disease, he had not been able to attend school or interact normally with his environment. Ambulation for more than a few feet was precluded by reduced pulmonary capacity and stiff, slow muscle movements which did not improve with medication. Because of hip extension contractures, he could not sit upright in a chair. An Amigo electric cart with a modified straddle seat enabled the patient to sit upright, attend school, and explore his environment with greater mobility. The unit is simple to operate, adaptable, and cost effective.