Mobility after hip fracture predicts health outcomes.

OBJECTIVES: Balance and gait are essential to physical functioning and the performance of activities of daily living. The objective of this study was to determine the predictive value of a balance and gait test on subsequent mortality, morbidity, and healthcare utilization among older hip fracture patients. DESIGN: A prospective study of hip fracture recovery. SETTING: Patients with a new hip fracture admitted from the community to one of eight Baltimore hospitals and followed in their homes for 2 years postfracture. PARTICIPANTS: A total of 306 patients with hip fracture, 65 years of age and older, who completed a gait and balance assessment at 2 months postfracture. MEASUREMENTS: The relationship between gait and balance test performance at 2 months postfracture and mortality, physician visits, rehospitalizations, nursing home placement, and falls up to 24 months postfracture was assessed by Cox proportional hazards and least squares regression. RESULTS: After adjusting for age, sex, race, and comorbidity, the balance score and the summary mobility score predicted mortality. A 17% increase in the risk of mortality was demonstrated for each unit decrease in the balance score (range 0-17), and a 10% increase was demonstrated for each decrease in the summary score (range 0-26). Unsteady balance during immediate standing, turning, sitting down, and rising from a chair were associated significantly with increased mortality. Poor balance, but not poor gait, was associated with an increase in hospitalizations up to 24 months postfracture. Both poor balance and poor gait were associated with nursing home placement, with 20% and 17% increased odds, respectively. Mobility did not predict future physician visits or falls. CONCLUSIONS: These findings demonstrate that balance and gait are predictive of future health outcomes for older hip fracture patients.

Recovery from hip fracture in eight areas of function.

BACKGROUND: This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. METHODS. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990-1991 were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. RESULTS: Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months). CONCLUSIONS: Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.

Rehabilitating older patients: primary care evaluation, treatment, and resources.

Elderly patients with functionally significant disabilities and handicaps may benefit from a comprehensive rehabilitation program. Patients may be treated while hospitalized or as outpatients. Age itself is not a contraindication to such a program and impaired mentation is not an absolute contraindication. Physiologic changes of aging may adversely affect function, but these effects may be partially reversible (if exacerbated by inactivity)--or may be compensated for by appropriate training. Emphasis is on functionally significant goals that can be achieved within a generally predictable period of time. The achievement of these significant goals would allow the patient to remain in or return to a home setting and avoid institutionalization. Through informed patient assessment and referral, the primary care physician can make optimal use of this resource.

Spinal anesthesia versus general anesthesia for hip fracture repair: a longitudinal observation of 741 elderly patients during 2-year follow-up.

The Baltimore Hip Studies, a multicenter, noninterventional, observational trial, provided an opportunity to investigate the effects of anesthetic technique on the long-term outcome of elderly patients after hip fracture repair. Detailed interviews assessing functional status and pain were conducted during the hospital stay. Out-of-hospital evaluations were repeated after the procedure at 2, 6, 12, 18, and 24 months with a portable gait and balance laboratory. Multivariate analysis was done to determine the effects of anesthetic technique on functional and other outcomes, after controlling for multiple baseline variables. Of 741 enrolled patients who completed the study, 430 and 311 patients received spinal anesthesia or general anesthesia, respectively. Subgroup analysis of three spinal anesthetics, tetracaine, lidocaine, and epinephrine, was also done. In the present large observational study, general anesthesia was at least as efficacious as spinal anesthesia, and possibly better, in affording good long-term outcome.

Median and ulnar muscle and sensory evoked potentials.

The medical literature was reviewed to find suggested clinical applications of the study of the amplitude of evoked muscle action potentials (MAP) and sensory action potentials (SAP). In addition, the literature was reviewed to ascertain the normal amplitude and duration of the evoked MAP and SAP as well as the factors affecting the amplitude: age, sex, temperature, ischemia. The present study determined the normal amplitude and duration of the median and ulnar MAP and SAP in fifty normal subjects. The amplitude of evoked muscle or sensory action potentials depends on multiple factors. Increased skin resistance, capacitance, and impedance at the surface of the recording electrode diminishes the amplitude. Similarly, increased distance from the source of the action potential diminishes its amplitude. Increased interelectrode distance increases the amplitude of the bipolarly recorded sensory action potential until a certain interelectrode distance is exceeded and the diphasic response becomes tri- or tetraphasic. Artifact or poor technique may reduce the potential difference between the recording electrodes or obscure the late positive phase of the action potential and thus diminish the peak to peak amplitude measurement. Intraindividual comparison indicated a marked difference of amplitude in opposite hands. The range of the MAP of the abductor pollicis brevis in one hand was 40.0--100% of the response in the opposite hand. For the abductor digiti minimi, the MAP was 58.5--100% of the response of the opposite hand. The median and ulnar SAP was between 50--100% of the opposite SAP. Consequent to these findings the effect of hand dominance on the amplitude of median and ulnar evoked muscle and sensory action potentials was studied in 41 right handed volunteers. The amplitudes of the median muscle action potential (p less than 0.02) and the median and ulnar sensory action potentials (p less than 0.001) were significantly less in the dominant hand. There was no significant difference between the ulnar muscle action potentials or for the median and ulnar distal motor and sensory latencies in the right and left hands of this group of volunteers.

Comparison of evoked potentials in the same hand in normal subjects and in patients with carpal tunnel syndrome.

The amplitude of the evoked median and ulnar sensory action potential (SAP) was measured in fifty normal volunteers (4) and median and ulnar SAP in opposite hands were compared. In addition, the amplitude of the median response was compared to the ulnar response. It was found that the lower limit of the range of observations for the median amplitude was 20 muV, the range of observations for the median/median SAP ratio was 50--100%, and that in only 3 observations out of 100 normal hands was the median/ulnar SAP ratio less than 80%. In a series of 60 patients with carpal tunnel syndrome (CTS), 22 had bilateral involvement. The median SAP was obtainable in 62 of these diagnosed cases of CTS. Forty of these 62 cases could be identified by one of the three amplitude criteria: median SAP of less than 20 muV; median/median amplitude percentage of less than 50%; or a median/ulnar amplitude of less than 80%.

Palmar conduction time of median and ulnar nerves of normal subjects and patients with carpal tunnel syndrome.

The wrist-palm conduction time for the median and ulnar nerves was determined using antidromic technique in thirty normal subjects. For the median nerve, the conduction time was 1.6 msec. to initial deflection from baseline and 1.7 msec. to peak of the initial negative deflection for the mean plus 2 SD. The median wrist-palm conduction time was then compared to the difference between the median and ulnar wrist-digit conduction times (mean plus 2 SD of 0.5 msec. measured either to initial deflection or peak negative deflection) in order to determine which technique aids more in the electrodiagnosis of patients with a presumptive clinical diagnosis of carpal tunnel syndrome but which normal distal sensory latencies. It was found in ten patients that the results of these two electrodiagnostic methods paralleled each other, and neither appeared more sensitive than the other in establishing the diagnosis.

Reappraisal of the electroneurographic and electromyographic diagnosis of diabetic peripheral neuropathy.

Twenty, otherwise unselected, subjects with Type II diabetes mellitus were studied using electroneurographic and electromyographic techniques. Latencies, conduction velocities, amplitude and duration of evoked responses and change of amplitude and duration over distance, as well as H reflex and ulnar F wave were determined for motor nerves. Latency to onset and peak of negative deflection and amplitude of the evoked action potential were determined for sensory nerves. Eleven subjects had amplitude and/or latency abnormalities of the sural, superficial peroneal, and median sensory nerves. One additional subject had abnormality of both the sural and superficial peroneal nerves. Five subjects had mononeuropathies and 2 of these also had membrane instability of the abductor hallucis muscle. Ten subjects had clinical or electrophysiologic findings compatible with carpal tunnel syndrome either as an isolated lesion or superimposed on underlying peripheral neuropathy. It was concluded that all subjects with abnormality of 3 sensory nerves (median, sural and superficial peroneal) had findings compatible with diabetic peripheral neuropathy and that additional electrodiagnostic studies (unless otherwise indicated) did not identify additional abnormalities diagnostic of peripheral neuropathy in the remaining subjects.

Handcuff neuropathy: two unusual cases.

Handcuff applications may result in compression of peripheral nerves at the wrist, and most reported cases involve only the superficial radial nerve. In this report, two cases of bilateral handcuff neuropathy involving multiple nerves were confirmed by electrodiagnostic findings of membrane instability, prolonged latencies and/or conduction block. In addition to the superficial radial nerves, one case involved the median nerves, and a second case the ulnar nerves. It was postulated that injury might occur to any nerve at the wrist as a result of pressure and edema from handcuffs, with the radial nerve most frequently involved due to its superficial location. Radial nerve injury has been described as functionally insignificant; however for the two cases presented, in which the median or ulnar nerves were involved, significant disability resulted, and a rehabilitation program was indicated.

Changes in duration and amplitude of the evoked muscle action potential (EMAP) over distance in peroneal, median, and ulnar nerves.

Standard nerve conduction techniques measure the conduction of the fastest conducting axons. Slower conducting axons determine the amplitude, duration, and configuration of the EMAP. Normal data showing the change in amplitude and duration of the evoked EMAP over a length of nerve segment as well as the change per centimeter of that nerve segment has been lacking. This study supplies this data for the peroneal, median and ulnar nerves (tables 2-5) and gives examples of clinical application of these techniques in the diagnosis of compression syndrome and peripheral neuropathies with demyelination. Emphasis is also placed on potential sources of error which may affect the results obtained using these techniques. Further study of the application of these techniques in the diagnosis of neuropathies is indicated.

Sensory conduction in the musculocutaneous nerve.

This report describes an antidromic technique for studying conduction in the sensory branch of the musculocutaneous nerve, the lateral cutaneous nerve of the forearm. Surface stimulation was done at the elbow where the nerve becomes superficial, and surface recordings were made 12 cm distally over the course of the nerve. Sixty nerves in 30 normal persons were examined. The mean latency to onset of the action potential was 1.8 +/- 0.1 msec with a mean conduction velocity of 65 +/- 3.6 meters/sec. Mean amplitude of the action potential was 24 +/- 7.2 muv.

Residency training in physical medicine and rehabilitation. I: Clinical and didactic experience.

A survey was conducted to determine the type of clinical and didactic training experience that was provided to resident trainees in physical medicine and rehabilitation (PM&R) in the 1987-1988 academic year. Chief residents from 43 (61%) of the 70 PM&R programs accredited by the Accreditation Council for Graduate Medical Education responded. According to respondents, the programs averaged 12.6 residents. The residents spent an average of 18.5 months on an inpatient bedservice, 12.6 months on outpatient exposures, and the remainder of the time attending other clinical experiences and didactic training. Forty percent of those responding reported that their programs required in-house call in postgraduate years (PGYs) 2 through 4, and 53% of the programs required no in-house call during the same clinical years. Seven percent of the programs required in-house call in PGYs 2 and 3, but none in PGY 4. The average time spent in electrodiagnostic studies was 7.6 months (range = 2 to 19 months). Electromyography exposure by completion of PGY 4 also varied widely, from 40 to 500 studies. Resident trainee exposure to inpatient and outpatient spinal cord injury, closed head injury, pediatric rehabilitation, sports medicine, and geriatric medicine, and rehabilitation fellowship positions being offered through the responding PM&R residency training programs were also surveyed. Some instances of apparent program imbalances or inadequate training which could reduce the scope of a resident's educational experience were noted.

Radial sensory conduction in the hand.

Radial sensory conduction has traditionally been performed by stimulating the nerve at the wrist, recording from the thumb or the base of the first web space. This paper describes a technique for measuring conduction in the more distal branches on the dorsum of the hand. Comparison is made with dorsal ulnar sensory conduction, and the area supplied by each nerve on the dorsum of the hand is investigated. Radial conduction was found obtainable to the area between the second and third metacarpals (MCPs) in all patients with a velocity of 56.8 +/- 4.2 m/sec. Conduction to the space between the third and fourth MCPs could be obtained in only 65% of the hands with a mean velocity of 58.9 +/- 4.5 m/sec. Dorsal ulnar sensory conduction to the same area was 59 +/- 4.2 m/sec and was present in 73% of the hands. Forty percent of patients have both radial and ulnar innervation to the area between the third and fourth MCPs on at least one side, while 33% have both radial and ulnar innervation to this area bilaterally.

Medication education program in an inpatient geriatric rehabilitation unit.

All patients admitted during a 6-month period to an inpatient geriatric rehabilitation unit were started on a medication education program incorporated into the rehabilitation program and utilizing existing staff. Patients were evaluated at admission, discharge, 90-day, and 1 year follow-up, using an 8-point medication knowledge scale. Of the 62 patients included in this study, at discharge 35 (group I, mean age 75.9) knew their medications and went home, 10 (group II, mean age 76.8) did not know their medications and went home, and 17 (group III, mean age 79.3) did not go home, whether they knew their medications or not. Mean length of stay (days) was: group I-30.9; group II-38.9; group III-33.3. This study describes a program for teaching an inpatient geriatric age group population self-medication management.

Asymmetric hamstring reflexes indicative of L5 radicular lesions.

There is no commonly accepted reflex from L5 innervated muscles. Hamstring muscles are primarily innervated by the L5 and S1 roots. It is shown that in the presence of symmetrically active gastrocsoleus reflexes, asymmetry of the hamstring reflexes indicates an L5 root lesion. We describe a method for eliciting the medial hamstring reflex by percussing the conjoint tendon of the semitendinosus and biceps femoris muscles at the level of the ischial tuberosity. Electromyographic, myelographic, and operative data confirmed the presence of an L5 root lesion in 7 patients with asymmetric hamstring reflexes.

Across-tarsal-tunnel motor-nerve conduction technique.

Tarsal tunnel syndrome is a commonly considered compression of the tibial nerve and its plantar divisions as the nerve curves behind the medial malleolus underneath the flexor retinaculum. Motor, sensory, and/or mixed-nerve conduction studies are used to confirm or exclude the presence of compression of the posterior tibial nerve and its plantar divisions. In previous studies, stimulation has been done either proximal to the tunnel or distally in the sole of the feet or in the toes. Thus, differentiation between compression of the nerve within the proximal tarsal tunnel, as distinguished from compression of the plantar nerves in the distal tarsal tunnel or distal to the tunnel, has not been feasible. In addition, onset latency is frequently difficult to measure, and peak latencies have not been reported for the motor-evoked action potential. This study reports across-tarsal-tunnel latencies and amplitude decrements for both the medial and the lateral plantar nerves. For the medial plantar nerve with active electrodes placed over the medial head of the flexor pollicis brevis, the calculated mean + 2SD across tunnel onset latency is 3.2msec, peak latency is 2.9msec, and amplitude decrement is 29.3%. For the lateral plantar division, the calculated across-tunnel onset latency is 3.2msec, peak latency is 2.9msec, and amplitude decrement is 27.2%. Medial plantar nerve latency distal to the tarsal tunnel for the mean + 2SD is 5.9msec to onset and 9.5msec to peak, and the lateral plantar nerve latency is onset 5.9msec and peak 9.7msec.

Brain injury obscured by chronic pain: a preliminary report.

Chronic pain patients and brain injured patients frequently exhibit anxiety, depression, perseveration, and fixed ideation about their injuries. Both populations also frequently suffer from decreased attention, impaired concentration, easy fatigability, personality changes, impaired relationships with family and friends, and difficulty maintaining a job. In cases where chronic pain coexists with traumatic brain injury, the brain injury is often obscured. Risk factors which should alert the medical team to possible coexisting brain injury include history of loss of consciousness at original injury, history of trauma to the head, whiplash injury to the neck, multisystem trauma, and admission of memory or attention deficits by the patient. When any of these risk factors are present, we have found that formal examination of cognitive function is required to explore the potential of coexisting brain injury; if pain is a prominent clinical feature, residual cognitive sequelae of mild brain injury is easily masked. Specific testing of attention, new learning ability, constructional ability, and higher cognitive functions are most helpful in this population, and they need to be included in the mental status examination when concomitant brain injury is suspected. In our study, seven patients were found to have undiagnosed brain injury in a series of 67 consecutive patient referrals to our pain rehabilitation program. Treatment failure is high in this subgroup of pain patients unless treatment is directed toward the sequelae of both brain injury and chronic pain.

Evoked sensory nerve action potentials: effect of different recording electrodes on distal latencies and amplitudes.

The evoked sensory nerve action potentials (ESAP) of the median nerve were studied in 20 subjects using an antidromic technique, recording the distal latency to onset and to peak, and peak to peak amplitude, using three different recording electrodes. The electrodes used were the TECA digital ring electrodes, AERO MED wire loop stretch and squeeze-type electrodes, and Neurodiagnostic finger clip electrodes. Because the Neurodiagnostic finger clip electrodes are wider than the others, they were placed at different points over the proximal and distal interphalangeal joints to evaluate any changes in the ESAP caused by different interelectrode distance. The values obtained for the distal latencies and amplitudes for each electrode were compared using the unpaired Student's t-test. There were no statistically significant differences found in the ESAP distal latencies to onset or peak using any of the electrodes or various placements. When comparing the amplitude responses, the only statistically significant difference was noted when the TECA digital ring electrodes were compared to a particular arrangement of the Neurodiagnostic finger clip electrodes (p less than 0.05). It was therefore concluded that any of these electrodes can be used to obtain reliable reproducible data for nerve conduction studies.

Pastoral needs and support within an inpatient rehabilitation unit.

Because patients reported concerns regarding the adequacy of pastoral service delivery during their inpatient rehabilitation hospitalization, a study was performed to ascertain the patient's pastoral needs and the extent of pastoral services provided. After discharge from the inpatient rehabilitation hospital, patients were surveyed as to their perceived religious and spiritual needs, as well as to the extent of religious, spiritual, and pastoral services provided during their inpatient stay. The majority of responders (74%) reported their religious and spiritual beliefs were important. Forty-five percent of responders indicated not enough attention was repaid to their religious or spiritual needs, whereas only 1% felt that too much attention was paid. A majority of patients (54%) desired pastoral visitation. Other needs were elicited, including expanded pastoral services, increased staff empathy for the patient's spiritual and religious needs, and improved availability of church or synagogue services or sacraments. Many Jewish patients reported concerns of being punished by God, whereas Christian patients were concerned that God was unaware of their personal needs. Some responders, regardless of personal faith, were also troubled with fears of death, God's failure to heal, and loss of purpose in life. There is a clear need to establish a mechanism to identifying the religious and spiritual needs of each individual patient. These needs must be considered with both sensitivity and compassion by all members of the rehabilitation staff. The rehabilitation facility must also develop a mechanism to identify pastoral care resources available within the hospital and local community, and to assure that the patient's needs are addressed.

Forearm pain secondary to compression syndrome of the lateral cutaneous nerve of the forearm.

This report describes a syndrome of compression of the lateral cutaneous nerve of the forearm (LCNF), the distal termination of the musculocutaneous nerve. Three patients presented with pain or numbness along the radial aspect of the distal forearm. There was a history of vigorous upper extremity exercise with elbow extension and arm pronation or resisted elbow flexion. Signs included: decreased sensation to pin and light touch in the distal forearm over the cutaneous distribution of the nerve; tenderness to palpation over the nerve where it pierces the deep fascia of the arm lateral to the bicipital tendon and proximal to the elbow crease; and decreased elbow extension with arm fully pronated. Electrodiagnostic studies revealed either a prolonged distal latency or decrease in amplitude of the evoked response of the lateral cutaneous nerve of the forearm in the symptomatic arm. Patients responded to treatment directed to the site of the lesion where the nerve pierces the deep fascia of the arm. Treatment methods included: restriction of upper extremity activity, use of a posterior splint to restrict elbow extension, transcutaneous electrical nerve stimulation (TENS), ultrasound, and surgical decompression. This syndrome may be readily differentiated from other causes of pain along the distal radial aspect of the forearm, making accurate diagnosis and treatment possible.