Skin perfusion responses to surface pressure-induced ischemia: implication for the developing pressure ulcer.

This study describes alterations in skin perfusion in response to step increases in surface pressure, before and after long-term (5 hr) exposure to pressure-induced ischemia. A provocative test was developed in which surface pressure was increased in increments of 3.7 mmHg until perfusion reached an apparent minimum by a computer-controlled plunger that included a force cell, a laser Doppler flowmeter to determine perfusion, and a thermistor to monitor skin temperature. Force was applied to the greater trochanters of adult male fuzzy rats. Skin perfusion (n=7) initially increased with low levels of surface pressure (up to 13.9+/-1.9 mmHg) and then decreased with further increases in pressure, reaching minimum (zero) perfusion at 58.2+/-3.64 mmHg. After pressure release, reactive hyperemia (3 x normal) was observed, with levels returning to normal within 15-30 min. The provocative test was then applied after a 5-hr ischemic episode (produced by 92 mmHg) and 3 hr of recovery. A comparison of responses between stressed and unstressed skin revealed: elevated (63%) control perfusion levels; loss of the initial increase in perfusion with low levels of increasing pressure; a depression (45%) in the hyperemic response with delayed recovery time; and a decrease (54%) in amplitude of low frequency (<1 Hz) rhythms in skin perfusion. Skin surface temperature gradually increased both during the control period and the period of incremental increases in surface pressure (total DT=3.3 degrees C). The results suggest a compromised vasodilator mechanism(s). The provocative test developed in this study may have clinical potential for assessing tissue viability in early pressure ulcer development.

Temperature effects on surface pressure-induced changes in rat skin perfusion: implications in pressure ulcer development.

The effect of varying local skin temperature on surface pressure-induced changes in skin perfusion and deformation was determined in hairless fuzzy rats (13.5+/-3 mo, 474+/-25 g). Skin surface pressure was applied by a computer-controlled plunger with corresponding skin deformation measured by a linear variable differential transformer while a laser Doppler flowmeter measured skin perfusion. In Protocol I, skin surface perfusion was measured without heating (control, T=28 degrees C), with heating (T=36 degrees C), for control (probe just touching skin, 3.7 mmHg), and at two different skin surface pressures, 18 mmHg and 73 mmHg. Heating caused perfusion to increase at control and 18 mmHg pressure, but not at 73 mmHg. In Protocol II, skin perfusion was measured with and without heating as in Protocol I, but this time skin surface pressure was increased from 3.7 to 62 mmHg in increments of 3.7 mmHg. For unheated skin, perfusion increased as skin surface pressure increased from 3.7 to 18 mmHg. Further increases in surface pressure caused a decrease in perfusion until zero perfusion was reached for pressures over 55 mmHg. Heating increased skin perfusion for surface pressures from 3.7 to 18 mmHg, but not for pressures greater than 18 mmHg. After the release of surface pressure, the reactive hyperemia peak of perfusion increased with heating. In Protocol III, where skin deformation (creep and relaxation) was measured during the application of 3.7 and 18 mmHg, heating caused the tissue to be stiffer, allowing less deformation. It was found that for surface pressures below 18 mmHg, increasing skin temperature significantly increased skin perfusion and tissue stiffness. The clinical significance of these findings may have relevance in evaluating temperature and pressure effects on skin blood flow and deformation as well as the efficacy of using temperature as a therapeutic modality in the treatment of pressure ulcers.

An animal model and computer-controlled surface pressure delivery system for the production of pressure ulcers.

Pressure ulcers continue to be a major health care problem. This paper describes an animal model and surface pressure delivery system for the production of experimentally derived pressure ulcers. A method for inducing dermal pressure lesions on the fuzzy rat was developed using a computer-controlled displacement column which produced a constant tissue interface pressure. The pressure column consists of a force transducer located between two 0.5-in (1.27-cm) diameter metal cylinders. The desired cutaneous pressure is maintained by a computer-controlled miniature stepper motor which displaces the column with the aid of interactive software. The force transducer signal is converted from analog to digital form, amplified, and recorded. Blood perfusion is monitored using a laser Doppler flowmeter (located in the tip of the column) during the application of pressure. The application of 145 mmHg pressure for 5 consecutive 6-hr sessions resulted in a greater than 90% incidence of pressure ulcers. The implications of our model and contributions of earlier animal models are discussed. This model provides a tightly controlled and measured environment making possible the scientific study of ulcer development and the evaluation of potential preventative or curative compounds.

Dysphagia: diagnosis and treatment in Kentucky.

Dysphagia, a disorder of swallowing, is commonly associated with neurological and neuromuscular disorders. Damage to the sensation or muscles of the swallowing mechanism leads to unsafe oral motor or pharyngeal movement patterns, placing a patient at risk for development of aspiration pneumonia. At present, multidisciplinary Dysphagia Teams are being used to improve the diagnosis and treatment of swallowing disorders. A survey including all 112 hospitals in the Commonwealth of Kentucky indicates 33 (29%) presently have such a team, while 42 (38%) offer outpatient dysphagia services. In addition, 56 (50%) of the hospitals indicate they perform modified barium swallows which is an essential test for diagnosing and treating dysphagia. An example of how a Dysphagia Team works in one Kentucky rehabilitation hospital is presented to illustrate how to provide early diagnosis and treatment of these problems.

Coding component important element of compliance plan.

In recent years the U.S. government has increased its fraud and abuse investigations in all sectors of the healthcare community. Healthcare providers that are successfully prosecuted may be excluded from the Medicare programs and are liable for monetary penalties. The best course of action is for providers to have a comprehensive compliance plan in place. An important element of such a plan is a component that will identify and address problematic coding issues.

A rheumatologic perspective on rehabilitation of shoulder problems in the older individual.

Shoulder dysfunction is a common but complex clinical problem among the aged. The shoulder is a diarthrodial joint that is designed to complement the elbow and wrist in stabilizing the arm and the hand. This complex joint has the greatest range of motion (ROM) of any joint in the human body. Unfortunately, the aging process increases the shoulder's vulnerability to many pathological conditions that decrease its ROM and interfere with self-care tasks. While initial therapy is typically managed by the primary care physician, the complexity of this problem often requires consultation across disciplines to assure pertinent management. This article provides an overview of rheumatologic considerations specific to geriatric persons with shoulder dysfunction. The differential diagnosis and issues of treatment and rehabilitation are discussed.

Gait disorders in adults: a classification for their differential diagnosis.

The increasing frequency and prevalence of functionally significant gait disorders in adults requires that more physicians become familiar with systematic assessment and treatment approaches. The classification system presented can help physicians organize their observations and their clinical management of patients with gait problems.

Mixing oil and water: the government's mistaken use of the Medicare anti-kickback statute in False Claims Act prosecutions.

In 1996, billing integrity generated a great deal of debate and litigation in the health care arena. Significantly, the federal government views a violation of the Anti-Kickback Act as a basis for a False Claims Act action. While federal courts are split on the issue, the author strongly contends that using the False Claims Act to do what the Anti-Kickback Act was intended to do is inappropriate, given Congress' intention in enacting each legislation.

Will all pressure ulcers heal?

Clinicians today are faced with the need to justify their care through outcomes data. However, this is difficult with chronic, nonhealing wounds or pressure ulcers, which do not follow the expected trajectory of wound healing. Therefore, outcomes are unpredictable. This paper discusses the phases of wound healing and progress toward identifying outcomes for chronic wounds, as well as future directions in research.

Recurrent traumatic brain injury.

This article reviews, analyses and provides commentary on the most recent literature concerning recurrent traumatic brain injury (RTBI) case histories. It is revealed that a significant proportion of TBI sufferers survive and recover most of the functions of daily living. However, relatively little is known about the epidemiology, effects, or causes of a new phenomenon: recurrent TBI.

Recurrent severe traumatic brain injury. Series of six cases.

Six of 141 persons treated for severe traumatic brain injury at the Medical College of Virginia were found to have a history of similar previous injury. These cases are presented in the context of the phenomenon of recurrent severe traumatic brain injury, which has received no systematic attention in epidemiologic studies of trauma.

Underutilization of physician assistants in physical medicine and rehabilitation.

This study was undertaken to determine the utilization of physician assistants (PAs) in physical medicine and rehabilitation (PM&R). Survey questionnaires were sent to members of the American Academy of Physical Medicine and Rehabilitation, members of the American Academy of Physician Assistants, and administrators of free-standing rehabilitation facilities. One hundred thirty-seven of 1,082 physiatrists (13% of those responding) reported PAs employed in their practice settings, 83 of 549 PAs (15% of those responding) identified PM&R as their specialty, and 17 of 65 hospital administrators, (27% of those responding) reported PAs working at their facility. Seventy-nine percent (713 of 903) of physicians and 77% (50 of 65) of administrators were unaware that PA services provided in inpatient settings are reimbursed by Medicare. Eighty-four percent (108 of 129) of physiatrists employing PAs indicated that they would continue to do so even if the supply of physiatrists were adequate. PA responsibilities were concentrated in inpatient clinical areas. It is concluded that PAs are an underutilized source of health care for rehabilitation patients. Increased professional visibility and formal specialty training are recommended to enhance their contribution to the field.

Compression syndrome involving the lateral antebrachial cutaneous nerve in high level quadriplegia.

This report describes an etiology for a compression syndrome involving the lateral antebrachial cutaneous nerve (LACN) that is unique to high level quadriplegia. Two cases are presented that involve this syndrome in C5-C6 quadriplegia. Electrodiagnostic techniques and normal values have previously been established for the LACN, but not involving high-level spinal cord injured patients. A series of asymptomatic high-level quadriplegics at various times since their spinal cord injury was studied for appropriate comparison with the symptomatic cases and previously reported normal values. In the cases described, electrodiagnostic evidence of compression was documented and a diagnostic block was performed by injecting a local anesthetic at Olson's point. Once the diagnosis was established, injection with a long-acting local anesthetic and corticosteroid was therapeutic.