Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies.

OBJECTIVE: To determine whether dysphagic stroke patients receiving oral (thickened-fluid dysphagia) diets or nonoral (enteral feedings supplemented with intravenous fluids) diets met their estimated fluid requirements. DESIGN: Cohort study. SETTING: University-affiliated hospital. PARTICIPANTS: Thirteen dysphagic patients with new strokes were studied for 21 days postadmission to hospital. INTERVENTIONS: Seven patients (group 1) were started on nonoral feeding and later progressed to oral diets and 6 patients (group 2) received oral dysphagia diets only. MAIN OUTCOME MEASURE: Fluid intake. RESULTS: Fluid intake of patients in group 1 significantly declined over the 21 days (mean +/- standard deviation, 3158 +/- 523mL/d vs 984 +/- 486mL/d; p < .0001), representing 134% +/- 26% and 43% +/- 20% of their fluid requirements, respectively. Mean fluid intake of patients in group 2 was 755 +/- 162mL/d, representing 33% +/- 5% of requirements. This volume was significantly lower than the fluid intake of patients who received nonoral feeding (p < .0001). CONCLUSIONS: Dysphagic stroke patients who received thickened-fluid dysphagia diets failed to meet their fluid requirements whereas patients on enteral feeding and intravenous fluid regimens received ample fluid.

Chronic pain and health care utilization in women with a history of childhood sexual abuse.

OBJECTIVE: This cross-sectional controlled study investigated the association between chronic pain, health care utilization and a history of childhood sexual abuse. SUBJECTS: Three groups, constituting 80 women in total, were studied (1) attendees at group therapy for individuals who had experienced childhood sexual abuse (n = 26); (2) Two control groups consisting of nonabused (a) psychiatric outpatients (n = 33); and (b) nurses (n = 21). SETTING: The setting was a university affiliated community and tertiary care hospital in London. Ontario. OUTCOME MEASURES: Each subject voluntarily completed questionnaires documenting history of childhood abuse, pain, psychological symptomatology and medical and surgical history. RESULTS: Sixty-nine percent of the women who had experienced childhood sexual abuse reported a chronic painful condition lasting more than three months, compared to 43% of the combined control groups (p = .026). Women who had experienced childhood sexual abuse reported a greater number of painful body areas (p = .003), more diffuse pain and more diagnoses of fibromyalgia (p = .013). They had more surgeries (p = .037), hospitalizations (p = .0004) and family physician visits (p = .046). CONCLUSIONS: Women with a history of childhood sexual abuse reported more chronic pain symptoms and utilized more health care resources compared to nonabused control subjects. Identification of such a history in the patient experiencing persisting pain may be the first step toward a successful combination of medical and psychosocial interventions.

Social issues in the rehabilitation of younger stroke patients.

OBJECTIVES: To study social factors and outcomes in stroke rehabilitation patients under the age of 50. STUDY DESIGN: Retrospective chart review examining (1) martial status and employment status on admission and at 3 months post discharge, (2) discharge destination, (3) the presence of absence of children under the age of 16, and (4) psychosocial difficulties as recorded by staff during hospitalization. SUBJECTS AND SETTING: Eighty-three consecutive stroke patients under the age of 50 admitted to a Canadian tertiary-care hospital rehabilitation unit. MAIN OUTCOME MEASURES: Discharge destination and primary caregiver at discharge, and return to work and marital separation 3 months after rehabilitation discharge. RESULTS: Of the 55 patients with spouses, 8 (14.5%) separated within 3 months of hospital discharge. Fifteen of the 83 patients (18.1%) were not able to return to their premorbid place of residence; 4 (4.8%) required institutionalization. Of the 64 patients employed outside the home or studying at the time of their stroke, only 13 (20.3%) were able to return to work within 3 months of their discharge to home. Only 9.4% of those working full-time were able to return to full-time employment. CONCLUSIONS: Rehabilitation of young stroke patients is associated with a variety of social problems, including marital breakup, child care responsibilities, and return to employment, which are uniquely important in this age group.

Sudden death in the dysphagic stroke patient--a case of airway obstruction caused by a food bolus: a brief report.

The clinical events leading up to the sudden death of a dysphagic stroke patient with dementia is described. A 63-yr-old man sustained right thalamic and mid-brain infarctions. On the inpatient stroke rehabilitation ward, he exhibited significant impulsivity and dementia, the latter felt to be premorbid. The patient frequently coughed, and modified barium swallow testing showed dysphagia, with aspiration occurring only when consuming greater than teaspoon amounts of liquid. He subsequently died at home while eating a meal. Autopsy showed an intact large cheese ball (bocconcini) occluding the airway. Sudden death in the impulsive stroke patient secondary to airway occlusion by a food bolus has not previously been reported, although such patients seem to be at greater risk. New eating-related interventions are warranted for dysphagic patients who exhibit impulsivity. It is proposed that food particle size be limited to 1 cm2 and that such patients be closely monitored while eating.

[Surgical treatment results in patients with severe forms of the carpal tunnel syndrome]. / Rezul'taty khirurgicheskogo lecheniia bol'nykh s tiazhelymi formami sindroma zapiastnogo kanala.

A retrospective and prospective study was undertaken to determine efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome (CTS). The criteria for inclusion in this study were clinical and nerve conduction studies (NCS). Between 1985-1991, 1511 NCSs performed were positive for CTS.

Pneumonia associated with aspiration following stroke.

OBJECTIVE: To determine the association between demonstrated aspiration and pneumonia in stroke patients. METHODS: Chart review of 441 consecutive stroke patients admitted to a stroke rehabilitation unit within 4 months of their stroke over an 8-year period. Videofluoroscopic modified barium swallow (VMBS) was performed on all patients suspected of aspirating. In all patients, the presence or absence of pneumonia was noted. RESULTS: Eighty-four of the 441 (19.0%) stroke patients transferred for rehabilitation demonstrated aspiration of thin liquids on VMBS. Twelve of the 441 (2.7%) developed pneumonia while in hospital, either in the acute or rehabilitation phases. The incidence of pneumonia among proven aspirators on VMBS was 10 of 84 (11.9%) patients. Two of the 357 (0.6%) patients who were presumed nonaspirators developed pneumonia. Brain stem and right hemispheric stroke patients had a higher incidence of pneumonia. CONCLUSIONS: Pneumonia is an uncommon complication of stroke. However, approximately 12% of stroke rehabilitation patients diagnosed as aspirators on VMBS developed pneumonia, a 20-fold increase over presumed nonaspirators. VMBS is a potentially valuable tool in determining those patients at risk of aspiration pneumonia.

Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients.

OBJECTIVE: To determine associations between the nutritional status of inpatient rehabilitation (rehab) unit stroke patients and (1) length of stay (LOS) and (2) functional outcome using Modified Barthel Index (MBI). Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. A priori hypothesis-LOS and MRI are adversely related to malnutrition. DESIGN: inception cohort study. SETTING: Tertiary care center. PATIENTS: 49 consecutive "middle-band" patients (4 declined). MAIN OUTCOME MEASURES: LOS and MRI at admission (T1), 1 month (T2), and discharge (T3). RESULTS: LOS was significantly related to overall malnutrition, T1 and T2MBI scores, T1 dysphagia, T1 enteral feeding (all p<.01), T1 malnutrition, peripheral vascular disease (negative relationship), and diabetes mellitus history (all p<.05). In analysis of covariance, adjusting for T1 MBI, overall rehab malnutrition was related to LOS (p=.011). Other covariates were not significant. T1 malnutrition was related to lower T2 MBI scores(p=.038). Lower T1 MBI scores was related to T2 malnutrition (p=.032). Diabetics (p=.005) and right hemispheric lesion patients(p=.015) had lower T1 MBI scores. Hypoalbuminemia was unrelated to LOS and MBI scores. Although malnourished and adequately nourished functionally dependent patients improved equally in MBI scores by discharge, prolonged LOS in the malnourished lowered their functional improvement rate ([T3 MBI - T1 MBI]/LOS) (p=.047). CONCLUSIONS: Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources.

Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors.

This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up. Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed > or = 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (> 70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.

Autonomic dysreflexia after brainstem tumor resection. A case report.

Autonomic dysreflexia is a poorly understood entity, typically occurring in the spinal cord-injured patient, with paroxysmal hypertension, bradycardia, severe throbbing headache, anxiety and sweating above the level of the lesion. An 18-year-old man underwent removal of a hemangioblastoma from the inferior portion of the fourth ventricle, a region known as the area postrema. Postoperatively he exhibited signs of autonomic failure. He later developed recurrent paroxysmal episodes of abdominal pain, hypertension, skin flushing and headaches. He subsequently was found to have a gastric ulcer. Symptoms and signs significantly improved with its treatment. We postulate that diminished sympathetic outflow occurred as a result of the surgery, creating a situation similar to the spinal cord-injured patient. Autonomic dysreflexia was elicited as a consequence of the noxious input of the gastric ulcer. In other cases of brainstem tumor resection, unrecognized episodes of autonomic dysreflexia may occur. This case also indicates that sympathetic supraspinal control is located at the level of the medulla or higher.

Patient awareness of physical medicine and rehabilitation.

The present study examined the extent to which patients referred to a specialist in physical medicine and rehabilitation (PM&R) could correctly identify the name or essential scope of the specialty the physiatrist practiced. The hypothesis, based on the author's experiences as a staff physiatrist, was that most patients would not be aware of the name and scope of the specialty of physical medicine and rehabilitation. This prospective study involved the administering of a questionnaire to 202 consecutive referrals to a University-affiliated PM&R outpatient clinic. Of the respondents, 19% were able to correctly identify that the physician they were referred to was either a PM&R specialist, a physical medicine specialist, a rehabilitation specialist or a physiatrist. Among the incorrect responses, orthopedist, neurologist and rheumatologist were most prevalent, and 33% of the respondents thought the physiatrist performed surgery. The implications of the findings are discussed. There continues to be a need to educate the public about the scope of practice of physiatry.

Exercise testing and training of persons with dysvascular amputation: safety and efficacy of arm ergometry.

Recent studies indicate that most persons with dysvascular amputation also have moderate to severe cardiovascular disease with impairment in functional capacity. This may limit the ability to achieve optimal function with their prosthesis because of inadequate conditioning. We developed an exercise testing and training program using arm ergometry in conjunction with standard rehabilitation for persons with acute dysvascular amputation who were profoundly deconditioned after complicated perioperative courses. The program consisted of daily arm ergometry, performed on an interval basis, at an intensity individually optimized through exercise testing. Twenty-five patients, with a mean age of 63 years, completed the inpatient program with pretest and discharge work performance assessment. There was no significant difference between pretest and discharge assessment of baseline or peak heart rate, systolic blood pressure, diastolic blood pressure, or Borg rating of perceived exertion. Peak systolic blood pressure was elevated at discharge compared to admission testing (p less than .04). Heart rate responses were decreased during the early stages of testing when comparing discharge telemetry to admission findings. The duration of exercise increased from 12.6 minutes to 16.3 minutes (p less than .0004), and the maximum work output increased from 17.1 watts to 23.5 watts (p less than .0004). There was no significant morbidity associated with either arm ergometry testing or the exercise program. We conclude that arm ergometry testing and training is a safe and effective method for improving the efficiency of arm work in the patient with acute dysvascular amputation.

Erythema and skin temperature following continuous sitting in spinal cord injured individuals.

Pressure sores are a severe and costly problem for many disabled individuals. There is a need for quantitative tools to assess damage produced by external loads on human skin and underlying tissues. Clinically, intensity and size of skin erythema have been used as indicators of tissue damage. Temperature is a quantifiable measure, and various studies have investigated the thermal response to localized pressure. The purpose of this study was to measure the effect of "long-term sitting" on skin temperature and erythema, in a situation that closely approximated what a spinal cord injured individual encounters on a regular basis. The resulting data indicated that: 1) a consistent skin temperature pattern occurred after pressure relief from the seated position; 2) skin temperature of experimentally-induced erythematous areas often remained elevated, even after one hour of pressure relief; and, 3) a qualitative, but not quantitative, correlation exists between erythema size and intensity and skin temperature. Implications of this research include the potential use of temperature to: 1) monitor the effectiveness of various strategies being used to prevent the development of pressure sores; and, 2) predict incipient tissue damage.

Arm ergometry exercise testing in patients with dysvascular amputations.

The purpose of this study was to test the agreement between the heart rate (HR) response and rating of perceived exertion (RPE) on an arm ergometry graded exercise test (GXT) in deconditioned persons with acute dysvascular amputations before and after an inpatient rehabilitation program. Twenty-six men were studied at admission, and 11 were retested after completion of the program. After obtaining resting measurements of HR and systolic and diastolic blood pressures, each patient performed the GXT using an arm ergometer. Patients maintained a cranking rate of 50rpm, which was monitored electronically. The workloads started with a warm-up period of 0 watts (stage 1) and increased by increments of 5 watts. Each stage lasted three minutes-2.5 minutes of exercise and 30 seconds of rest. The RPE was taken five seconds before the end of each exercise stage. During the rest period, HR and blood pressures were recorded. Scatter plots and linear regression analyses revealed no statistically significant relationship, either at early stages of GXT or at peak work, between HR and RPE. The results suggest that RPE cannot be used reliably as a surrogate for direct pulse measurement in exercise training of persons with acute dysvascular amputations.