Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I.

OBJECTIVE: To investigate the effectiveness and cost of physical therapy (PT) or occupational therapy (OT) in patients with reflex sympathetic dystrophy (RSD). DESIGN: Prospective randomized controlled trial, with 1 year follow-up. SETTING: Two university hospitals. PATIENTS: One hundred thirty-five patients who had been suffering from RSD of one upper extremity for less than 1 year. INTERVENTIONS: Patients were assigned to PT, OT, or a control group (social work). MAIN OUTCOME MEASURES: Improvement in impairment level sumscore (ISS) over 1 year (Student's t test). A difference of 5 ISS points between the groups was defined as being clinically relevant. Furthermore, severity of disability and handicap was measured and tested exploratively (Wilcoxon; alpha = .05), and cost-effectiveness of the groups was calculated. RESULTS: PT and, to a lesser extent, OT resulted in a significant and also more rapid improvement in the ISS as compared with controls (6 and 4 ISS points, respectively). On a disability level, a positive trend was found in favor of OT. On a handicap level, no differences were found between the groups. PT had an advantage over OT regarding the cost-effectiveness ratio. CONCLUSION: In different ways PT and OT each contribute to the recovery from RSD of the upper extremity.

Do physical therapy and occupational therapy reduce the impairment percentage in reflex sympathetic dystrophy?

Reflex sympathetic dystrophy (RSD) is a disorder that can potentially result in permanent impairment. Because there are no adequate comparative studies regarding the additional value of physical therapy (PT) or occupational therapy (OT) for reducing the severity of permanent impairment in RSD, we prospectively investigated their effectiveness. At two university hospitals, we randomly assigned 135 patients with RSD of one upper limb, existing for <1 yr, to PT, OT, or control therapy (CT). One year after inclusion, impairment percentages were calculated according to the general method of the American Medical Association's Guides to the Evaluation of Permanent Impairment. For statistical evaluation, the Wilcoxon's signed-rank test (two-sided; alpha = 0.05) was used. The mean whole body impairments were as follows: PT, 21.6% and 19.1%; OT, 22.8% and 22.1%; CT, 22.0% and 22.1% (intention-to-treat and per protocol analysis, respectively). There were no significant differences between the groups. We conclude that impairment percentages in RSD patients treated with PT or OT did not differ significantly from those treated with CT at 12 months after inclusion.

[Nursing diagnosis. Keys for its development]. / Diagnóstico de enfermería. Claves para su desarrollo.

The authors carried out a study of the taxonomy used at the 1990 NANDA Conference. A few of the authors findings were some diagnostic labels were found to be imprecise; some of the diagnostic labels relate to causes which would only allow nurses to work in collaboration with other medical team professionals; other labels described symptoms which were hard to define objectively or were non-verifiable, imprecise and vague defining the problem. As a conclusion to this study, the authors contend that in order to develop nursing diagnostics it is necessary to validate the existing labels, develop new labels, make diagnostic tests serve as an appraisal and detection instrument, and to develop the critical symptoms necessary for identifying diagnostic labels. This study is based on a paper presented at the "First International Symposium on Nursin Diagnostics" which was celebrated in Barcelona.

Posttraumatic multiple organ failure--a report on clinical and autopsy findings.

In a retrospective analysis, clinical data and histological specimens were obtained from patients (n = 59) who died of severe injury. Three groups with comparable injury severity were differentiated according to the time of death. In group A (death, within 24 h) (n = 15) despite multiple injuries, patients almost always died from brain injury. Pulmonary failure was the leading cause of death in group B (death, days 2-7) (n = 16). The majority of group C patients (death, > 7 days) (n = 28) died of multiple organ failure. Organ weights at autopsy were all pathologically high but did not show an association with the amount of intravenous volume infused during intensive care. Organ histology revealed signs of interstitial edema and infiltration of polymorphonuclear leukocytes in group B patients especially in the lung, and in all groups to a lower degree in liver and kidney. The distribution of interstitial edema and cell necrosis appeared to be organ-specific. Our data confirm the presence of a generalized inflammatory reaction in patients with severe trauma. The pattern of organ failure, in addition to known pathogenetic changes (mediators, endotoxemia, etc.), appears to be influenced by organ structure and perfusion.

Intestinal permeability after severe trauma and hemorrhagic shock is increased without relation to septic complications.

After thermal injury, alterations in intestinal permeability have been demonstrated and have correlated with subsequent infections. We measured intestinal permeability on the second day after severe trauma and hemorrhagic shock (ruptured abdominal aneurysm). The mean (+/- SD) lactulose-mannitol (L/M) excretion ratio was 0.012 +/- 0.005 in seven healthy control subjects, 0.069 +/- 0.034 in 11 severely traumatized patients, and 0.098 +/- 0.093 in eight patients with aneurysm, indicating a significant increase of intestinal permeability in both patient groups. No significant correlation was found between L/M ratios and age, severity of injury or shock, lactate levels on admission, APACHE (acute physiology and chronic health evaluation) II score, daily pulmonary gas exchange parameters, or mean multiple organ failure scores. No difference in intestinal permeability between patients with and without subsequent infections could be demonstrated. In 11 patients we looked for endotoxin in the systemic circulation. In six patients endotoxemia was present immediately after admission and before the L/M test. However, during the L/M test and 1 day afterward no circulating endotoxin was observed. The present data provide evidence for the hypothesis that increased intestinal permeability and subsequent infectious complications are independent phenomena, frequently seen in patients after severe trauma or hemorrhagic shock.

Whole-body inflammation in trauma patients. An autopsy study.

In a review of autopsy specimens and reports in 35 trauma cases, we found signs of generalized inflammation and tissue damage with increases in organ weights in organs not primarily injured. These abnormalities occurred independent of the time of death and were also found in patients who died of brain injury alone. The most pronounced signs of inflammation and increases in organ weights were found when the adult respiratory distress syndrome, hypovolemic shock, or multiple organ failure were the causes of death. These findings are similar to those found in several organs of rabbits after four hours of complement activation in combination with 20 minutes of hypoxia. Therefore, the autopsy findings in this series of trauma patients might represent the morphologic features of adult respiratory distress syndrome and multiple organ failure in an early, preclinical stage.

Posttraumatic complications and inflammatory mediators.

In a series of 71 patients with trauma, we measured weekly the blood levels of a number of complement proteins and activation products. We also measured the following: leukocytes, platelets, granulocyte enzyme elastase, alpha 1-antitrypsin, total protein, albumin, haptoglobin, and fibronectin. The intensity of complement activation and the blood levels of elastase correlated with the following factors: injury severity (especially the severity of limb injury), development of adult respiratory distress syndrome, development and severity of multiple organ failure, and probability of a fatal outcome. The plasma elastase level seemed to be the best predictor of adult respiratory distress syndrome and the best correlate of injury severity and multiple organ failure severity. Our findings support the hypothesis that posttraumatic activation of the complement system leads to activation of granulocytes, followed by microvascular injury and finally by organ failure.

Ogilvie's method applied to infected wound disruption.

Nylon mesh was used without closing the skin in 26 patients in whom it was not possible to close the infected abdominal wall without undue tension. A total of 73 meshes were implanted. Major complications consisted of three wound disruptions in two patients and formation of a sinus tract necessitating excision of the mesh in one patient. Definitive closure generally consisted of skin grafting on the granulation tissue growing through the mesh. Mortality was high, due to underlying diseases. In three of 13 survivors, an incisional hernia developed.