Rates and characteristics of lower limb amputations in Taiwan, 1997.

This study aims to describe the national incidence rate and characteristics of lower limb amputations (LLA) in 1997 from an island-wide database of the national health insurance programme in Taiwan. Some 117,647 discharge records from a sampled database (1 in 20) of the National Health Insurance Research Database were analysed. This study included records (n=171) containing LLA procedures. The LLA procedure rates were obtained by multiplying the number of identified procedures by 20 as the numerator and mid-year total population of Taiwan in 1997 as the denominator. Each procedure was further analysed according to the demographic characteristics of the patients, cause and level of amputation. Summarised gender ratios of LLA procedure rates were obtained by Poisson regression analysis. The crude LLA procedure rate was 18.1 per 100,000 population per year and the crude major LLA procedure rate was 8.8 per 100,000 population per year in Taiwan in 1997. The major cause of LLA procedures was peripheral vascular disease (72%), and the toe was most frequently amputated (48%). The LLA procedure rates, which increased logarithmically with age of patients, were significantly higher in men with a summarised male to female rate ratio of 1.65. The age-standardised LLA procedure rate in Taiwan was lower than that reported in the United States, Finland, the Netherlands, the United Kingdom (Leeds, Middlesborough, and Newcastle), but higher than Spain, Italy, and Japan. The trend of an increasing proportion of PVD-related LLA procedures will prompt the health professionals to develop strategies for LLA prevention.

Energy expenditure of wheeling and walking during prosthetic rehabilitation in a woman with bilateral transfemoral amputations.

OBJECTIVE: To compare the energy expenditure of locomotion by wheelchair with that required for prosthetic ambulation in a person with bilateral transfemoral (TF) amputations. DESIGN: Observational, single patient, descriptive. SETTING: An 80-meter long rectangular hallway in a rehabilitation unit. PATIENT: A 41-year-old woman with bilateral TF amputations that were performed 79 days before her admission to the rehabilitation unit. MAIN OUTCOME MEASURES: The oxygen uptake, oxygen cost, heart rate, speed, cadence, and stride length of walking measured during a 4-month course of prosthetic rehabilitation. Five locomotion conditions were evaluated: (1) wheelchair propulsion, (2) walking with short-leg prostheses (stubbies) and a walker, (3) long-leg prostheses and a walker, (4) long-leg prostheses without knee mechanism and axillary crutches, and (5) long-leg prostheses with right polycentric knee and left locked knee and axillary crutches. A portable and telemetric system was used to measure the metabolic parameters. An arm ergometry graded exercise test was performed at the end of rehabilitation. RESULTS: Oxygen cost (range, 466%--707% of that of wheeling) and heart rate (range, 106%--116% of that of wheeling) were higher during walking with various combinations of prostheses and walking aids. The speed of prosthetic walking was only 24% to 33% of that of wheeling. Our patient preferred using a wheelchair to prosthetic walking after discharge. CONCLUSIONS: People with bilateral TF amputations require very high cardiorespiratory endurance to fulfill the energy demand during prosthetic rehabilitation. The high energy cost of prosthetic walking will limit its application in daily activities.

Long-term care services needs for spinal-cord injury patients in Taiwan.

According to official health statistics, accidents and their adverse effects are the third leading cause of death in Taiwan. More accident victims are surviving thanks to treatment using high medical technology, but this results in many disabled patients with irreversible impairments. The demand for long-term care (LTC) services for spinal cord injury (SCI) patients has thus become a major concern. However, homebound SCI patients may easily face exclusion from LTC services because they are often ineligible for benefits under the regulations of National Health Insurance (NHI). The purposes of this study were: 1. To quantify the LTC needs of SCI patients, and 2. To evaluate the correlation between SCI patient health status and LTC needs. A total of 133 samples were visited from Kaohsiung City and Pingtung County. The results of this study showed that the average age of subjects was 43.15, with 72.9% male. The health status of most of the research subjects was fair (M = 2.33). The test of physiological health status was a 20-item scale with a five-point response format. The worst dysfunctions were urination (M = 3.36, SD = 1.06), sexual function (M = 3.30, SD = 0.88), excretion (M = 3.26, SD = 1.06), comfort (M = 3.25, SD = 0.84), and mobility (M = 2.75, SD = 1.11). All of the above items showed higher mean scores than average. More than one third of the subjects (36.8%) used wheelchairs, had better mobility and went out often. However, half of subjects were completely bedridden (45.9%). The mean psychosocial health status was poor with a mean score of 2.80 which showed higher mean score than average. The subjects were less satisfied with role function (M = 2.92), emotional stability (M = 2.92), and application for community resources (M = 2.79). The most needed LTC services for SCI patients was home-making services; referral and monitoring services ranked second. Suggestions derived from this study were to coordinate nursing care services with social support services for LTC patients and to allocate LTC resources based on patients' health status and their need for LTC services.

Dysphagia in patients with brainstem stroke: incidence and outcome.

OBJECTIVE: This study was conducted to delineate the incidence and outcome of dysphagia among hospitalized patients who were referred for rehabilitation because of brainstem stroke. DESIGN: We retrospectively reviewed the medical records of 36 patients who were admitted because of brainstem stroke. Information on the patients' clinical features, feeding status, and the results of clinical and videofluoroscopic swallowing examinations were obtained through chart review. Follow-up interviews were conducted via telephone to learn the general medical condition and feeding status of the patients 7-43 mo after hospital discharge. RESULTS: A total of 81% of the patients had dysphagia at the time of initial clinical swallowing evaluation, which was performed 10-75 days after the onset of stroke. A total of 79% of the dysphagic individuals depended on tube feeding at the initial evaluation; 22% of all individuals could not resume oral intake at discharge. Statistical analyses revealed a significant association between poor outcome and disease involving the medulla, the presence of a wet voice during the initial swallowing test, and a delay or absence of the swallowing reflex. The incidence of aspiration pneumonia was 11%. There was a correlation between the detection of aspiration by modified barium meal videofluoroscopy and the development of aspiration pneumonia. Follow-up interviews showed that 88% of the 27 patients who were contacted had resumed full oral intake 4 mo after the onset of stroke. CONCLUSIONS: The incidence of dysphagia was relatively high in our study population. The long-term outcome was favorable.

Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation.

OBJECTIVE: To determine the ambulatory outcome and predictive factors of successful ambulation training in patients with both hemiplegia and lower extremity amputation. DESIGN: A retrospective study. SETTING: A rehabilitation center of a university hospital. PATIENTS: Twenty-three patients with dual disabilities consecutively admitted to the rehabilitation center from 1984 to 1994. MAIN OUTCOME MEASURES: Ambulatory outcome was measured using physical therapists' and physicians' notes at discharge or the last available clinical visit. Ambulation ability was graded as community and noncommunity ambulation, which included indoor ambulation and nonambulation. Several clinical features were reviewed to assess their association with ambulation outcome. RESULTS: About two thirds of the 23 patients could be trained to be ambulatory: 10 (43.8%) achieved community ambulation and 5 (21.7%) achieved indoor ambulation. Of the clinical factors, only mental status showed a statistically significant association with good ambulation outcome (p<.05). When odds ratios were considered, several factors, including mild motor involvement, transtibial amputation, amputation before cerebrovascular accident, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation, showed trends toward association with increased ambulation achievement, although these associations were not statistically significant. CONCLUSION: Impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation. If subjects with dual disabilities are properly selected, satisfactory results of ambulation training will be obtained.

Quality of life of spinal cord injured patients in Taiwan: a subgroup study.

The major purposes of this study were to assess the quality of life (QOL) of spinal cord injured patients, and to assess the possible factors affecting the QOL. The survey was conducted from 1992-1993 by mailed questionnaires to members of Spinal Cord Injury Association of the Republic of China. There were 347 quality responses with the mean age of 37.5 +/- 10.2 years old and the mean duration of illness of 7.8 +/- 6.8 years. The questionnaire included five domains, physical mobility, environment-transportation, psychosocial adjustment, education and economics for a total of 39 items. Each item contained a rating of 'importance' and 'satisfaction'. The quality of life index (QLI) was calculated by multiplying the satisfaction score with the importance score, then dividing by the possible highest score. The major results included: (1) the subjects had mild to moderate dissatisfaction with most items in five domains except psychosocial adjustment: (2) quality of life in those with complete tetraplegia (QLI = -0.41) and incomplete tetraplegia (QLI = -0.31) was significantly lower than that of those with complete paraplegia (QLI = -0.13) and incomplete paraplegia (QLI = -0.04); (3) both the severity of injury and the post-injury working status were the major factors affecting the life quality of spinal cord injured patients in Taiwan.

The hypothalamus-pituitary-ovary and hypothalamus-pituitary-thyroid axes in spinal cord-injured women.

Sixteen women with spinal cord injury (SCI) underwent studies of the hypothalamus-pituitary-ovary (HPO) and hypothalamus-pituitary-thyroid (HPT) axes with luteinizing hormone (LH) releasing hormone (LHRH) and thyrotropin (TSH) releasing hormone (TRH) stimulation tests during the early follicular phase. The mean interval from injury to participation in this study was 7.5 years (range, 1.5 to 13.1). All subjects were menstruating regularly. Five (35.7%) SCI subjects who were menstruating before injury had postinjury amenorrhea for 1 to 12 months, and the other nine (64.3%) SCI subjects had no interruption of menstruation after injury. Two SCI subjects whose injury occurred in preadolescence proceeded to menarche without any delay. The amount of menstrual flow was noted to be reduced in nine (64.3%) SCI subjects. Two and three SCI subjects had elevated follicle-stimulating hormone (FSH) and prolactin (PRL) levels, respectively. LH responses to LHRH were significantly higher in the SCI group (P < .001). Ten (62.6%) SCI subjects had enhanced LH responses to LHRH. The mean TSH, PRL, and FSH responses to TRH and LHRH of the SCI group were not significantly different from those of age-matched controls. However, five (31.2%), four (25.0%), and five (31.2%) SCI subjects had enhanced TSH, PRL, and FSH responses to TRH and LHRH, respectively. Six (37.5%) SCI subjects had a delayed FSH response to LHRH. In total, 13 (81.2%) SCI subjects had at least one axis abnormality. These findings are consistent with the hypothesis that changes of central neurotransmitters may occur after SCI.

Clinical experience in rehabilitation of spinal cord injury associated with schizophrenia.

OBJECTIVE: To identify the clinical features and rehabilitation outcomes in spinal cord injury (SCI) patients with preexisting schizophrenia. DESIGN: A retrospective study conducted by reviewing the charts of all patients diagnosed with both SCI and schizophrenia hospitalized from 1987 throughout 1994 in 2 rehabilitation units. SETTING: Rehabilitation wards of two hospitals in Taiwan. PATIENTS: Seventeen traumatic SCI patients with schizophrenia, including 7 men and 10 women. Patients without neurological deficits were excluded. INTERVENTION: All subjects received psychiatric intervention and intensive rehabilitation programs during hospitalization. MAIN OUTCOME MEASURES: The injury pattern and psychiatric condition were described. Abilities of locomotion, management of activities of daily living, and bladder control were measured. RESULTS: Fifteen injuries caused by a voluntary fall subsequently resulted in thoracolumbar insult. Ten incomplete paraplegics were able to ambulate with or without a device on discharge. Four subjects had poor bladder control. The outcome of self-care skills was worse in those with high level injury. Psychiatric symptoms were one of the main obstacles during rehabilitation. CONCLUSION: Voluntary fall that caused thoracolumbar injuries was the main cause of injuries in these patients. Psychiatric symptoms were present in the majority and might hinder the prognosis of treatment. Nevertheless rehabilitation programs were found to benefit subjects after their psychiatric problems were under control.

Suppression of the hypothalamus-pituitary somatotrope axis in men with spinal cord injuries.

Thirty-two men with spinal cord injury (SCI) were studied for evaluation of the hypothalamus-pituitary somatotrope axis, using growth hormone-(GH)-releasing hormone (GHRH) and insulin-induced hypoglycemia. Twenty-six age-matched normal male volunteers served as controls. Six SCI subjects (18.7%) had elevated basal follicle-stimulating hormone (FSH) levels, eight (25.0%) had hyperprolactinemia, and 11 (34.4%) had reduced serum insulin-like growth factor-1 (IGF-1) levels. Twenty SCI subjects (62.5%) had reduced and/or delayed GH responses to GHRH, and eight (25.8%) had reduced GH response to insulin-induced hypoglycemia. Seven of eight hyperprolactinemic SCI subjects showed reduced GH response to GHRH and/or insulin-induced hypoglycemia. These findings are consistent with the notion that SCI subjects have a reduced central dopaminergic tone.

Pulmonary embolism presenting as syncope in paraplegia: a case report.

Syncope as an initial presentation of pulmonary embolism is unusual. A 16-year-old girl, with T7 paraplegia after a traumatic spinal cord injury, developed syncope on the 33rd hospital day. The episode occurred approximately 3 hours after her first tilting table training and just after her attendant had assisted passive range-of-motion exercise. Subsequent studies showed pulmonary embolism at the left lower branch of the left pulmonary artery, and the branch to lower segment of the lingual lobe. Doctors should be alert to possible diagnosis of pulmonary embolism in such high-risk patients, especially when new onset symptoms or signs appear.

Evident risk factors for younger stroke patients in Taiwan.

Risk factors for stroke in the young are often different from those in older patients. Since a rather high incidence of stroke exists in Taiwan, we prospectively studied risk factors in 208 stroke patients aged between 15 and 45 years seen in four main hospitals in Taiwan from 1986 to 1993. Of the 116 patients with cerebral infarction, 48 (41.4%) had related premature atherosclerosis mainly caused by hypertension (18.1%), hyperlipidemia (4.3%), and diabetes mellitus (3.4%). Thirty-four patients (29.3%) had an identifiable predisposing factor of cardiac origin including valvular diseases. In 92 patients with cerebral hemorrhage, hypertension was present in 30 patients (32.6%) and a vascular malformation of brain in 21 patients (22.8%). For a specific district in Taiwan, the major risk factors for strokes in younger patients were hypertension, rheumatic heart disease, and vascular malformation of brain. Cardiac and neuroradiologic investigations are particularly indicative, and clinical effort in the management of these treatable causes needs emphasis.

[General introduction to the clinical application of non-invasive respiratory aids].

Intermittent positive pressure ventilation via tracheostomy has been the most common method of providing ventilatory support for patients with respiratory failure since the late 1950s. It is the standard procedure for individuals who suffer from acute respiratory failure, impaired consciousness, and severe restrictive lung disease. However, numerous adverse complications from these invasive techniques have been reported in those who are long-term ventilator users. This paper describes the evolution and current application of non-invasive respiratory aids in both acute and long-term settings. The respiratory function can be aided by applying forces to the body or intermittent pressure to the air ways. The devices are negative pressure body ventilators which act on the body by creating negative pressure around the thorax and abdomen such devices effectively maintain the ventilation of individuals with respiratory failure, but have the shortcomings of bulkiness, high expense, and limitation on the users' activities. The non-invasive positive pressure ventilator applies intermittent pressure directly to the airway by a non-invasive interface; namely mouthpiece, nasal, or face masks. In this way, it can prevent patients from requiring either tracheostomy or endotracheal tube, but is not effective enough to ventilate patients with markedly decreased lung compliance because the high airway resistance provides air leakage from the non-invasive interface. Non-invasive respiratory aids should be the first choice to maintain ventilation for patients with respiratory failure secondary to neuromuscular disorder, because of their benefits of easy application, satisfactory results, fewer complications and early active rehabilitation. Increased understanding of non-invasive respiratory aids should assist in the management of patients with chronic respiratory failure.

[Barium-pudding: a new medium for videofluoroscopic examination].

The evaluation of swallowing function is crucial in the management of dysphagic patients. It includes clinical assessment and laboratory tests that consist of fiberoptic endoscopic examination of swallowing (FEES) and videofluoroscopic examination. The "modified barium swallow" has been regarded as the standard procedure of videofluoroscopic examination since its introduction in 1983. The technique enables the entire process of deglutition to be observed with the benefits of safety, easily performance, and information. However, pitfalls developed in patients with pseudobulbar paralysis. Discrepancy always occurs between barium meals and real food and the refusal of swallow and misswallowing to the airway in videofluoroscopic examination sometimes occurs because of the unsatisfactory taste of barium meal. All these things make the procedure impractical and inaccurate. We developed a barium sulfate pudding that is better tasting, similar to real food as a pudding, is adequate to visualise on videofluoroscopic examination, and has the ability to represent the patient's capacity to swallow solid food. We present a case of hypoxic encephalopathy where the patient was considered to be in danger of aspiration when swallowing any consistency of foods. Barium-pudding study showed the patient had the ability to eat solid food with safety. We removed her nasogastric tube following barium-pudding assessment and successfully restored her oral feeding function within 2 weeks. Barium-Pudding is a better medium of videofluoroscopic examination by which to evaluate the swallowing function of solid food than Barium paste in patient, who have disturbed swallowing.

[Clinical application of the ice water test in evaluation of neurogenic bladder dysfunction].

Ice water test (IWT) and cystometrography (CMG) were performed on 51 in patients with spinal cord injuries (SCI) to evaluate the sensitivity and specificity of the IWT in detecting detrusor reflex. A three-step grading system as established by Balmaseda et al was applied to determine the presence of detrusor activity on IWT. The test was considered 3+ when the catheter was expelled from the bladder within one minute following instillation of 90 mL of ice water; a 2+ test indicated voiding around the catheter after instillation of 90 mL of ice water; and a 1+ IWT was defined as voiding around the catheter or expelling the catheter after instilling another 210 mL of ice water into the bladder. The results showed that the sensitivity of IWT in detecting the presence of detrusor reflex in patients with neurogenic bladder dysfunction was 96% and the specificity was 79%. Among the four patients having false positive IWT, three of them were diagnosed with poor-compliance bladders. One patient with false negative IWT was found to have severe detrusor-sphincter dyssynergy. There was a significant difference in the strength of detrusor activity among the patients with 3+ IWT, with 2+ IWT, and with 1+ IWT. IWT is a useful technique to predict the existence of detrusor reflex in SCI patients. Its use as a supplement method to cystometrogram could be helpful in the bedside evaluation of patients with neurogenic bladder dysfunction.

Tardy effect of neurogenic muscular atrophy by magnetic stimulation.

The influence of pulsed magnetic stimulation on denervated muscles was investigated in this study. Of 24 rats divided into three groups for experiment, 8 rats served as control; 16 rats with bilaterally severed sciatic nerves were divided into two groups for different modes of stimulation. Magnetic stimulation with a high power output that induced an intensive contraction of muscle was applied at one side-denervated gastrocnemius muscle for 1 mo in a group of rats; electric stimulation with high intensity at 6 Hz frequency and 1-ms pulse duration served as a contrast in the other group. Muscular weight, volume, fiber diameter and percentage of fiber types were measured after the experiment. A significant retardation of weight loss in denervated muscles via magnetic stimulation (P < 0.05) was confirmed by observed results. Type II fiber atrophy was retarded in denervated muscles by magnetic stimulation as well as in denervated muscles via electric stimulation. Magnetic stimulation, used as a method that induces muscular activity, was verified in this study as being capable of retarding denervated muscular atrophy. Its benefits of painless stimulation as well as deeply activated muscular contraction could be expected to function as a new model for rehabilitation of paralyzed muscles.

Cardiorespiratory responses of Tai Chi Chuan practitioners and sedentary subjects during cycle ergometry.

Tai Chi Chuan (TCC; shadow boxing) is a traditional Chinese conditioning exercise. To evaluate its beneficial effect on cardiorespiratory function, 21 male and 20 female TCC practitioners, ranging in age from 50 to 64 years, voluntarily participated in this study. The control group comprised 23 male and 26 female sedentary subjects. Breath-by-breath measurement of the cardiorespiratory function was obtained during the incremental exercise of leg cycling. At the maximal exercise level, the oxygen uptake (VO2), O2 pulse and work rate of the TCC group were significantly higher than the respective values of the control group (p < 0.01). At the ventilatory threshold, the TCC group also showed a higher VO2, O2 pulse and work rate (p < 0.05). The results imply that TCC training may be beneficial to the cardiorespiratory function of older individuals. To estimate the exercise intensity of TCC, heart rate (HR) was monitored in 15 men and 15 women while they performed the classical Yang TCC. During the steady-state performance of TCC, the mean HR was 130 +/- 14 bpm for men and 127 +/- 13 bpm for women. The mean HR during TCC exceeded 70% of their HRmax. Our data substantiate that TCC is aerobic exercise of moderate intensity, and it may be prescribed as a suitable conditioning exercise for the elderly.

Traumatic spinal cord injuries in the rural region of Taiwan: an epidemiological study in Hualien county, 1986-1990.

In order to survey the epidemiological characteristics of traumatic spinal cord injuries (SCI) in Hualien county, a retrospective study was conducted from January 1986 to December 1990 in four local general hospitals. During this period, 135 traumatic SCI patients were identified and 99 of them were residents of Hualien county. The estimated annual incidence of traumatic SCI in Hualien county was 56.1 per million population. As a result of injury 36 patients were tetraparetic, 33 tetraplegic, 12 paraparetic and 18 paraplegic. The male/female ratio was 4:1. The mean age of onset for male patients was 44 years, and that for female patients was 46 years. The major causes of SCI were traffic accident (61.6%) followed by accidental falls (23.3%). The average duration of hospitalisation ranged from 62 days in paraparetics to 132 days in tetraplegics. Ten patients died of respiratory failure or sepsis, and the mortality rate was 10.1%. Our data revealed that traumatic SCI was prevalent in Hualien county in comparison with epidemiological studies elsewhere. The special population composition of Hualien county and the preponderance of the motorcycle as a transportation vehicle in this area might result in its unique epidemiological characteristics.

Anaerobic threshold and maximal oxygen consumption during arm cranking exercise in paraplegia.

The major purpose of this investigation was to compare the anaerobic threshold (AT) and maximal cardiopulmonary responses to arm exercise between persons with paraplegia and the able-bodied. The locomotive stress on the heart in paraplegic subjects was also examined. Thirty-nine paraplegic subjects (T1-L4 lesions) and 32 able-bodied subjects completed a continuous, progressive, resisted arm cranking exercise test. The AT was determined from the ventilatory parameters. At the AT, the mean values of Vo2/body weight (BW) for class II (T1-T5, N = 9), III (T6-T10, N = 11), and IV (T11-L4, n = 19) paraplegic subjects were 10.9, 13.2, and 13.5mL/kg/min, respectively, and only class II had significantly lower value than the able-bodied (14.4mL/kg/min). During maximal exercise, the mean values of maximal oxygen consumption per body weight (Vo2max/BW) for class II and III paraplegics were 17.4 and 17.7mL/kg/min, respectively, which were significantly lower (p < 0.05) than that of class IV (21.3mL/kg/min) and the able-bodied (28.2mL/kg/min). The heart rate (HR) during wheelchair-propelling (119bpm, n = 37) was significantly less than that at the AT (134bpm), but the HR during crutch-walking (151bpm, n = 17) was significantly higher. The results indicate that both submaximal and maximal cardiopulmonary functions in high-lesion paraplegics were less than that of the able bodied. Furthermore, the intensity of wheelchair-propelling at comfortable speed is not enough for improving the cardiopulmonary functions.

Scrotal temperature in spinal cord injury.

Twenty-five spinal cord-injured (SCI) males and 25 normal volunteers were studied for their scrotal and thigh temperatures by using contact liquid crystal thermography. The initial temperature was recorded after transfer and disrobing which took about 2 minutes. Later temperature was recorded 10 minutes after exposing the genitalia to room air (20-22 degrees C). The initial scrotal and thigh temperatures of SCI subjects were significantly higher than those of normal volunteers (32.8 +/- 0.8 degrees C v 31.6 +/- 0.4 degrees C; 32.9 +/- 0.8 degrees C v 31.7 +/- 0.4 degrees C, respectively, P < 0.001), although their rectal temperatures were not different. The scrotal and thigh hyperthermia of SCI subjects disappeared after 10 minutes of exposure to room air. There was no significant difference between scrotal and thigh temperatures in either the SCI subjects or the normal volunteers in the later temperature reading. Sitting in a wheelchair for 2 hours results in an increase of average 0.8 degrees C of scrotal and thigh temperature in five normal volunteers. Our study suggests that scrotal hyperthermia of SCI subjects is mainly the result of local factors such as a prolonged sitting position, adduction of the thighs, the cushion's insulating effect and infrequent movement of the buttocks. Adequate ventilation of the scrotal area can overcome the impaired scrotal heat dissipation of SCI subjects. Liquid crystal thermography is a useful, noninvasive method for detecting hyperthermia in SCI subjects.