A comparison of regular rehabilitation and regular rehabilitation with supported treadmill ambulation training for acute stroke patients.

The purpose of this pilot study was to compare differences in motor recovery between regular rehabilitation (REG), and regular rehabilitation with supported treadmill ambulation training (STAT) using the performance on a bicycle exercise test and the locomotor scale of the Functional Independence Measure (FIM-L). Twelve patients with acute strokes were randomly assigned to either REG or STAT for 2 to 3 weeks. The STAT group received daily gait training utilizing a treadmill with partial support of body weight. After intervention, the STAT group had higher oxygen consumption (11.34+/-0.88 vs 8.32+/-0.88 ml/kg/min, p=0.039), total workload (58.75+/-7.09 vs 45.42+/-7.09 watts, p=ns), and total time pedaling the bike (288.91+/-30.61 vs 211.42+/-30.61 s, p=ns) compared to the REG group. The FIM-L scores were not different for the two groups. This pilot study suggests that the STAT intervention is a promising technique for acute stroke rehabilitation, and that future studies with larger sample sizes are warranted to establish the effectiveness of this intervention.

Coping with chronic pain: a comparison of two measures.

Cognitive-behavioral models of chronic pain hypothesize that how a person copes with pain influences how well he or she adjusts to the pain. Several measures have been developed to assess pain coping, but no studies have yet examined whether these measures are complementary or redundant. In the current study, two pain coping measures (the Chronic Pain Coping Inventory, CPCI, and the Coping Strategies Questionnaire, CSQ) were completed by a large number (N=564) of primarily male veterans referred to a chronic pain program. Regression analyses indicated that the CPCI scales did not contribute unique variance to the prediction of depression over and above the CSQ scales. The CSQ Catastrophizing scale was the single most powerful predictor of depression, although several other CSQ scales (Coping Self-Statements, Diverting Attention, and Increasing Behavioral Activities) also contributed. Both the CPCI and the CSQ contributed unique variance to the prediction of disability, although the CPCI scales appear to be more strongly related to disability than the CSQ scales. The CPCI Guarding scale was the single most powerful predictor of disability of all the coping responses assessed in this study. Other scales predicting disability were the CPCI Seeking Social Support, the CSQ Catastrophizing, and the CSQ Increasing Behavioral Activities. While both CSQ and CPCI contribute unique but modest variance to the prediction of pain severity, the CSQ Catastrophizing scale was the single most powerful predictor of pain severity. The findings of this study are consistent with cognitive-behavioral models of pain. Future research will need to determine whether changes in coping responses (catastrophizing and guarding, in particular) merely reflect, or actually influence, adjustment to chronic pain. In the meantime, clinicians would be wise to give these coping responses particular attention in chronic pain programs.

Vocational rehabilitation outcomes of veterans with substance use disorders in a partial hospitalization program.

The authors examined factors that influenced the employment rates of 529 veterans with severe alcohol and other substance use disorders who were being treated at an addictions partial hospitalization program. The employment rate was significantly higher for veterans who completed the hospitalization program, participated in a Veterans Industries work-for-pay program, and received drug-free supportive housing.

Sexuality in persons with lower extremity amputations.

PURPOSE: There is a paucity of information regarding sexual functioning in persons with lower extremity amputations. The purpose of this study was to describe sexual and psychological functioning and health status in persons with lower extremity amputation. METHODS: Self-report surveys assessed sexual functioning (Derogatis Inventory), depression (Beck Depression Inventory, anxiety (State-Trait Anxiety Inventory), and health status (Health Status Questionnaire) in a convenience sample of 30 men with lower extremity amputations. Mean age of the participants was 57 years (range 32-79). Mean duration since amputation was 23 months (range 3-634 months). Twenty one subjects (70%) had trans-tibial and seven subjects (23%) had trans-femoral amputations. RESULTS: A majority of subjects were experiencing problems in several domains of sexual functioning. Fifty three percent (n = 16) of the subjects were engaged in sexual intercourse or oral sex at least once a month. Twenty seven percent (n = 8) were masturbating at least once a month. Nineteen subjects (63%) reported orgasmic problems and 67% were experiencing erectile difficulties. Despite these problems, interest in sex was high in over 90% of the subjects. There was no evidence of increased prevalence of depression or anxiety in these subjects when compared to other outpatient adult populations. CONCLUSIONS: Sexual problems were common in the subjects studied. Despite these problems, interest in sex remained high. Few investigations have been directed toward identifying the psychological and social factors that may contribute to these problems and more research with a larger population is needed in this area.

Prospective study of fatigue in localized prostate cancer patients undergoing radiotherapy.

The objectives were to (1) prospectively evaluate fatigue utilizing validated instruments in patients with localized prostate cancer, and (2) examine the relationships between fatigue, depression, quality of life, and sleep disturbance. The instruments used included: Piper Fatigue Scale, Beck Depression Inventory, Epworth Sleepiness Scale, and Functional Assessment of Cancer Therapy for Prostate Scale. Data on cancer stage, prostate specific antigen levels, hematocrit, patient's body weight and radiation dosage were recorded. Patients were evaluated preradiotherapy, middle of radiotherapy, completion of radiotherapy, and at 4-5 weeks follow-up. Thirty-six veterans with localized prostate cancer were studied. Mean age was 66.9 years (range 55-79). Duration of treatment was 7-8 weeks. Univariate procedure and Wilcoxon Signed Rank-test were used to examine changes in pretreatment scores for each of the three subsequent study periods. To adjust for multiple comparisons Bonferroni test was used. Spearman Correlations were calculated among parameters. No significant changes were noted in mean scores of hematocrit and body weight during the study period. On the Piper Fatigue Scale, adjusted for multiple comparisons, the median scores were significantly higher at completion of radiotherapy as compared with preradiotherapy values. Three patients (8%) were experienced fatigue according to Piper Fatigue Scale before treatment as compared to nine patients (25%) at completion of radiotherapy. On Prostate Cancer Specific and Physical Well Being subscales of the Functional Assessment for Prostate Cancer Therapy, the scores were significantly lower at middle and completion of radiotherapy than at pretreatment. At preradiotherapy, middle of radiotherapy, completion of radiotherapy and follow-up evaluation, patients scoring higher on the Piper Fatigue Scale were more likely to report a poorer quality of Physical Well Being on Functional Assessment of Cancer Therapy for Prostates. No significant changes were noted in the Beck Depression Inventory and Epworth Sleepiness Scale scores during treatment. Eight patients scored 10 or more on the Beck Depression Inventory before starting radiotherapy, suggesting depressive symptomatology. Of these, only seven patients scored 10 or more at completion of treatment. The incidence of fatigue is lower in our study than in previously published data. A relationship exists between fatigue scores and physical well being subscale scores. Higher scores on the Piper Fatigue Scale at the completion of radiotherapy, as well as no changes on depression and sleepiness scales, suggest that fatigue may not be the result of depression or sleep disturbance. Based upon our previous work, we propose that the physical expression of fatigue may be secondary to a decline in neuromuscular efficiency and enhanced muscle fatigue.

Sexuality and sexual adjustment of patients with chronic pain.

PURPOSE: To describe sexual functioning and its relationship with psychological measures in chronic pain patients. METHOD: It is a self report survey with a convenience sample. Seventy consenting chronic pain patients responded to a questionnaire. Mean age was 49.9 years (range 29-74); mean pain duration was 146.7 months (range 6-624). Participants endorsed a wide variety of pain conditions. INSTRUMENTS USED: (1) Derogatis Inventory of Sexual Functioning; (2) Multidimensional Pain Inventory; (3) Center for Epidemiological Studies Depression Scale: (4) Multidimensional Health Locus of Control; (5) Hopkins Symptom Check List; (6) Vanderbilt Pain Management Inventory; (7) Coping Strategies Questionnaire. RESULTS: Sixty-six per cent of patients were interested in sex, 50% were satisfied with current sexual partner and 20% considered current sexual life to be adequate. Over 70% fantasized at least once a month. Only 44% experienced normal arousal during intercourse; 33% practiced masturbation and 47% were involved in sexual intercourse or oral sex at least once a month. The majority were dissatisfied with orgasmic activities. No relationship was found between pain severity, duration, frequency and sexual functioning. A relationship was found between disability status, age and several psychological variables and various domains of sexual functioning. CONCLUSIONS; Sexual problems are common in chronic pain patients. Patients who reported symptoms of depression and distress had more sexual problems.

Neuromuscular fatigue in prostate cancer patients undergoing radiation therapy.

OBJECTIVE: To determine the etiology of fatigue in prostate cancer patients undergoing radiation therapy (RT). METHODS: Thirteen prescreened men (60 to 76 years in age, 58 to 130 kg in body weight) were evaluated for neuromuscular fatigue (NMF) of the tibialis anterior (TA) muscle, cardiopulmonary fatigue (CPF), and psychological-subjective fatigue (PSF) at 1 to 2 weeks before RT (Pre), at the end of 8 weeks of RT (RT), and at 5 to 6 weeks after completion of RT (Post). OUTCOME MEASURES: For NMF, the TA muscle was fatigued by sustained isometric contraction at 80% of maximum voluntary contraction for 60 seconds on a force dynamometer. Neuromuscular efficiency (NME) expressed as a ratio of isometric force (in Newtons) and respective integrated electromyograms were measured. For CPF, stress testing was performed on a treadmill using the modified Bruce protocol. Piper Fatigue Scale, Beck Depression Inventory, and Epworth Sleepiness Scale were administered to evaluate PSF. DATA ANALYSIS: Paired t tests, single factor analysis of variance, and nonparametric analysis. RESULTS: At RT, there was a significant decline in NME of TA at the beginning (18.4%, p < .01) and the end (29.2%, p < .001) of sustained muscle contraction for 60 seconds. Post values were lower but nonsignificant in comparison with Pre values. NME recovered within 5 to 6 weeks after RT. No abnormalities were detected in CPF or PSF. No correlation was found between the decline in NME and psychological status of the patients. CONCLUSION: Results provide definitive evidence of transient decline in NME in prostate cancer patients at the completion of RT. The effect seems to be specific for neuromuscular performance alone and is independent of the cardiovascular or psychological status of the patients.

Sexuality in head and neck cancer patients.

OBJECTIVE: To describe sexual functioning and its relationship with age, extent of disfigurement, performance status, and psychological functioning in head and neck cancer patients following radiation therapy with or without surgery. DESIGN: Descriptive study, self-report survey, convenience sample. SETTING: Academic tertiary care Veterans Administration Medical Center. PATIENTS: Fifty-five of 101 consenting patients responded to the questionnaire. Mean age of the patients was 65.1 years (range 48 to 76); 54 were men. The mean duration since diagnosis was 30.6 months (range 3 to 216). All patients received radiation therapy and 26 also underwent surgery. MAIN OUTCOME MEASURES: Instruments included were: The Derogatis inventory of Sexual Functioning, Multidimensional Health Locus of Control. The Center for Epidemiological Studies Depression Scale, Hopkins Symptom Check List, and List Performance Status Scale. RESULTS: Eighty-five percent showed interest in sex. Fifty-eight percent were satisfied with their current sexual partner and 49% were satisfied with their current sexual functioning. Most of them were able to fantasize: however, a majority reported arousal problems, 58% did not participate in sexual intercourse, and 58% had orgasmic problems. Most patients were not depressed. As a group these patients reported significantly more somatic distress but significantly less generalized feeling of distress when compared with a group of nonpatient nurses. Patients with "powerful others" locus of control showed significantly worse sexual functioning. There was no correlation between sexual functioning and performance status or severity of disfigurement. Patients younger than 65 years of age had more advanced disease, lower performance status and significantly poorer sexual functioning; those older than 65 years were more satisfied with their sexual partner and current sexual functioning. CONCLUSION: Despite experiencing sexual problems, sexuality continues to be a priority in the majority of patients studied.

Post-stroke autonomic nervous system function: palmar sympathetic skin responses thirty or more days after cerebrovascular accident.

We studied sympathetic nervous system (SNS) function after cerebrovascular accident (CVA) by measuring hypothenar sympathetic skin responses (SSR) to normal or hemiplegic arm electrical stimulation. We anticipated SNS function after CVA to be asymmetric and selected null hypotheses of bilaterally symmetric SSR latencies and amplitudes irrespective of side of stimulation and/or recording. Thirteen patients between ages 44 and 77 years (median 59) were tested between 1 and 72 months (median 15) after CVA. Hypothenar recording and dorsal reference surface electrodes were used. Amplifier bandwidth was set from 0.5 to 100 Hz. Gain was adjusted to allow adequate recognition of the waveforms. Sweep speed was set to 500ms/div. Stimulus width was set to 0.2 ms and intensity was increased stepwise from 10mA initially until optimum responses were obtained. Nonparametric statistics were used to analyze the data. SSRs were present in all patients on both the normal and the hemiplegic sides irrespective of the side of stimulation. Median SSR latency recorded homolaterally to the stimulus site was found to be 80ms shorter than median SSR latency recorded heterolaterally. Median SSR latency in left hemiplegics was found to be 16% longer than in right hemiplegics. Otherwise, neither side of hemiplegia, side of stimulation, side of recording nor any paired combination thereof were found to be significant. Our finding of bilaterally obtainable SSRs after CVA diverges from that of Uncini and colleagues but presumably only reflects the difference in poststroke chronology between the respective samples.

Neuromuscular adaptations during 30 days of cast-immobilization and head-down bedrest.

Prolonged skeletal muscle disuse, during space flights and on Earth, produces distinct adaptive changes in the neuromuscular system of human subjects. There is a significant decline in muscle mass and strength, exercise capacity, fatigue resistance, integrated EMG (IEMG) output and time-dependent alterations in the behavior of Hoffman (H) and deep tendon reflexes. The objective of this study was to examine the changes in excitability of segmental motoneuronal network and its influence upon gastrocnemius-soleus (G-S) function in healthy male and female subjects, who underwent either 6 degrees head-down bedrest (HDB) or unilateral cast-immobilization (CIM) for a period of 30 days.

Changes in medical stability upon admission to a rehabilitation unit.

The implementation of Medicare's prospective payment system in acute care has coincided with a steady increase in medically unstable admissions to our freestanding rehabilitation facility. We investigated the consequences of these admissions by collecting medical information regarding transfers beginning in 1983. Patients requiring transfer back to the acute setting within 1 day of admission were considered medically unstable and their charts were reviewed. The number of patients requiring transfer back within 1 day increased from 1.5% of all first admissions to 3.1% in 1988 (Mantel - Haenszel chi 2 = 8.03, (df = 1), p < .01), but the increase among Medicare patients alone was not significant. This progressive increase was most pronounced in the cerebrovascular accident and spinal cord injury populations. Beginning in 1988, an intensified preadmission evaluation program was implemented, resulting in a significant decline in unstable patient transfers from hospitals where our consultants were on staff. Physiatric consultations at referral institutions decreased the number of unstable patients at admission.

Intraoperative monitoring of an unusual brachial plexus tumor.

This case illustrates the importance of intraoperative monitoring of neuronal function to help separate tumor tissue from neural tissue in a 54-year-old patient with left shoulder pain resulting from a desmoid tumor. Preoperative nerve conduction and electromyographic studies showed a lesion in the lateral cord of the brachial plexus, which was found to be intimately involved with the tumor mass and was splayed into a very thin effaced sheet of neural tissue. Stimulation of the tumor/nerve tissue mass proximal to the lesion was impossible due to the invasion of the brachial plexus by the tumor. The technique that was adapted for this unusual presentation was to stimulate the tumor/nerve tissue mass itself and record compound muscle action potentials distally. With the technique described, a subtotal resection of an aggressive fibromatosis enmeshed in the proximal brachial plexus was possible, and excellent relief of pain symptoms and retention of functional capabilities of the involved extremity were achieved.

Management of apraxic gait in a stroke patient.

There is little information available regarding management of apraxic gait. We present a 61-year-old man with a five-year history of right-sided cerebrovascular accident, apraxic gait, difficulty in walking, and frequent falls. A CT head scan revealed moderate cerebral atrophy, a small lacunar infarction. The patient was unable to initiate walking, was bed ridden and housebound. Traditional gait training and balance exercises failed to improve his gait. Two straight canes were modified by fixing florescent horizontal projections approximately two inches up from the tip of the cane. The patient was instructed to step over the horizontal projected portion, making use of visual cues from the florescent painted projections. The patient became independent with safe ambulation after practicing for approximately three weeks and was discharged home.

Work and power in gait of stroke patients.

Biomechanical analysis of the work and power patterns involved in gait provides insight into the nature of gait deficits and suggests methods for improvement. The purpose of this study was to describe the work and power characteristics during gait for both limbs of hemiplegic patients, and to determine the work and power variables related to self-selected speeds of walking. The gait of 30 ambulatory adults between the ages of 47 and 79 years was studied using two-dimensional cinematography and force-plate data in a link-segment model. About 40% of the positive work required for walking was performed by the muscles of the affected side. Major contributors were the ankle plantar flexors, hip flexors, and hip extensors. The results suggest interdependence between the limbs and between muscle groups of the same limb; a need for further research is indicated.

Cardiac pacemaker inhibition by transcutaneous electrical nerve stimulation.

The use of transcutaneous electrical nerve stimulation (TENS) has increased in recent years for the management of chronic pain. One of its few contraindications is the presence of a cardiac pacemaker. Clinicians have recommended that cardiac monitoring be performed for a short interrupted period during the first application of TENS to ensure safety. We present two patients who were given trials of TENS for different chronic pain complaints. In both cases, electrocardiograms during the TENS trial did not reveal cardiac pacemaker dysfunction, but extended cardiac monitoring with the Holter monitor showed interference with pacemaker function. The abnormalities did not recur after reprogramming the sensitivity of the pacemakers. We suggest the use of extended cardiac monitoring for patients with cardiac pacemakers during the prolonged use of TENS to ensure safety and to determine any need for reprogramming of the pacemakers. Patients with cardiac pacemakers should not be excluded from the use of TENS, but careful evaluation and extended cardiac monitoring should be performed.

Reflex sympathetic dystrophy in central cord syndrome: case report and review of the literature.

Reflex sympathetic dystrophy (RSD) has been reported in incomplete spinal cord injury patients, most often occurring unilaterally; however to our knowledge, bilateral RSD has not been reported in patients with a central cord syndrome. We report a case of bilateral RSD in a patient with incomplete cervical myelopathy and the clinical picture of central cord syndrome. Diagnosis of RSD was based upon clinical, roentgenographic and scintigraphic findings. Management of RSD included elevation of forearm and hands, gentle active and passive range of movements of all upper extremity joints and systemic corticosteroids. With treatment, pain subsided, the range of motion of the joints improved and the patient achieved good functional recovery.

Differential treatment responses on somatic pain indicators after EMG biofeedback training in back pain patients.

Treatment responses to relaxation-oriented EMG biofeedback (EMGBF) in patients categorized in terms of the Back Pain Classification Scale (BPCS) were examined. It was demonstrated that the previously observed effectiveness of EMGBF training became even more pronounced when the patients were divided into "organic" and "functional" subtypes according to the BPCS. The "organic" group showed the greatest degree of improvement. The mechanism of treatment effectiveness is discussed with reference to physiological changes, i.e., restoration of appropriate back muscle strength and back muscle functioning.

Cardiovascular responses to acute exercise in patients with cerebrovascular accidents.

Blood pressure (BP) and heart rate (HR) responses to isometric hand grip, exercise with the cybex arm ergometer, and cybex fitron cycle ergometer were recorded for 19 stroke subjects and 19 control subjects matched by age and gender. Mean age in both groups was 66 years. There was no significant difference in the resting HR (controls: 69 +/- 10, patients: 70 +/- 11 beats per minute) and BP measurements (systolic--controls: 140 +/- 17, patients: 135 +/- 21; diastolic--controls 80 +/- 8, patients: 75 +/- 11mmHg). There was also no significant difference in either the mean HR (controls: 79 +/- 10, patients: 81 +/- 12 beats per minute) or BP (systolic--controls: 174 +/- 23, patients: 165 +/- 27; diastolic--controls: 98 +/- 15, patients: 92 +/- 14) response to exercise. With the arm ergometer test, the control group attained a significantly higher maximum systolic (190 +/- 23 mmHg) and diastolic blood pressure (102 +/- 15mmHg) than the stroke group (systolic 165 +/- 23; diastolic 91 +/- 10mmHg). During the leg ergometer exercise test, results were similar in both groups except that work completed was significantly higher for the control group (3592 +/- 1162kg) than for patients (2512 +/- 1348kg). None of the patients reported symptoms of dizziness, fainting, or chest pain. Prescribed exercise in stroke patients under supervision and within patient tolerance was found to be safe.