Pulmonary embolism in rehabilitation patients: relation to time before return to physical therapy after diagnosis of deep vein thrombosis.

OBJECTIVE: There is increased risk of a pulmonary embolism (PE) after a deep vein thrombosis (DVT). The effect of mobilizing the affected lower extremity has not been well studied. The purpose of this study was to detect any change in the rate of PE occurrence dependent on time to mobilization in patients diagnosed with a DVT in a rehabilitation hospital. DESIGN: Retrospective case-control study. SETTING: Urban rehabilitation hospital. PATIENTS: Data were collected from charts of 190 patients with a discharge diagnosis of PE or DVT at an urban rehabilitation hospital from January 1991 to June 1995; 127 patients met inclusion criteria in the study. INTERVENTIONS: Measurement of time to return to physical therapy after diagnosis of DVT. MAIN OUTCOME MEASURES: A DVT was diagnosed with either Doppler ultrasound or venogram testing, a PE by ventilation/perfusion (V/Q) scan, and time to mobilization in hours until return to physical therapy. RESULTS: One hundred twenty-one patients had a DVT without a subsequent PE and a mean time of 123.2 hours until mobilization. Six patients had a subsequent PE and a mean time of 48.3 hours until mobilization (p = .021). A Fischer exact test comparing patients with and without PE who were returned to therapy before 48 hours and after 48 hours (p = .018), and before and after 72 hours (p = .059), supports the hypothesis that patients who return to physical therapy earlier are more likely to develop a PE than patients who return later. CONCLUSIONS: It is imperative to prophylactically treat all patients at risk of a DVT with anticoagulation if possible. Once a DVT is diagnosed it is prudent to keep the affected limb immobilized for at least 48 to 72 hours while the patient is being anticoagulated. A large prospective cohort study is needed to answer the question of when to mobilize a patient after diagnosis of a DVT.

Common obstacles to the daily functioning of pediatric traumatically brain injured patients: perceptions of caregivers and psychologists.

Common difficulties encountered by patients with pediatric traumatic brain injuries (referred to hereafter as pediatric TBI patients) were identified, and the congruence between caregiver and professional perceptions of these problems was examined. Forty-seven caregivers identified 118 obstacles experienced in the care of their pediatric TBI patients. Another sample of 46 caregivers cross-validated these problems by rating each for its frequency and difficulty. Items were tank ordered by their composite score, a derived measure obtained for each item by cross-multiplying the frequency and difficulty ratings. Twenty psychologists who work with pediatric TBI patients also rated each of the 118 problem situations. A modest correlation (tau = .28, p < .001) between the two groups' rank orders of the problem situations, although significant, suggests that there are discrepancies between caregiver and professional perceptions of problem situations. Items perceived as most common and difficult by caregivers often received far lower ratings by psychologists and vice versa. The results suggest that carefully evaluating individual patient concerns may contribute to more efficient use of professional resources and improved patient education and follow-up care.

Neuropsychological patterns of adolescents and young adults with spina bifida.

The purpose of this study was to examine neuropsychological profiles for patients with spina bifida. The sample consisted of 37 subjects with spina bifida between the ages of 14 and 23. Each of the subjects was seen individually and administered the Halstead-Reitan Neuropsychological Test Battery as well as the appropriate Wechsler Intelligence Scale. Scores from the Halstead-Reitan were subjected to cluster analysis to formulate clinical subtypes. The results indicated a three group solution was most appropriate, which appeared to reflect a continuum of dysfunction. Implications for rehabilitation programming are discussed.

Developing anxiety-reduction procedures for a ventilator-dependent pediatric patient.

This study evaluated two strategies to reduce anxiety behaviors which interfered with the daily tracheostomy care and ventilator maintenance of an eight-year-old ventilator-dependent boy. A multiple-baseline design (across ventilator and tracheostomy procedures) was used to evaluate the effectiveness of an information-only procedure and combined relaxation and cognitive distraction procedures. Partial-interval recording was used to measure heart rate, disruptive mouth noises, and demands and complaints to staff members. The patient's behavior did not change during a no-intervention baseline or during the information-only condition. Cognitive distraction and relaxation procedures were introduced, first during ventilator checks and then during tracheostomy care; corresponding decreases in heart rate, mouth noises, and demands and complaints were noted. Gains were maintained at one year follow-up. Results suggest that information alone may not effectively reduce anxiety behaviors for some ventilator-dependent patients unless additional anxiety-reduction procedures are implemented.

Protocol for the use of videofluoroscopy in pediatric swallowing dysfunction.

A clinical and research protocol was developed to compare the sensitivity and clinical value of videofluoroscopy with the traditional bedside clinical evaluation in the evaluation of children's swallowing dysfunction. The bedside and videofluoroscopic evaluations of 33 children were reviewed retrospectively. Our findings indicated that recommendations for feeding changed for 14 of the children as a result of the information gained from videofluoroscopic evaluation. The results suggest that videofluoroscopy provides therapists with more objective evidence than a bedside evaluation for determining the etiology of swallowing dysfunction and directing the management or treatment of this dysfunction.

Behavioral rehabilitation of functional alexia.

A 10-year-old boy with a functional reading deficit (i.e. functional alexia) was successfully treated with hospital based escape/avoidance procedures. A multiple baseline design was used to evaluate the effectiveness of treatment. Generalization of treatment effects across individuals, settings and time was demonstrated. Extension of these procedures to other functional deficits is discussed.