Attitudes of rehabilitation medicine doctors toward medical ethics in Malaysia.

INTRODUCTION: Medical ethics issues encountered in rehabilitation medicine differ from those in an acute care setting due to the complex relationships among the parties involved in rehabilitative care. The study examined the attitudes of Malaysian rehabilitation doctors toward medical ethics issues commonly encountered during patient care. METHODS: We surveyed 74 rehabilitation physicians and residents in Malaysia using a self-administered descriptive questionnaire. The questions covered medical ethics issues on allocation of resources, patient confidentiality, discharge planning, goal-setting, reimbursement documentation, decision-making capacity and withdrawal of life support. RESULTS: The overall response rate was 69 percent. More than 80 percent of respondents would disclose confidential information to their team members if it would affect the rehabilitation process. More than two-thirds of respondents would not allocate scarce rehabilitation resources if the functional outcome is marginally positive. Issues involving patients' autonomy in decision-making, both in life-threatening and non-life-threatening situations, showed mix responses. The least common response was on the issue of discharge planning, where 51 percent of respondents would send a patient back to a nursing home with suboptimal care if there were no other alternatives. CONCLUSION: The attitude of Malaysian rehabilitation doctors toward ethical issues is reflective of the level of maturity of rehabilitation medicine in Malaysia. Issues on allocation of resources, discharge planning and decision-making capacity are significantly influenced by limited rehabilitation facilities in parts of the country. The lack of influence from external factors, such as a developed health insurance system, contributes to the difference in attitude between rehabilitation doctors in Malaysia and those in developed countries.

The use of unconventional pressure redistributing cushion in spinal cord injured individuals.

STUDY DESIGN: Case report. OBJECTIVES: To report an unconventional pressure-redistributing cushion used by spinal cord injured individuals. SETTING: Department of Rehabilitation of Medicine, University Malaya, Kuala Lumpur, Malaysia. METHODS: Description of three cases of persons with spinal cord injury (SCI) using unconventional pressure relieving cushions, and despite high pressure noted on pressure mapping they did not develop pressure ulcer. CONCLUSION: Education and awareness of pressure ulcer prevention is most important in SCI population, as technology is still an adjunct.

Benefit of triple-strap abdominal binder on voluntary cough in patients with spinal cord injury.

STUDY DESIGN: A cross-sectional experimental study. OBJECTIVE: The purpose of this study is to examine the benefit of elastic abdominal binders on voluntary cough in persons with spinal cord injury. SETTING: Spinal rehabilitation unit in a teaching hospital. METHODS: We measured voluntary cough peak expiratory flow rate (in 21 subjects with spinal cord injury, (18 tetraplegia, 3 paraplegia) under three conditions: without abdominal binder as the baseline, with single-strap abdominal binder and triple-strap abdominal binder. RESULTS: The results showed that the mean cough peak expiratory flow rate in all subjects without abdominal binder was 277.1 l per min. There was a significant increase in flow rate with the use of abdominal binders: 325.7 l per min with single-strap abdominal binder and 345.2 l per min with triple-strap abdominal binder (P<0.05, paired t-test). The mean cough peak expiratory flow rate in tetraplegic subjects using triple-strap abdominal binders was significantly higher compared with those using single-strap abdominal binders (322.1 l per min and 299.4 l per min, respectively). CONCLUSION: Abdominal binders can be used as an effective method to improve cough ability in spinal cord injured patients, with triple-strap abdominal binder achieving greater cough peak expiratory flows.

Return to work after spinal cord injury: factors related to time to first job.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To investigate factors related to length of time between spinal cord injury (SCI) onset and start of first post-injury employment. SETTING: Persons living with SCI in the community who are members of a disability support organization. METHODS: Participants were randomly selected from the membership list of a non-governmental voluntary organization. They met the following four criteria: traumatic SCI, minimum of 15 years of age at the time of survey, a minimum of 2 years after SCI and had been employed for some time since SCI. The main outcome measure was time (in years) from injury onset to beginning first post-injury job. RESULTS: Participants averaged 4.9 years (s.d. 5.1) from the time of SCI to their first post-injury job, with a range of 3 months to 20 years. Fifty percent of the participants who eventually returned to work had done so by 4 years. Return to pre-injury employer and employment were associated with early return, whereas having less years in education and being older at the time of injury were associated with longer time to return to work. CONCLUSION: Rehabilitation team need to consider return to employment as a realistic goal even many years after SCI. Perhaps a focus on returning more people to their pre-injury employer and employment with added focus and input from rehabilitation team for those with lower education status and older age at time of injury might expedite the process of reintegration.

Barriers to sexual activity: counselling spinal cord injured women in Malaysia.

STUDY DESIGN: This study is a cross-sectional, face-to-face interview. OBJECTIVES: To examine the sexual activity in a sample of Malaysian women with traumatic spinal cord injuries (SCIs), identify the physical and psychological barriers to it, and explore their experiences with sexual counseling and rehabilitation. SETTING: This study was conducted at the Spinal Rehabilitation Unit of a teaching hospital. METHODS: All women who attended scheduled check-ups, over 1 year, and who met the inclusion criteria (age above 18 years, spinal injury of traumatic aetiology, living in the community and having completed the rehabilitation) were consecutively included in a face-to-face interview using a self-constructed questionnaire. Sociodemographic and disability-related variables, barriers to sexual activity/satisfaction and experiences of sexual rehabilitation services were obtained. RESULTS: During the study period, 33/36 subjects were recruited. Although 67% indicated interest in sexual activity, only 24% was sexually active. The frequency of sexual activity declined after the injury, from 4.6 times per month to 1.5 times per month. Feeling unattractive, unable to satisfy the partner and less confident about sexual ability were top three psychological barriers to sexual activity, and the top three physical barriers were impaired genital sensation, positioning and vaginal lubrication. In all, 50% received some sexual information during rehabilitation. Rehabilitation professionals were expected to initiate sexual counseling by 62.5% of subjects. CONCLUSION: The effect of SCIs on sexual function is tremendous. Sexual counseling services must be improved and take into account the impact of psychological factors.

Compressive radial neuropathy induced by 'hooking' manoeuvre in a tetraplegic person.

STUDY DESIGN: Case report. OBJECTIVE: To describe a case of radial nerve compression neuropathy caused by a common wheelchair technique (hooking manoeuvre) used by a tetraplegic person to maintain truncal stability on a wheelchair. SETTING: Department of Rehabilitation Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. METHOD AND RESULTS: A 45-year-old man with American Spinal Injury Association Impairment Scale A C6 for the last 32 years developed progressive weakness of the right upper limb that was associated with pain in the shoulder and arm. Serial physical examinations demonstrated motor and sensory deterioration. Magnetic resonance imaging of the spinal cord showed no evidence of syringomyelia. Electrodiagnostic study showed motor and sensory neuropathy of the right radial nerve in the axillary region. CONCLUSION: The act of hooking the arm behind the wheelchair push handle causes trauma leading to radial nerve compression neuropathy. Because this technique is used frequently by wheelchair users, future studies should examine the prevalence of radial neuropathy in this population and develop alternative methods to maintain balance on the wheelchair.

Spinal pseudomeningocoele: a diagnostic dilemma.

STUDY DESIGN: Case report. OBJECTIVE: To describe the difficulty in diagnosing spinal pseudomeningocoele. SETTING: Department of Rehabilitation Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. CASE REPORT: A case of progressive sacral swelling in a paraplegic man who sustained spinal cord injury 14 years ago is presented. Although his clinical features were suggestive of pseudomeningocoele, we were unable to confirm the diagnosis preoperatively. CONCLUSION: Traumatic spinal pseudomeningocoele is very rare. Even with the available modern diagnostic imaging techniques, it is still difficult to diagnose a spinal pseudomeningocoele.