Ambulatory efficiency in persons with acquired brain injury after a rehabilitation intervention.

OBJECTIVE: the purpose was to assess changes in cardiorespiratory responses to treadmill ambulation in a sample of patients with acquired brain injury. RESEARCH DESIGN: a repeated measures, pre-test post-test design examined differences between submaximal and peak responses at admission and discharge. METHODS AND PROCEDURES: forty individuals (29 male, 11 female) were studied. Subjects performed an ambulatory treadmill test during which heart rate (EKG) and oxygen consumption (VO(2)) were monitored continuously. Total ambulation time (TAT) was also recorded. RESULTS: TAT increased from 10.3 (SD 3.1) minutes to 13.6 (SD 3.5) minutes (p < 0.01). Peak HR did not change (168 (SD 20) bpm vs. 167 (SD 21 bpm)) nor did peak VO(2) (23.5 (SD 6.6)ml/min/kg vs. 24.3 (SD 6.4)ml/min/kg; p = 0.09). However, both sub-maximal HR and VO(2) decreased (p < 0.05) between 2-12 minutes when most subjects were still capable of ambulating. CONCLUSIONS: the results suggest an improvement in both aerobic capacity and movement efficiency. Further controlled studies will be necessary to distinguish between cardiorespiratory and neuromuscular adaptations. The changes observed should allow for greater community participation and functional independence after discharge.

Issues and dilemmas of developing a new faculty practice plan.

Due to changes in health care and increased knowledge of the public concerning health care, faculty need to assume a more active role in practice settings. Faculty involvement in the practice of their disciplines allows them to remain on the "cutting edge" as well as be models for their students. Most faculty practice plans will provide some external funding but more importantly will allow additional educational opportunities for the students as they work with the faculty. These plans allow faculty to interact with the community and strengthen the ties of the community and the academic institution. However, there are dilemmas in establishing faculty plans, for the quality of teaching cannot be threatened, and most universities expect their faculty also to be involved in scholarly activities. This article discusses 1) the process used in planning and developing a faculty practice plan; 2) details of the plan, to include faculty incentives, administrative cost, etc.; and 3) strategy for implementation.

A patient-oriented health status measure in outpatient rehabilitation.

OBJECTIVES: The purpose of this study was to assess the utility of a patient-centered health status measurement tool in multiple outpatient rehabilitation clinics and to characterize health status before and after an outpatient physical therapy intervention as part of that assessment. DESIGN: Six outpatient rehabilitation clinics voluntarily agreed to incorporate a standardized patient-centered health status questionnaire into everyday practice. Patients completed the SF-36 health status questionnaire before initiating treatment and again at discharge. Only nonsurgical patients without comorbidities were enrolled. RESULTS: Voluntary application of the SF-36 on a small scale was achieved over a period of 3-4 mo. All health concepts improved except general health perceptions. CONCLUSION: The results suggest that (1) a standard patient-oriented health status questionnaire can be incorporated into outpatient rehabilitation clinics, and useful information can be derived regarding outcomes; (2) careful administrative coordination is necessary to optimize follow-up and decrease burden on both patients and clinicians; (3) although improvements in health status were demonstrated, small sample sizes and the lack of control groups prevents conclusions regarding the effectiveness of physical therapy treatment; and (4) the magnitude of effect sizes suggests that controlled studies could be performed by clinicians partnering with researchers to improve outpatient rehabilitation.

Comparison of asynchronous versus synchronous arm crank ergometry.

STUDY DESIGN: A direct comparison of synchronous versus asynchronous arm crank ergometry has not been carried out previously. Therefore, a comparative research design was employed. OBJECTIVE: To assess the physiological responses of arm cranking when performed asynchronously (arms moving opposite to each other) versus synchronously (both arms moving in the same direction simultaneously). SETTING: A university hospital setting in Galveston, Texas, USA. METHODS: Seventeen individuals between the ages of 19 and 53 years were studied, 11 with paraplegia and six with no apparent disability. Two maximal arm crank graded exercise tests were performed with the subject seated in a wheelchair. Testing consisted of both arms (1) asynchronously (reciprocally) pushing and pulling the crank handles and (2) pushing and pulling the crank handles synchronously. Each test consisted of 2 min stages starting at 20 W and increasing 10 W per stage thereafter until exhaustion. Heart rate, oxygen consumption, and minute ventilation were measured and recorded during each stage. Blood lactate levels were monitored before and after each test. Statistical analysis was performed using the multivariate Hotelling's T2 followed by post hoc univariate tests. RESULTS: Greater power and longer test times (both groups, P<0.05) and higher post test blood lactates (nondisabled P<0.01, paraplegic P<0.05) were achieved with asynchronous cranking versus synchronous cranking. While submaximal responses were similar between the two modes of cranking, there was a tendency for all variables to be lower with asynchronous. All subjects preferred asynchronous rather than synchronous cranking. CONCLUSION: Despite few statistically significant differences, based on the subjective reports from all subjects, we believe there is a clinically significant difference between the two modes of cranking. The results suggest that the mode of cranking may have implications for arm crank testing, training, and functional locomotion in individuals with lower extremity impairments.

Reliability of static standing balance in nondisabled children: comparison of two methods of measurement.

Static standing balance is commonly measured with research laboratory systems (LabSys) or clinical systems (ClinSys). The purposes of this study were to (1) assess the reliability of two systems designed to measure static standing balance in nondisabled children, (2) compare the findings derived from the two systems of measurement, and (3) examine the relationship between anthropometric measures and postural sway. Twenty-five nondisabled children (12 male, 13 female) ages 1 year 11 months to 12 years 2 months (mean = 6 years 4 months; SD = 4 years 3 months) participated in the study. Each child stood on the LabSys and the ClinSys for three consecutive 10 second measurement periods. Intraclass correlation coefficients (ICC (2, 1)) for the three trials on each system were 0.62 (LabSys) and 0.63 (ClinSys). The level of agreement between the two systems was 0.61 (ICC (2, 1)). Younger children exhibited more variability and less agreement between measurement trials using the ClinSys. However, older children demonstrated more similar sway indices when comparing the two systems of measurement. Two-way analysis of variance indicated that there were significant differences between sway indices measured by the two systems (p < 0.01) and between the youngest children (aged 2-4 years) and all other children (p < 0.01). In addition, agreement among trials for the two systems was different depending on the age group measured. Correlation coefficients for sway index and age, height, weight, and foot length ranged from -0.52 to -0.64 for the LabSys (p < 0.01) and -0.62 to -0.73 for the Clin-Sys (p < 0.01). Stepwise multiple regression analysis indicated that height was the most significant predictor of sway when measured by the ClinSys (R2 = 0.536, p < 0.01) whereas age was the most significant predictor when sway was measured using the LabSys (R2 = 0.403, p < 0.01). The results suggest that the degree of postural sway and the reliability of the measurement itself are influenced by the age of the child and the measurement system employed.

Initial health status of patients at outpatient physical therapy clinics.

BACKGROUND AND PURPOSE: The purpose of this study was to characterize the health status of individuals upon initiation of treatment in outpatient physical therapy clinics. SUBJECTS: Six outpatient clinical sites participated in the study. Three clinics were hospital based, and three clinics were privately owned by physical therapists. Patients who were referred with muscular, skeletal, or peripheral nerve involvement and who were not postoperative were included in the study. METHODS: One hundred nine patients completed the SF-36 health status questionnaire, which assessed eight health concepts: physical function, role physical (ie, limitations in role functioning such as duties in the home or at work due to physical problems), bodily pain, vitality, social function, role emotional (ie, limitations in role functioning due to emotional problems), mental health, and general health. RESULTS: Patients referred for treatment to hospital-based or privately owned clinics had similar ages and diagnoses. No differences in health status were found between patients to be treated at hospital-based clinics and those to be treated at privately owned clinics, or between male and female patients. Only physical functioning scores were lower in patients with lower-quarter (lumbar or lower-extremity) disorders versus patients with upper-quarter (cervical or upper-extremity) disorders. All health concept scores, except general health, were found to differ from previously published normative data on the US population. CONCLUSION AND DISCUSSION: A subgroup of patients seeking outpatient physical therapy had lower health concept scores than did the general population in not only the physical domain of health but also the psychological and social domains. These data reinforce the concept that physical impairment interacts with the emotional and social aspects of health. In addition, the health concept scores of our sample as compared with other patient groups who have responded to the SF-36 revealed some similarities and some marked differences. The results suggest that these types of data will provide practicing clinicians, as well as third-party payers and policy-makers, with a greater understanding of the severity of the patient's condition. Because the SF-36 provides information on health not routinely assessed by physical therapists, it may be a useful screening tool. [Mossberg KA, McFarland C. Initial health status of patients at outpatient physical therapy clinics.

Increase in alpha-CGRP and GAP-43 in aged motoneurons: a study of peptides, growth factors, and ChAT mRNA in the lumbar spinal cord of senescent rats with symptoms of hindlimb incapacities.

Sprague-Dawley rats develop progressive motor dysfunctions during the third year of life. We use this as a model to examine possible neuronal mechanism(s) that may cause motor impairments occuring during aging. In this study we have used indirect immunofluorescence histochemistry (IF) and in situ hybridization histochemistry (ISH) to study quantitatively and qualitatively the staining pattern and mRNA expression of calcitonin gene-related peptide (alpha-CGRP), growth-associated protein 43 (GAP-43), and acidic fibroblast growth factor (aFGF) in spinal lumbar motoneurons of young adult (2-3 months) and aged (30 months) Sprague-Dawley rats. In addition, mRNAs encoding choline acetyltransferase (ChAT), beta-CGRP, and cholecystokinin (CCK) were analyzed. All aged rats used in this study disclosed symptoms of hindlimb incapacity, ranging from mild weight-bearing insufficiency to paralysis of the hind limbs. The symptoms were confined to the musculature of the hindlimb and hip regions. Only a small number (approximately 15%) of the large motoneurons that innervate the hindlimb muscles were lost in those aged rats that had clinical symptoms of hindlimb motor incapacities. The remaining motoneurons expressed ChAT mRNA at levels similar to those of young adult rats. The vast majority of these motoneurons showed increased mRNA levels for alpha-CGRP and GAP-43. Aged motoneurons contained more CGRP like immunoreactivity (LI), but the number of immunoreactive neurons was smaller than in adult rats. GAP-43-LI could be detected in motoneurons in aged, but not in adult, rats. GAP-43-LI was always colocalized with CGRP-LI in aged motoneurons. Studies of individual aged rats revealed that the increase of GAP-43 mRNA-positive cell bodies occurred in cases with the most severe clinical symptoms, whereas the increase in alpha-CGRP was even evident in rats with mild symptoms. No alterations in content of aFGF-LI or aFGF mRNA could be detected in the aged rat, and the content of CCK and beta-CGRP mRNAs was also normal. The usefulness of this rat model for studies of neuromuscular aging and possible functional roles for GAP-43 and CGRP in plastic and regenerative processes during aging are discussed.

Effects of cardiovascular medications on exercise responses.

Many patients who are referred for physical therapy take medications that affect either their physiological responses to exercise or their ability to exercise. The purpose of this article is to discuss how medications potentially can affect cardiovascular responses to exercise. The effects of selected medications on heart rate, blood pressure, and electrocardiographic responses during exercise; on exercise performance; and on training adaptations are discussed. The types of medications included in this review are beta-adrenergic receptor antagonists, vasodilators, diuretics, digitalis, and antiarrhythmic agents. The mechanisms of action and the clinical indications are described for each category of drugs. Ways in which each of the categories of drugs interacts with exercise responses, exercise performance, and training adaptations are described. Knowledge of a person's medications can provide valuable information on current physical condition and medical history and can alert therapists as to how exercise responses may be altered. Potential complications that are likely to occur during exercise can be identified, facilitating the design of safe and effective treatment programs.

Simultaneous confocal recording of multiple fluorescent labels with improved channel separation.

Confocal microscopes are often used to study specimens labelled with fluorophores. A commonly used method for simultaneous recording of the distribution of multiple fluorophores is to divide the fluorescent light emitted by the specimen into different wavelength regions using dichroic and bandpass filters. These different wavelength regions are then distributed to multiple detectors. However, the broad and overlapping spectra of commonly used fluorophores often result in considerable crosstalk between channels. A new technique, intensity-modulated multiple-beam scanning (IMS) microfluorometry, can be used to reduce this cross-talk substantially. The IMS technique is implemented with two laser beams of different wavelengths, intensity-modulated at different frequencies, which illuminate the specimen simultaneously. The two laser wavelengths predominantly excite one fluorophore each. Fluorescent light from the specimen is divided into two wavelength regions (red and green) which are detected by two photomultiplier tubes. The output signals from the photomultiplier tubes are connected to lock-in amplifiers. The effect of using modulated laser beams, in combination with lock-in amplifiers, is strongly to reduce cross-talk between the channels. The performance of the IMS technique using various types of specimen is compared with the results obtained using the conventional multi-detector method.

Morphometric studies of the localization of the glucocorticoid receptor in mammalian cells and of glucocorticoid hormone-induced effects.

We studied the subcellular distribution of the glucocorticoid receptor (GR) by light microscopy (LM) and confocal laser scanning microscopy (CLSM) in different mammalian cell types. The effect of added glucocorticoid hormones on GR distribution was investigated by photometric quantitation on optical sections obtained by CLSM followed by statistical analysis. In the control interphase cytoplasm, the distribution of GR was fibrillar in some and diffuse in other cell types. Fibrillar GR was distributed along cytoplasmic microtubules (MTs) with predilection for a subset of MTs. GR was also observed in the centrosomes. Nuclear GR was both diffuse and granular in distribution. During cell division, GR appeared in the mitotic apparatus at all stages of mitosis. These findings were not fixation-dependent. Glucocorticoid treatment increased both the nuclear and cytoplasmic GR signal. However, this was detectable only after precipitating but not cross-linking fixation. There was both intra- and intercellular GR heterogeneity in the absence and presence of hormone but no indication of a hormone-induced nuclear translocation of GR. We present a hypothetical model of two independent GR populations in the nucleus and cytoplasm, respectively, without any discernible ligand-induced nuclear translocation of GR. The extranuclear GR population may exert effect(s) on site in the cytoplasm without involving nuclear genomic transcription.

Skeletal muscle glucose uptake during short-term contractile activity in vivo: effect of prior contractions.

The goal of the present study was to examine the time course of skeletal muscle glucose uptake and changes in intracellular metabolites occurring with the onset of in situ stimulation, and to assess the effect of a prior period of contractions on subsequent contraction-induced increases in glucose uptake. Hindlimb muscle in anesthetized rabbits was studied noninvasively using the positron-emitting glucose analog 18F-2-fluoro-deoxy-D-glucose (FDG). Fractional rates of FDG phosphorylation were measured on a minute-to-minute basis during rest, 3.5 minutes of priming exercise (PE), 15 or 30 minutes of PE recovery, and a subsequent 15-minute period of contractions. Muscles were electrically stimulated at 2 Hz, and force production was held constant during the contraction period(s). FDG uptake did not differ from control values either during PE or during 60 minutes of recovery from PE. In response to 15 minutes of contractions, muscle stimulated without PE demonstrated increased FDG uptake, but only after a delay of 5.0 +/- 0.7 minutes. Muscle with PE but rested 15 minutes had increased FDG uptake with a delay of 0.5 +/- 0.2 minutes, and muscle with PE but rested 30 minutes had increased FDG uptake after a delay of 8.0 +/- 0.9 minutes (P < .01 all groups). All groups reached similar levels of FDG uptake by the end of 15 minutes of contractions. Both groups with PE had control levels of adenosine triphosphate (ATP), phosphocreatine (PCr), and glucose-6-phosphate (G6P) after PE recovery, but glycogen level was lower than the control value (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for reversible, non-microtubule and non-microfilament-dependent nuclear translocation of hsp90 after heat shock in human fibroblasts.

A monoclonal antibody (29A) directed against rat liver heat shock protein M(r) 90,000 (hsp90) was produced. By Western immunoblotting of cytosols prepared from several different tissues and species, 29A was shown to specifically recognize only one band with M(r) approximately 90,000. Localization of hsp90 in human gingival fibroblasts was studied using the 29A antibody by indirect mono- and double-staining immunofluorescence and confocal laser scanning microscopy. The distribution was compared to that of the glucocorticoid receptor (GR) and various cytoskeletal structures. Cells were analyzed in interphase and mitosis under basal culture conditions, after heat shock and after microtubule and microfilament depolymerization, sometimes combined with heat shock. A major part of hsp90 immunoreactivity was diffusely distributed throughout the interphase cytoplasm, but a weak nuclear staining with non-stained nucleoli was also present, however, only detectable after methanol and not after formaldehyde/Triton X-100 fixation. Heat shock induced a time-dependent translocation of hsp90 from the cytoplasm to the cell nucleus reaching a plateau after 15 h. This compartment shift was reversible and also occurred in the absence of intact microtubules or intact microfilaments.

Time course of skeletal muscle glucose uptake during euglycemic hyperinsulinemia in the anesthetized rabbit: a fluorine-18-2-deoxy-2-fluoro-D-glucose study.

Since skeletal muscle has been implicated as the major site of insulin resistance, the purpose of this study was to examine in detail the time course of muscle glucose uptake during the onset and maintenance of euglycemic hyperinsulinemia. Uptake of 18F-2-deoxy-2-fluoro-D-glucose (FDG) by the thigh muscle of an anesthetized rabbit was monitored by a single pair of coincidence photon detectors. Graphical analysis of tissue and plasma radioactivity concentrations was performed to derive fractional rates of FDG phosphorylation continuously. FDG phosphorylation rates were determined during rest (glucose 7 mM, insulin 5-10 microU/ml) and subsequent 5-min intervals under conditions of euglycemic hyperinsulinemia (glucose 6-8 mM; insulin 350-400 microU/ml plasma). FDG phosphorylation did not increase above resting control levels until 5.5 +/- 1.5 min after intravenous insulin administration. After 20-30 min of hyperinsulinemia, FDG phosphorylation and calculated glucose metabolic rates were increased by 50%. At 35-40 min of the clamp in place, there was a second increase in tracer phosphorylation which plateaued at 200% of control (p less than 0.01) and remained at this level for the remainder of the experiment. In conclusion, we have described a method for making rapid, serial estimates of insulin-mediated skeletal muscle glucose uptake. We suggest that appraisal of the time course of glucose uptake with FDG will aid in the understanding of normal and pathophysiologic states of insulin action in vivo.

Imaging of fluorescent neurons labelled with fluoro-gold and fluorescent axon terminals labelled with AMCA (7-amino-4-methylcoumarine-3-acetic acid) conjugated antiserum using a UV-laser confocal scanning microscope.

This paper describes the implementation of an ultraviolet (UV) laser (Spectra Physics 171-18 with 3 lines: 334, 351 and 364 nm in UV) as light source for fluorescence confocal scanning microscopy. With this instrument it is possible to use fluorophores not previously available for confocal laser microscopical imaging of fluorophores such as fluoro-gold and AMCA. In the study we show confocal laser microscopical imaging of fluorescent motoneurons labelled by retrograde transport of fluoro-gold and AMCA-fluorescent axon terminals labelled with antisera against immunogenes as thyrotropin-releasing hormone (TRH) and calcitonin gene-related peptide (CGRP). These two fluorophores may be recorded simultaneously or separately by using a filter that suppresses the emission of one of the fluorophores. The described instrument should also be useful in applications involving detection of monoamines by the Falck-Hillarp technique, as well as measurements of cytosolic free calcium by indicators such as Fura-2 and Indo-1. Measurements performed in reflected and fluorescence light indicated that the resolution along the optical axis improved by about 25% when UV (351 nm) is used instead of visible light (514 nm). This figure is close to that expected on theoretical basis. There are, however, also serious problems related to the use of UV excitation. Firstly, objectives must be selected based on their UV transmission properties. Secondly, chromatic aberration may cause a substantial focal shift between illuminating and emitted light, calling for a flexible instrumental design in order to allow for compensation. As shown here, this problem can be circumvented by using reflecting objectives but at a price of lower resolution compared with high-aperture refracting objectives.

Evidence for colocalization of glucocorticoid receptor with cytoplasmic microtubules in human gingival fibroblasts, using two different monoclonal anti-GR antibodies, confocal laser scanning microscopy and image analysis.

The cellular distribution of the glucocorticoid receptor (GR) in relation to the microtubule protein tubulin was studied in human gingival fibroblasts, using two different anti-GR antibodies of different Ig-classes, by indirect immunofluorescence immunocytology. Further studies were performed by confocal laser scanning microscopy and digital image analysis. The study focused on fluorochrome separation, optical sectioning, digital subtraction techniques and reconstruction of projections obtained using stacks of recorded transversal sections. The data presented further strengthens the notion of a structural colocalization between GR and cytoplasmic microtubules in human fibroblasts.

Dihydroergotamine as a pharmacologic euglycemic clamp in the surgically traumatized rabbit.

We assessed the utility of a pharmacologic euglycemic clamp technique by examining the metabolic and hemodynamic changes brought about by administration of dihydroergotamine (DHE) prior to anesthesia and operative trauma in the rabbit. New Zealand white rabbits received an intramuscular injection of 0.15 mg DHE/kg body weight 20 minutes before general anesthesia and minor surgical trauma, which consisted of carotid artery and jugular vein catheterizations followed by femoral artery and vein cannulations. Arterial blood was sampled every 20 minutes and assayed for glucose, lactate, nonesterified fatty acids (NEFA), and insulin. Rates of hindlimb skeletal muscle glucose uptake (Rg) and blood flow were determined 2 hours after the initial administration of DHE. DHE did not produce any effects on heart rate, blood pressure, blood flow, and Rg when compared with control animals. Liver glycogen levels were significantly higher after DHE treatment (140 +/- 31.4 v 34 +/- 9.6 mumol/g dry weight, P less than .01). Those animals receiving DHE had significantly lower and more stable plasma glucose levels than untreated animals (ranges, 5 to 9 v 7 to 22 mumol/mL plasma) and circulating NEFA were also lower and less variable (ranges, 0.1 to 1.0 v 0.1 to 2.0 muEq/mL plasma). The results show that DHE prevents stress-induced hyperglycemia in vivo in the rabbit without altering glucose uptake by skeletal muscle. The technique provides control over circulating glucose levels during the study of skeletal muscle glucose uptake without apparent negative physiologic effects.

Enkephalin-like immunoreactivity levels increase in the motor nucleus after an intramedullar axotomy of motoneurons in the adult cat spinal cord.

Neuropeptide- and serotonin-like immunoreactivities were studied in the lumbar spinal cord of the cat after a longitudinal incision in the ventral funiculus. This lesion, which accomplishes a central axotomy of motoneurons, was accompanied by increased level of Met-enkephalin-like immunoreactivity in nerve endings in those parts of the motor nucleus (lamina IX) which harbored severed motoneurons. This increase, which was evident in the fluorescence microscope, could be verified photometrically by use of a confocal scanning laser microscope.

Temporal analysis of myocardial glucose metabolism by 2-[18F]fluoro-2-deoxy-D-glucose.

To assess kinetic changes of myocardial glucose metabolism after physiological interventions, we perfused isolated working rat hearts with glucose and 2-[18F]fluoro-2-deoxy-D-glucose (2-FDG). Tissue uptake of 2-FDG and the input function were measured on-line by external detection. The fractional rate of 2-FDG phosphorylation was determined by graphical analysis of time-activity curves. The steady-state uptake of 2-FDG was linear with time, and the tracer was retained predominantly in its phosphorylated form. Tissue accumulation of 2-FDG decreased with a reduction in work load and with the addition of competing substrates. Insulin caused a significant increase in 2-FDG accumulation in hearts from fasted but not from fed animals. We conclude that in the isolated working rat heart there is rapid adjustment of exogenous substrate utilization and that most interventions known to alter glucose metabolism induce parallel changes in 2-FDG uptake. Qualitative differences in the in vitro response to insulin may be affected by the presence of either endogenous insulin or glycogen.