Apichana Kovindha

Conservative treatment of the neuropathic bladder in spinal cord injured patients

Different conservative treatment modalities for the lower urinary tract dysfunction in patients with spinal cord lesion are reviewed. Conservative treatment is still the mainstay of the urological management in these patients. Growing experience has changed the classical approach. Spontaneous voiding with and without triggered voiding and/or bladder expression has proven to be less safe except in well defined patients with regular urological follow-up. Nowadays, intermittent catheterisation and self catheterisation with and without bladder relaxants are accepted as the methods of choice. Condom catheters are still needed if incontinence persists, while penile clamps have no place in the treatment of patients with spinal cord lesions. Long-term indwelling catheters should be avoided. External electrical stimulation can be used to correct the neurogenic dysfunction by neuromodulation and/or to induce a direct therapeutic response in the lower urinary tract.Spinal Cord (2001) 39, 294–300.

Complications during the rehabilitation period in Thai patients with stroke: a multicenter prospective study.

Kuptniratsaikul V, Kovindha A, Suethanapornkul S, Manimmanakorn N, Archongka Y: Complications during the rehabilitation period in Thai patients with stroke: a multicenter prospective study. Am J Phys Med Rehabil 2009;88:92–99. Objective:To examine the frequency and types of complications in patients with stroke. Design:A multicenter, prospective cohort study was performed in 327 patients with stroke (134 women, 193 men), who attended inpatient rehabilitation in nine centers. The frequency and severity of consequences and complications related to strokes were monitored weekly. In addition, correlations with stroke-related complications were analyzed. Results:At least one complication after a stroke was found in 232 (71.0%) patients. The mean age was 62 (±12) yrs, and 59% were men. Shoulder subluxation was found in 37.3% with mild to moderate degree. Limb spasticity was presented in 41.6%, and almost all were a severity grade of less than 3 on the Modified Ashworth Scale. The common complications were musculoskeletal pain (32.4%), bowel/bladder dysfunction (31.5%), infection (16.5%), depression (13.8%), and anxiety (5.8%). Symptomatic urinary tract infection was found in 35 (10.7%) patients. Urinary incontinence was the most common among bowel/bladder problems (24.5%). Time since onset of stroke ≥1 mo (adjusted odds ratio [OR] = 2.12; 95% confidence interval [CI] = 1.07–4.17), length of stay >21 days (adjusted OR = 2.36; 95% CI = 1.26–4.43), and anxiety score at admission ≥11 (adjusted OR = 6.87; 95% CI = 2.45–19.29) were statistically associated with stroke-related complications. Conclusions:Medical complications were common among patients with stroke who had been hospitalized longer, during inpatient rehabilitation and among those who had high anxiety scores.

Efficacy of an insole shoe wedge and augmented pressure sensor for gait training in individuals with stroke: a randomized controlled trial:

Objective: To determine whether external feedback to promote symmetrical weight distribution during standing and walking would improve gait performance and balance in people with stroke. Design: Randomized, controlled, assessor-blinded trial. Setting: Rehabilitation unit and physical therapy department. Subjects: Thirty-five individuals with stroke (mean (SD) age = 53.0 (9.3) years) were randomly assigned to an experimental (n = 17) or control group (n = 18). Time post stroke was less than six months for most subjects (n = 27, 77%). Interventions: Subjects participated in 15 rehabilitation sessions including 30 minutes of gait retraining per session. During gait retraining, the experimental group used an insole shoe wedge and sensors set-up (I-ShoWS) while the control group received a conventional programme. The I-ShoWS set-up consisted of a wedge insole and a footswitch for the non-paretic leg and a pressure sensor on the paretic leg. Outcome measures: Gait speed, step length and single support time asymmetry ratio, balance and amount of load on paretic leg during stance were evaluated twice: one day before and after training. Results: The experimental group demonstrated significant increase in standing and gait symmetry compared with the control group (P < 0.05). They demonstrated 3 times greater improvement in gait speed than the control group (P = 0.02). Balance improvement was significantly greater for the experimental than for the control group (P < 0.05). Conclusion: Gait retraining using the I-ShoWS set-up was more effective in restoration of gait speed, standing and walking symmetry and balance than a conventional treatment programme. These results indicate the benefit of implementing feedback during gait retraining.

Reused silicone catheter for clean intermittent catheterization (CIC): Is it safe for spinal cord-injured (SCI) men?

Study Design: Study of reusable catheter.Objective: To investigate whether a silicone cathether reused over years for clean intermittent catheterization (CIC) was safe for spinal cord injured (SCI) men.Setting: Maharaj Hospital, Chiang Mai, Thailand.Method: A cross-sectional study was obtained from SCI men who had used CIC with a reusable silicone catheter for more than a year. Demographic data, urological management and urinary tract complications focusing on the radiologic status of the urethra were reviewed and analyzed. In addition, two reused and one new catheters were studied under electron microscope for catheter morphology (surface and lumen) and stiffness.Results: There were 28 SCI men included in this study. The average duration of CIC use was 4.8 years and the average time of usage for each catheter was 3 years (range 1–7 years). In all, 26 men previously used indwelling catheterization (ID) during the acute phase. In all, 23 men performed self-catheterization. Regarding urinary complications, three reported urethral bleeding, five had episodes of pus per urethra, five had epididymitis, four had passing stones, 18 had occasional foul smelly urine, 10 developed fever and cloudy urine during the past year. Of 17 patients who had ultrasonography done, four had pathologic findings in kidney and one had bladder calculi. Demographic data, urinary management and complications did not have significant relation to the abnormality of the urethrogram or urinary tract infection. However, where the frequency of CIC was higher, the abnormality of the urethra was lower (P<0.05). All had serum Cr level ⩽1.3 mg/dl. Electron microscopic findings of reused catheters for 2 years revealed encrustation but no obstruction in the lumens and 20% increase in stiffness.Conclusion: The clinical outcome, especially with regard to urethral abnormalities with this reusable silicone catheter is as good as with a disposable one. However, to reuse urinary catheters, one should consider the increasing risk of infection. For SCI patients in developing countries, CIC with a reusable silicone catheter may be a suitable and safe choice if one cleans and applies it properly to reduce infection. In order to answer the question how long a person in a developing country should use the same silicone catheter, further research should be conducted.

PREVALENCE OF INCONTINENCE IN PATIENTS AFTER STROKE DURING REHABILITATION: A MULTI-CENTRE STUDY

OBJECTIVE To report the prevalence and degree of isolated urinary and faecal incontinence and double incontinence (i.e. both urinary and faecal incontinence) in patients after stroke during post-acute rehabilitation and the factors related to incontinence. DESIGN A multi-centre prospective study. METHODS Data were extracted from the Thai Stroke Rehabilitation Registry. A total of 185 patients admitted within 4 weeks post-stroke were recruited. Based on the Barthel Index of Activities of Daily Living, the prevalence and degree of isolated urinary incontinence or faecal incontinence, and double incontinence were reported. Multivariate analysis was performed to identify any factors related to incontinence. RESULTS The admission prevalence for isolated urinary incontinence was 12.4%, for isolated faecal incontinence 7.6% and for double incontinence 33%. At discharge, the prevalence had decreased, to 8.1% for isolated urinary incontinence, 4.9 % for isolated faecal incontinence and 15.1% for double incontinence. Cognitive (adjusted odds ratio (OR) 3.63; 95% confidence interval (CI) 1.71-7.70) and leg muscle functions impairments (adjusted OR 2.79; 95% CI 1.29-6.07) were significantly related to urinary incontinence; whereas, age (adjusted OR 1.98; 95% CI 1.07-3.67) was related to faecal incontinence at admission. CONCLUSION Double incontinence was more prevalent than isolated incontinence in patients after stroke during post-acute rehabilitation. The decrease in prevalence at discharge reflected a recovery of bladder and bowel control. Age, cognitive and leg motor function impairments were related to incontinence.

MAIN OUTCOMES OF STROKE REHABILITATION: A MULTI-CENTRE STUDY IN THAILAND

OBJECTIVE To estimate the efficiency of inpatient rehabilitation for patients after stroke in Thailand. DESIGN Multi-centre, prospective study. SUBJECTS Patients after stroke, aged >or= 18 years, with stable medical signs, able to follow 1-step commands and to sit for at least 30 min. METHODS Main outcomes included Barthel Index (BI) scores, BI effectiveness, BI efficiency, length of stay, Thai Hospital Anxiety and Depression Scale (HADS) scores, and quality of life. RESULTS Of a total of 327 patients, 285 completed the programmes, with a mean length of stay of 27.3 days. Mean age was 62.1 (standard deviation (SD) 12.1) years and 59% of patients were male. Mean BI scores on admission and at discharge were 7.48 (SD 3.96; range 0-19) and 13.27 (SD 4.86; range 0-20), respectively. The change score was 5.79 (SD 3.89) and the efficiency of functional score was 0.28 points/day. Using multivariate analysis, factors associated with change in BI score were age, previous stroke and length of stay. Sixty-four patients (25.5%) had anxiety and 95 (37.8%) had depression on admission. At discharge, the numbers of patients with anxiety and depression decreased to 17 (6.8%) and 41 (16.3%), respectively. The quality of life scores at discharge were significantly higher than those on admission. CONCLUSION Inpatient rehabilitation enabled stroke patients to reach optimal functional ability, and improved psychological status and quality of life.

Short-latency somatosensory evoked potentials (SSEPs) of the tibial nerves in spinal cord injuries

Stimulations of the tibial nerves of 76 spinal cord injured patients revealed short-latency somatosensory evoked potentials (SSEPs) especially P37 recorded from the scalp. The SSEPs findings can be classified by degrees of impairment into 5 different types as follows:Type 1: Absence of P37. This was found in all patients with complete cord lesions as well as patients with loss of joint sense.Type 2: Decreased amplitude and prolonged latency. This was elicited in patients with moderate to severe central cord lesions.Type 3: Prolonged latency only.Type 4: Decreased_amplitude only.Type 5: Normal P37, which was mostly seen in patients with mild central cord lesion.The study demonstrated that SSEPs of the tibial nerves are related to joint sense and seem to relate to the extent of cord damage, especially of central cord and complete cord lesions. It can be done as early as during the first week post injury, particularly in an uncooperative patient suspected of having spinal cord injury, in which case the clinical assessment may be difficult and unreliable.

Physiology and Pathophysiology

Understanding the physiology of the LUT and the pathophysiological changes after SCI is essential as it helps us interpret data from the UDT correctly.

Inpatient rehabilitation services for patients after stroke in Thailand: a multi-centre study.

OBJECTIVE To set a baseline for measuring the development of medical rehabilitation services and outcomes for patients after stroke and promoting rehabilitation medicine in Thailand. DESIGN Multi-centre, prospective study. SUBJECTS Patients after stroke in Thai Stroke Rehabilitation Registry (TSRR), aged > or = 18 years, with stable medical signs, able to follow a 1-step command and sit for at least 30 min. METHODS Rehabilitation services were recorded daily as units of treatment (1 unit = 20 min). Length of stay and treatment costs were calculated. RESULTS Of 327 patients enrolled in the study, 285 (87.2%) completed their treatment programme. Mean length of stay was 29.4 (standard deviation 17.9) days. The average number of total treatment units for stroke rehabilitation was 319.5 (range 27-1674 units), with 205 units of nursing, 40 units of physical therapy and 34 units of occupational therapy as the top 3 services provided. The mean total cost for all treatments during rehabilitation was 28,399 (standard deviation 22,511) baht (approximately USD 789). The ratio of costs not related to rehabilitation to those related to rehabilitation was approximately 2:1. CONCLUSION This study reports the baseline for measuring the development of rehabilitation services for patients after stroke with a mean length of stay of one month, and for estimating the reasonable costs.

Prevalence of Pressure Ulcers in Thai Wheelchair Users with Chronic Spinal Cord Injuries

Study design:A cross-sectional study.Objectives:To study prevalence of pressure ulcers (PrUs), quality of life (QoL) and effect of wheelchair cushions used by Thai wheelchair users with chronic spinal cord injury (SCI).Setting:Maharaj Hospital, Chiang Mai, Thailand.Methods:Thai chronic SCI wheelchair users, aged over 18 years and non-ambulatory with ASIA impairment scale A, B or C were recruited. They completed the PrUs questionnaire and rated the EuroQoL-5D and their health status with a visual analog scale (VAS). Demographic data of each participant were extracted from medical records. The EQ-5D health states were transformed to utility scores by using the Thai algorithm and the prevalence of PrUs was reported. The EQ-5D, the utility scores and the health status VAS were compared between those with and without current PrUs and between those participants using foam and air-filled cushions.Results:Of 129 participants, 26.4% had current PrUs at the time of the study, 27.9% had healed PrUs and 45.7% never had PrUs. The median VAS score for health status was 70 (Q1=50, Q3=80). Based on the EQ-5D, only one dimension (anxiety/depression) was significantly different between those with and those without current PrUs (P=0.015). Those using an air-filled cushions had a mean utility score four times higher than of those using a foam cushion (0.131 vs 0.032, P=0.089) but not statistically significant.Conclusions:PrUs are still prevalent among Thai wheelchair users with chronic SCI. Anxiety/depression is associated with current ulcers.