Donald M. Currie

Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes.

Bowel incontinence is a major social impairment for 90% of patients with spina bifida. This study assess the bowel continence of children and young adults with spina bifida before and after a toileting intervention that emphasized patient/family education and a regular, consistently timed, reflex-triggered bowel evacuation. Bowel continence defined as one or fewer incontinent stools per month, rose from 13% (5/40) to 60% (24/40) following intervention. Twenty-four of the 35 initially incontinent patients were compliant. Seventy-nine percent (19/24) of the compliant subjects achieved continence whereas 0/11 of the noncompliant subjects achieved continence p < 0.0001). Presence of the bulbocavernosus (BC) and anocutaneous (AC) reflexes correlated significantly with achieving continence (either vs none p < .02, AC vs no AC p < .01). Instituting bowel training before age 7 correlated with improved outcomes by means of better compliance. Excluding noncompliant subjects, 83% (24/29) of the original sample of 40 patients satisfied our strict definition of bowel continence after this simple low technology intervention.

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

PURPOSE We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.

The challenge of teaching rehabilitative care in medical school

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.

Topical treatment of sclerodermoid chronic graft vs. host disease

Sclerodermoid chronic graft vs. host disease is a severe adverse immunologic reaction following allogeneic bone marrow transplantation, with deposition of collagen in the skin and possibly other soft tissues, resulting in loss of range of motion and functional capabilities. We present a case of a 14-yr-old girl who received a matched, unrelated donor bone marrow transplant for myelodysplastic syndrome complicated by sclerodermoid chronic graft vs. host disease, causing severe contractures of the shoulders, elbows, wrists, fingers, hips and knees. This case report and review of the literature regarding chronic graft vs. host disease suggest that a controlled trial of a multimodality therapeutic approach, including topical treatment, is warranted to determine whether this approach improves function in these patients.

The Physiatrist's Perspective1

It is difficult for many persons with physical disabilities to find and access primary health care. This article discusses this problem from the perspective of a physiatrist. It discusses the components of primary health care and then compares and contrasts the current status of the training, skills, and interest levels of generalist physicians and physiatrists in providing primary medical care for disabled persons. It includes a discussion of the artificiality of the specialist/generalist dichotomy and the concept of specialists providing true primary care to certain patient populations. General and personal strategies are suggested to influence and to change the health care system so disabled persons can find and have improved access to good primary health care.

3. Specific diseases

Abstract This self-directed learning module provides review and references for basic concepts of, and highlights new advances in, the area of specific diseases affecting nerve and muscle. It is a section of the chapter on rehabilitation in nerve and muscle disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section deals with 1) focal neuropathies, 2) generalized neuropathies, 3) myopathies, and 4) diseases of the neuromuscular junction. The emphasis is on physiology, on concepts for evaluation and diagnosis, and on specific treatments when these are available.