John Hunter

Parkinson’s disease and driving ability

Objectives: To explore the driving problems associated with Parkinson’s disease (PD) and to ascertain whether any clinical features or tests predict driver safety. Methods: The driving ability of 154 individuals with PD referred to a driving assessment centre was determined by a combination of clinical tests, reaction times on a test rig and an in-car driving test. Results: The majority of cases (104, 66%) were able to continue driving although 46 individuals required an automatic transmission and 10 others needed car modifications. Ability to drive was predicted by the severity of physical disease, age, presence of other associated medical conditions, particularly dementia, duration of disease, brake reaction, time on a test rig and score on a driving test (all p<0.001). The level of drug treatment and the length of driving history were not correlated. Discriminant analysis revealed that the most important features in distinguishing safety to drive were severe physical disease (Hoehn and Yahr stage 3), reaction time, moderate disease associated with another medical condition and high score on car testing. Conclusions: Most individuals with PD are safe to drive, although many benefit from car modifications or from using an automatic transmission. A combination of clinical tests and in-car driving assessment will establish safety to drive, and a number of clinical correlates can be shown to predict the likely outcome and may assist in the decision process. This is the largest series of consecutive patients seen at a driving assessment centre reported to date, and the first to devise a scoring system for on-road driving assessment.

Depression and anxiety symptoms after lower limb amputation: the rise and fall

Objective: To examine the time course of anxiety and depressive symptoms over a three year period after amputation. Design and settings: A prospective study in inpatients admitted to a rehabilitation ward after lower limb amputation. Subjects: Successive admissions over a one-year period of whom 68 were alive at follow-up, 2—3 years later. Interventions: Nil. Main measures: Hospital Anxiety and Depression Scale (HADS) on admission and discharge from inpatient rehabilitation and at a 2.7(SD=0.4) year mean follow-up period with correlation to demographic and patient features. Results: Of the 68 responding patients, 12 (17.6%) and 13 (19.1%) had symptoms of depression and anxiety respectively. This compared to an original incidence of 16 (23.5%) for both on admission and 2 (2.9%) on discharge. This rise in incidence from time of discharge was highly significant for both depression (P<0.001) and anxiety (P<0.001). Depression at follow-up was correlated to depressive symptoms at admission (P=0.03) and to having other significant comorbidities (P=0.02). Anxiety symptoms were commoner in younger patients (P=0.03). There was no association with age, gender, living in isolation, vascular cause for amputation, wearing a limb prosthesis or length of original inpatient stay. Conclusions: Depression and anxiety are common after lower limb amputation but resolve during inpatient rehabilitation. The incidence then rises again after discharge.

The rapid resolution of depression and anxiety symptoms after lower limb amputation

Objective : To ascertain the course of depressive and anxiety symptoms shortly after amputation and again after a period of inpatient rehabilitation. Design and settings : A cohort study in inpatients admitted to a rehabilitation ward after lower limb amputation. Subjects : One hundred and five successive admissions over a one-year period. Interventions : Nil. Main measures : Hospital Anxiety and Depression Scale (HADS) on admission and discharge with correlation to demographic and patient features. Results : At admission, 28 (26.7%) and 26 (24.8%) patients had symptoms of depression and anxiety respectively. This dropped to 4 (3.8%) and 5 (4.8%) by time of discharge, a mean of 54.3 days later. These reductions were statistically significant, as was the association between patients having symptoms of both depression and anxiety (P < 0.001). Patient stay was longer in those with symptoms (depression, P < 0.03; anxiety P < 0.001). There was no association with level of amputation, success of limb-fitting, age or gender. Depressive symptoms were associated with presence of other medical conditions (P < 0.01) and anxiety scores with living in isolation (P < 0.05). Conclusion : Depression and anxiety are commonly reported after lower limb amputation and previously thought to remain high for up to 10 years. We have found that levels of both depression and anxiety resolve rapidly. It is possible that a period of rehabilitation teaching new skills and improving patient independence and mobility may modify the previous bleak outlook of amputees. This positive finding may be useful in the rehabilitation of even the most distressed of amputees.

Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation: completion of the audit cycle

Objectives: To study the factors contributing to falls among recent lower limb amputees, and to reduce the number of falls during inpatient rehabilitation and resulting injuries. Design: Retrospective, followed by prospective, cohort study, then a follow-up study conducted after interventions. Setting: Twenty-bedded inpatient rehabilitation unit for amputees. Subjects: Lower limb amputees. Interventions: Patient education, environmental modifications and application of a bivalve plaster of Paris stump protector to patients who were aged 70 or over, or cognitively impaired. Main outcome measures: Numbers of falls and other accidents, and resulting injuries. Results: In phase 1 of the study, a retrospective audit of incident forms that had been completed on lower limb amputees who had an accident during their inpatient rehabilitation, between 1 April 1996 and 31 Ocotber 1998, was carried out. This showed that approximately a third of admissions (32%) were complicated by an accident. Most accidents were falls. In phase 2, a prospective study of 113 patients admitted to the unit was undertaken. Patients who fell were significantly older than those who did not. In phase 3, 62 consecutive patients were studied. There were 37 accidents in total, of which 35 were falls. Compared with the phase 2 study, there was no reduction in the proportion of patients who had a fall or other accident in phase 3, but significantly fewer falls resulted in any injury (p/0.05). Conclusions: Although the interventions employed did not reduce the proportion of patients who had falls or other accidents, significantly fewer falls resulted in injuries.

A comparison of three measures of progress in early lower limb amputee rehabilitation

Objective: To assess the responsiveness to change and validity of three established outcome measures in relation to early lower limb vascular amputee rehabilitation: the Functional Independence Measure (FIM), the Office of Population Censuses and Surveys Scale (OPCS) and the Amputee Activity Score (AAS). Design: Prospective observational study. Setting: Inpatient amputee rehabilitation unit. Subjects: Fifty-one consecutive patients admitted for rehabilitation following lower limb amputation for vascular disease. Procedure: To study the responsiveness to change differences between total scores and between subsection scores at different times were analysed. To assess validity, comparisons of the total scores of the measures were made with each other, and the total scores for each measure were compared with other outcomes. Results: Complete scores were obtained on 34 subjects. All measures showed significant change between admission and discharge (p < 0.00001) but only the AAS showed change between discharge and follow-up (p < 0.0001). Subsection analysis revealed expected improvements in mobility. During the inpatient stage progress was also detected in certain activities of daily living in the FIM and OPCS. The measures correlated with each other (p < 0.001). All of the measures’ admission scores correlated with duration of stay (OPCS p < 0.005, AAS p < 0.006, FIM p < 0.009) and admission OPCS also correlated with discharge placement (p < 0.036). Conclusion: The FIM and OPCS are suitable for the inpatient stage but the AAS would appear to be the best measure at time of discharge and thereafter, and further studies are justified.

Gender differences in amputation outcome

Purpose.u2003To assess the influence of gender on the success of limb-fitting after amputation. Methods.u2003One-hundred and five successive in-patients admitted to an amputee rehabilitation ward were followed to assess the success of limb-fitting at discharge. The influence of demographic, clinical and social factors on the success of lower limb-fitting was assessed using linear regression analysis and group comparisons. Results.u2003There were 35 (33%) women in a cohort of 105 successive admissions. Men and women were comparable in terms of age, length of stay, medical comorbidity and level of amputation. Women were less likely to be successfully fitted with a prosthetic limb at discharge than men (42.9% vs 68.6%, p = 0.011), and more women lived alone (57.1% vs 38.6%, p = 0.021). Linear regression revealed that gender was an independent significant factor in the success of limb-fitting; age, level and cause of amputation, co-morbidity and length of stay were not significant factors. Conclusions.u2003Women were less likely to be successfully fitted with a lower limb prosthesis after amputation.

Predicting those who will walk after rehabilitation in a specialist stroke unit

Objective: To establish whether the ability to use a wheelchair shortly after a stroke or continence are related to the likelihood of walking by time of discharge. Design and subjects: An observational study in patients admitted to a stroke rehabilitation unit for under-65s over a three-year period. Methods: Functional Independence Measure (FIM) subscores for walking were examined on all patients at time of admission and discharge. Walking was defined by an FIM ≤ 5 in that section. Comparisons were then made between those who could self-propel a wheelchair within a week of admission with those who could not. Continence (defined by an FIM subscore of ≥ 6 in that category) was also correlated to walking at discharge. Main outcome measure: Walking at time of discharge defined by an FIM ≥ 5 in that section. Results: From 393 admissions, 135 were excluded because they could already walk (FIM subscore ≥ 5 in that particular section) and three died during their admission. Out of the remaining 255 patients, 108 could self-propel on admission and 147 could not. While 105 (97%) of the self-propellors could walk by time of discharge, only 91 (62%) of the non-propellors could do so (χ2=42.237, df=1, P < 0.001, odds ratio (OR) 21.54 (6.52-71.51)). Although continence also predicted improved likelihood of walking, this was at a lower level of significance and correspondingly lower odds ratio (χ2=5.894, df=1, P=0.015, OR 1.94 (1.13-3.32)). Conclusions: The ability to self-propel a wheelchair shortly after a stroke is a significant predictor of eventually being able to walk. Our data suggest that it is even more significant than continence, which is the most consistent predictor previously found.

Lectures ON THE SYMPATHETIC INNERVATION OF STRIATED MUSCLE

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Validation studies of the OPCS scale — more useful than the Barthel Index?

The OPCS scales of disability were developed as a survey tool to estimate the prevalence of disability amongst adults in the UK. This study evaluates the use of the OPCS scales in a clinical setting. A total of 265 patients attending a rehabilitation unit and wheelchair centre were assessed. The OPCS scales were validated against the standard Barthel Index and sensitivity to change over time was examined. An inter-rater reliability study was also performed. The results showed good correlation between the OPCS scales and Barthel Index (0.82, p < 0.001, n = 265) and it was shown that the OPCS scales were sensitive to clinical change over a six-month period. Inter-rater reliability was also good (0.96, p < 0.001, n = 120). The 95% confidence limits were also examined. The ceiling effect of the Barthel Index is not found in the OPCS scales of disability. The results of the study support further use of the OPCS scales and suggest that it has a place in the assessment of rehabilitation outcome.

Clinical trial of incontinence garments: recognition of the possible influence of the Hawthorne effect

The results of clinical trials must be interpreted with care, recognizing that they may be affected by factors other than the items being tested. Different garments were routinely supplied from two distribution centres in Edinburgh, Urocare to the majority of patients in North Lothian and Hygi to those in South Lothian. One hundred patients were recruited and a crossover comparative trial carried out. The response in the two areas was different. Whereas patients in South Lothian found no significant difference between the two garments, those in North Lothian rated the Hygi garment better in terms of comfort (p=0.01), leakage (p<0.001), odour (p=0.01) and avoidance of skin problems (p=0.01). It is suggested that the difference in response may be explained by the Hawthorne effect and this should be taken into account when planning future equipment trials.