Kent A. Questad

Psychological effects of severe burn injuries.

Severe burn injuries provide researchers with an opportunity to study the effects of painful but usually transient trauma on psychological functioning. To that end, this article presents a review of the 3 main areas of this body of literature: (a) premorbid characteristics of people who sustain severe burn injuries, (b) psychological reactions during hospitalization, and (c) long-term adjustment. The general implications of these studies are discussed and then used to illuminate the circumstances under which individuals suffer the most from this type of trauma, the effects of such injuries on personality function, and how meaningful units of measurements can be defined. Potential clinical applications are also described.

Continuous-scale physical functional performance in healthy older adults: A validation study

OBJECTIVE The continuous-scale physical functional performance test (CS-PFP) is an original instrument designed to provide a comprehensive, in-depth measure of physical function that reflects abilities in several separate physical domains. It is based on a concept of physical function as the integration of physiological capacity, physical performance, and psychosocial factors. SETTING The test was administered under standard conditions in a hospital facility with a neighborhood setting. The CS-PFP consists of a battery of 15 everyday tasks, ranging from easy to demanding, that sample the physical domains of upper and lower body strength, upper body flexibility, balance and coordination, and endurance. Participants are told to work safely but at maximal effort, and physical functional performance was measured as weight, time, or distance. Scores were standardized and scaled 0 to 12. The test yields a total score and separate physical domain scores. DESIGN The CS-PFP was evaluated using 148 older adults-78 community dwellers, 31 long-term care facility residents living independently, and 39 residents with some dependence. MAIN OUTCOME MEASURES Maximal physical performance assessment included measures of maximal oxygen consumption (VO2max), isokinetic strength, range of motion, gait, and balance. Psychosocial factors were measured as self-defined health status using the Sickness Impact Profile (SIP), self-perceived function using the Health Survey (SF36), and Instrumental Activities of Daily Living (IADL). RESULTS IADL scores were not significantly different among the groups. Test-retest correlations ranged from .84 to .97 and inter-rater reliability from .92 to .99 for the CS-PFP total and 5 domains. Internal consistency was high (Cronbachs alpha, .74 to .97). Both total and individual domain CS-PFP scores were significantly different for the three groups of study participants, increasing with higher levels of independence, supporting construct validity. CS-PFP domain scores were significantly correlated with measures of maximal physical performance (VO2max, strength, etc) and with physical but not emotional aspects of self-perceived function. CONCLUSION The CS-PFP is a valid, reliable measure of physical function, applicable to a wide range of functional levels, and having minimal floor and ceiling effect. The total and physical domains may be used to evaluate, discriminate, and predict physical functional performance for both research and clinical purposes.

Comprehensive analysis of dynamic elastic response feet: Seattle ankle/lite foot versus SACH foot

This study evaluated biomechanical and metabolic performance differences between two prosthetic foot designs in light of their mechanical properties. Ten unilateral below-knee amputee subjects, at least 1 year after amputation, capable of walking and running, were studied. Differences in heel and forefoot compliance explained differences in gait events and alignment. Increased efficiency of pushoff in the Seattle Ankle/Lite Foot exists as evidenced by the decrease loading on the opposite limb during double support and a less shortened step length on the sound side compared to the SACH foot. The natural frequency of oscillation for the prosthetic feet was determined to be too high to provide energy storage and release synchronized with kinematic requirements because neither metabolic cost savings nor differences in metabolic efficiency were found. Comfortable walking speed and the nadir of metabolic rate and efficiency are not different. Via accelerometer measurement, it was found that the more compliant and lossy SACH foot heel was less likely to transmit high frequency vibration.

Agitation and restlessness after closed head injury: A prospective study of 100 consecutive admissions

Agitation and restlessness are two of the most striking and problematic behaviors for patients with traumatic brain injury (TBI), their caregivers, and their families. These behaviors are often treated with physical and chemical restraints which have potentially harmful side effects. There are, however, few prospective studies which clearly define agitation and restlessness in a representative sample of TBI patients. Subjects for this study were 100 consecutive patients with traumatic, closed head injury (CHI) admitted to a regional Level I Trauma Center with a Glasgow Coma Scale score of less than 8, who had more than one hour of coma, and who required more than one week of hospitalization. Agitation was defined as episodic motor or verbal behavior which interfered with patient care or clearly required physical or chemical restraints to prevent damage to persons or property. This variable was rated on the Overt Aggression Scale, a 16-item scale, in four categories: verbal aggression; physical aggression against objects; physical aggression against self; or physical aggression directed at others. Systematic direct observations, caregiver interviews, and chart reviews were used to determine the frequency and duration of agitation. Patients were also monitored for restlessness, which was defined as behavior that interfered with staff or required some action by staff, such as change of activity, but either did not meet the severity criteria for agitation, or was continuous. Only 11 of the 100 subjects exhibited episodic agitation which met the criteria. Eight subjects were agitated for one week, one for two weeks, one for three weeks, and one for four weeks. Only one subject went directly from being unresponsive to being agitated.(ABSTRACT TRUNCATED AT 250 WORDS)

Footwear And Posture: Compensatory Strategies for Heel Height

The belief that wearing high-heeled shoes increases lumbar lordosis is firmly ingrained in clinical folklore. Proponents of negative heel footwear argue that because high positive heels increase the lumbar lordosis, negative heels will decrease the lumbar lordosis. Quantitative documentation of the assumption regarding high heels is not to be found in the literature, although sporadic attempts to prove this assumption have been made throughout the 20th Century. Although other effects, such as decreased gait speed and step length, and increased knee flexion at heel strike have been found in more than one study, no increase in lumbar lordosis has been found. Where an actual decrease in lordosis has been found, authors tend to explain it away as inconsistent with what every clinician feels that he or she has observed. We felt it appropriate, then, to conduct both a static and a dynamic study to assess the effects of heel height on lumbar spine and lower limb joint kinematics in the sagittal plane, as well as other strategies to compensate for heel height. The results indicate that the greatest compensation is at the ankle and knee. Where a significant effect occurred in the lumbar spine (males, dynamic study), high heels decreased the lumbar lordosis, i.e., resulted in less swayback rather than more.

The stretch reflex response in the normal and spastic ankle: Effect of ankle position

OBJECTIVE The influence of stretch of the gastrocnemiussoleus muscle on the stretch reflex activity was studied, by varying the ankle angle in steps from 10 degrees of plantarflexion (PF) to 5 degrees of dorsiflexion (DF). DESIGN Nonrandomized control trial. SETTING Department of Rehabilitation Medicine of a university medical center. PATIENTS Sixteen subjects with and 16 subjects without spasticity. MAIN OUTCOME MEASURES The passive elastic stiffness and active reflex response, expressed by the total and elastic path lengths, were determined at each ankle angle as a sinusoidal displacement of 5 degrees was applied to the joint at frequencies from 3 to 12 Hz. RESULTS The elastic stiffness showed no difference between the spastic and normal subjects for all ankle angles (p > .05). The elastic stiffness increased linearly similarly in both groups when the ankle was dorsiflexed. The reflex response was significantly greater in the spastic group for all positions (p < or = .01). The total and elastic path lengths showed a linear increase in both groups when the ankle angle was varied from PF to DF. The spastic group, however, had a significantly faster increase (p < or = .005). Between-group comparison showed a significant quadratic trend in the elastic path length for the spastic group (p < or = .05), with a maximum at 2.5 degrees of DF. CONCLUSIONS This study showed that the stretch reflex activity varies with the ankle position. This must be considered when performing spasticity tests subsequent to an intervention that has changed the available range of motion and when comparing subjects measured at different ankle positions.

The effect of local cooling on postfracture swelling. A controlled study.

Observations on rabbit hindlimbs following tibial fracture suggest that no regimen of cooling lessens swelling. Temperatures of 5 degrees to 15 degrees led to significantly increased swelling when applied for 24 hours. Increased swelling is the product of the perfusion of vessels rendered hyperpermeable by cold induced ischemia, and indicates that controlled investigations are needed to establish the validity of local cooling in orthopedic management.

Hypnotherapy as an Adjunct to Narcotic Analgesia for the Treatment of Pain for Burn Debridement

This paper presents a hypnotherapeutic intervention for controlling pain in severely burned patients while they go through dressing changes and wound debridement. The technique is based on Barbers (1977) Rapid Induction Analgesia (RIA) and involves hypnotizing patients in their rooms and having their nurses provide posthypnotic cues for analgesia during wound cleaning. Five subjects who underwent hypnotherapy showed reductions on their pain rating scores (Visual Analogue Scale) relative to their own baselines and to the pain curves of a historical control group (N = 8) matched for initial pain rating scores. Although the lack of randomized assignment to experimental and control groups limited the validity of the results, the findings provide encouraging preliminary evidence that RIA offers an efficient and effective method for controlling severe pain from burns.

Hypnotherapy as a Treatment for Pain in Patients With Burns: Research and Clinical Considerations

Hypnotherapy has increasingly been included in the management of burn patients, particularly in the area of acute pain. To better understand such issues as (1) overall efficacy of hypnotherapy to alleviate acute burn pain, (2) instances in which hypnotherapy is contraindicated, (3) interaction of hypnotherapy with medication, (4) standard induction techniques to use with various age groups, (5) role of nursing and other staff in facilitating hypnotic effects, and (6) future methodological directions, we examined the clinical and methodological merits of recent studies of hypnoanalgesia. Through a computer search of the medical literature and cross-referencing recent bibliographies, we were able to find 17 studies in which hypnotherapy was applied to the management of burns. The literature generally supports the efficacy of this approach to reduce burn pain; however, little else can be concluded from these studies. Several recent studies have applied hypnotherapy to aspects of burn care other than pain using excellent experimental designs. It is suggested that future studies of acute pain management follow suit.

Mass and mass distribution of below-knee prostheses: Effect on gait efficacy and self-selected walking speed

OBJECTIVE To study mass and mass distribution effect on function of below-knee prostheses. DESIGN Design modifications were done to produce proximal center of mass location versus distal center of mass location variations, and prosthesis weight was modified from 42% to 70% of normal limb weight. Work across joints of affected and unaffected extremities was compared to assess the ability of the prosthesis to substitute for function loss. SETTING University biomechanics laboratory. PARTICIPANTS Fifteen volunteers with below-knee amputations, residual limb length greater than 8.3 cm, but excluding Syme amputations. INTERVENTIONS Patients walked with all configurations at self-selected walking speeds and 120 m/min. MAIN OUTCOME MEASURES Self-selected walking speed and metabolic efficiency. Work across the joints of affected and unaffected sides was compared. RESULTS Proximal center of mass location produced a more efficient gait. Weight change from 42% to 70% of normal had no significant effect. Mechanical studies show that the prosthesis is a relatively poor substitute for the normal limb; most work is done by the nonamputated side. Particularly, the prosthesis failed to produce effective forward impulses on the body, resulting from push-off and deceleration of the swing leg. CONCLUSIONS For a proximal center of mass, lightweight distal components (e.g., feet) should be used; it is questionable whether further expenditure to develop ultralightweight prostheses would be cost effective for level walking.