Richard Goldstein

Contractures in burn injury: defining the problem.

This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.

Having a son or daughter with Down syndrome: Perspectives from mothers and fathers

This study asks parents who have children with Down syndrome (DS) how they feel about their lives so that such information could be shared with expectant couples during prenatal counseling sessions. A valid and reliable survey instrument was mailed to 4,924 households on the mailing lists of six non‐profit DS organizations. Of the 2,044 respondents, 99% reported that they love their son or daughter; 97% were proud of them; 79% felt their outlook on life was more positive because of them; 5% felt embarrassed by them; and 4% regretted having them. The parents report that 95% of their sons or daughters without DS have good relationships with their siblings with DS. The overwhelming majority of parents surveyed report that they are happy with their decision to have their child with DS and indicate that their sons and daughters are great sources of love and pride.

Depression amongst outpatients with traumatic brain injury.

The incidence of depression and its association with subject characteristics in outpatients with traumatic brain injury (TBI) were investigated. Logistic regression was estimated with depressed/not-depressed as the dependent variable in 41 outpatients with TBI who filled out the Beck Depression Inventory-II (BDI-II). Twenty-four of 41 subjects (59%) scored in the depressed categories based on BDI-II scores >13. Fourteen (34%) scored in the moderate or severe depression categories (BDI>19). Logistic regression demonstrated a positive relationship amongst depression and age, female gender, mild TBI, and use of antidepressant and stimulant drugs; and a negative relationship between depression and violent aetiology of injury. ANOVA demonstrated that individuals with mild TBI were significantly older than those with moderate or severe TBI, which might account for the association between depression and age. The implications of these results are discussed.

Increased Velocity Exercise Specific to Task Training Versus the National Institute on Aging's Strength Training Program: Changes in Limb Power and Mobility

BACKGROUNDnThis study was designed to evaluate the benefits of InVEST (Increased Velocity Specific to Task) training on limb power and mobility among mobility-limited older adults.nnnMETHODSnWe conducted a single blinded, randomized controlled trial among 138 mobility-limited community-dwelling older adults, evaluating two 16-week supervised exercise programs. The intervention group participated in InVEST training, and the control group participated in the National Institute on Agings (NIA) strength training program. Primary outcomes were changes in limb power per kilogram and mobility performance as measured by the Short Physical Performance Battery (SPPB).nnnRESULTSnAfter 16 weeks, InVEST produced significantly greater improvements in limb power than NIA (p=.02). There was no significant difference in strength improvements. Both groups had significant changes in SPPB of greater than 1 unit. Self-reported function was also significantly improved in both groups. Differences between groups were not statistically different. In a post hoc analysis when participants were categorized by the manifestation of baseline leg velocity impairments (N=68), InVEST training produced effect size differences in SPPB that were clinically meaningful (SPPB Group x Time difference 0.73 units, p=.05).nnnCONCLUSIONSnAmong mobility-limited older adults, both NIA and InVEST produce robust changes in observed physical performance and self-reported function. These improvements were not meaningfully different by statistical or clinical criteria. Compared with NIA, InVEST training produced greater improvements in limb power and equivalent improvements in strength. Observed differences between NIA and InVEST based upon baseline leg impairment status are informative for futures studies.

Are Changes in Leg Power Responsible for Clinically Meaningful Improvements in Mobility in Older Adults

OBJECTIVES: From among physiological attributes commonly targeted in rehabilitation, to identify those in which changes led to clinically meaningful differences (CMDs) in mobility outcomes.

Predictors of survival after severe dysphagic stroke.

AbstractBackground and PurposeDysphagia is estimated tonoccur in up to 50% of the strokenneurorehabilitation population.nThose patients with severe neurogenicnoropharyngeal dysphagian(NOD) may receive feedingngastrostomy tubes (FGT) if noninvasiventherapies prove ineffectivenin eliminating aspiration or sustainingnadequate nutritional intake.nOur aim was to quantify the recoverynof swallowing function, and tonidentify variables predictive ofnsurvival after dysphagic strokenrequiring FGT placement.MethodsWe identified consecutive strokenpatients with severe dysphagicnstroke requiring FGT placement admittednto a rehabilitation hospitalnbetween May 1998 and Octobern2001. The medical records were reviewed,nand demographic, clinical,nvideofluoroscopic (VSS) and neuroimagingninformation werenabstracted. A follow–up telephoneninterview was performed to determinenwhether the FGT was still innuse, had been removed,or if the patientnhad died. State death certificatenrecords were reviewed to ascertainndate of death for subjects whonhad expired by the time of follow–up.nUnivariate and multivariatenanalyses were performed.Results11.6 % (77/664) of stroke patientsnadmitted during the study periodnhad severe dysphagic stroke withnFGT insertion. Follow–up wasnavailable for 66 (85.7 %) of thesenindividuals at a mean of two yearsnafter acute stroke. On follow–upn64% (42/66) of the patients werenalive and 45 % had had the FGTnremoved and resumed oral diets.nOn univariate analysis patients whonwere alive at the time of follow–upnhad received FGT feeding for anshorter period of time (p < 0.0003),nshowed no signs of aspiration onnthe Clinical Assessment of Feedingn& Swallowing (CAFS,p < 0.020) andnon the Videofluoroscopic SwallowingnStudy (VSS, 0.001), had a betterndischarge FIM–Score (FunctionalnIndependence Measure) for eatingn(p < 0.0002) and cognitive functionn(p < 0.002) as well as better dischargenFCM–Score (FunctionalnCommunication Measure) fornswallowing (p < 0.0001). On multivariatenanalysis we developed anmodel consisting of FGT removal atndischarge from the rehabilitationnhospital (p < 0.011) and non–aspirationnduring VSS (p < 0.040) thatnwas significantly associated withnlonger survival time during follow–up.ConclusionsSevere dysphagianrequiring FGT is common in patientsnwith stroke referred for neurorehabilitation.nPatients who had anFGT in place at the time of dischargenfrom the stroke rehabilitationnunit or aspirated during VSSnwere substantially more likely tonhave died by the time of follow–upncompared to those who had had thenFGT removed and had no signs ofnaspiration on VSS. However functionalnoutcome measurementsn(FIM, FCM) including the cognitivenfunction (attention, concentrationnetc.) could play an important rolenfor prediction of swallowing regenerationnand survival in neurorehabilitation.nThese findings may havenpractical utility in guiding physiciansnand speech language pathologistsnwhen advising patients andnfamilies about prognosis in strokensurvivors with severe dysphagia.

Self-perceptions from people with Down syndrome†

This study asks people with Down syndrome (DS), ages 12 and older, about their self‐perception so that their information could be shared with new and expectant parents of children with DS. We analyzed valid and reliable survey instruments from 284 people with DS on the mailing lists of 6 non‐profit DS organizations around the country. Among those surveyed, nearly 99% of people with DS indicated that they were happy with their lives, 97% liked who they are, and 96% liked how they look. Nearly 99% people with DS expressed love for their families, and 97% liked their brothers and sisters. While 86% of people with DS felt they could make friends easily, those with difficulties mostly had isolating living situations. A small percentage expressed sadness about their life. In our qualitative analysis, people with DS encouraged parents to love their babies with DS, mentioning that their own lives were good. They further encouraged healthcare professionals to value them, emphasizing that they share similar hopes and dreams as people without DS. Overall, the overwhelming majority of people with DS surveyed indicate they live happy and fulfilling lives.

Contractures in burn injury part II: investigating joints of the hand.

This study prospectively examines the incidence and severity of hand contractures after burn injury and determines predictors of contracture development. Data were collected prospectively from 1993 to 2002 for adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. Primary outcome measures include presence of contractures, number of contractures, and the severity of contractures at each of the hand joints at hospital discharge. The metacarpal-phalangeal, proximal inter-phalangeal (PIP), and distal inter-phalangeal joints of all digits and the wrist joints are included in this study. Regression analysis was performed to determine predictors of the presence, severity, and number of contractures. Of the 985 study patients, 23% demonstrated at least one hand contracture at hospital discharge. Those with a contracture averaged ten contractures per person. Most contractures were mild (48%) or moderate (41%) in severity. The wrist was the most frequently affected joint (22%). Statistically significant predictors of contracture development include concomitant medical problems, total body surface area grafted and presence of hand burn and hand grafting (P < .05). Predictors of the number of contractures include length of stay, concomitant medical problems, burn size and presence of hand burn and grafting (P < .05). Contractures of the hand are a significant complication of burn injury. Clinicians can use the contracture predictors to help target interventions for those patients most at risk of developing hand contractures. Given the functional importance of the hand in daily living, the burn care community is challenged to find new ways of preventing and treating hand contractures.

A comparison of chronic pain patients and controls on traumatic events in childhood

Purpose : The purpose was to examine the incidence of traumatic events in childhood, such as sexual and physical abuse, in a chronic pain group and a control group of hospital employees without chronic pain. Method : Ninety two patients with chronic pain, age range 20-62, were consecutively recruited from the outpatient clinics of a rehabilitation hospital and a general hospital. Ninety eight hospital employees, age range 20-62, were consecutively recruited from the employee health office of a rehabilitation hospital. All participants responded to nine questions related to sexual, physical and verbal abuse in childhood and completed the Childhood Traumatic Events Scale. A logistic regression with age, gender, sexual, physical, and verbal abuse, death of a family member, childhood illness, major upheaval before age 17, as independent variables were used to predict membership in the pain group contrasted with the control group. Results : Child abuse was reported in the childhood history by 54.4% of the chronic pain group, compared with 21.4% of the control group. A logistic regression showed that after adjusting for gender and age, sexual and verbal abuse were statistically significant predictors of being a member of the pain group. Odds ratios were sexual abuse: 2.67, p < 0.05, CI 1.00-7.14. Verbal abuse: 4.39, p < 0.001, CI 1.93-9.97. A logistic regression was modelled to predict child abuse when gender was taken into account. The results of the logistic regression showed that pain was a significant predictor for sexual abuse after adjusting for gender and age: odds ratio 4.37, p < 0.001, CI 1.80-10.60. Gender was not a statistically significant predictor for sexual abuse, after adjusting for pain and age: odds ratio 2.92, p < 0.072, CI 0.91-9.42. Conclusions : A history of physical, sexual and verbal abuse is more likely to occur in a chronic pain group than in a control group of hospital employees. Although child abuse is reported to be as high as 25% in the general American population, the statistics for chronic pain patients are twice as high as in the general population. The mechanisms for abuse include age, gender, and early family environment.

Age‐ and fitness‐related alterations in vascular sympathetic control

In the current study we explored (1) if there were differences in sympathetic activity and baroreflex function by age, sex, or physical activity status, (2) if any aspect of baroreflex function related to differences in resting sympathetic activity, and (3) if mechanical and/or neural baroreflex components related to differences in integrated baroreflex gain. Electrocardiogram, blood pressure, carotid diameter and muscle sympathetic nerve activity were recorded continuously at rest and during sequential bolus injections of sodium nitroprusside and phenylephrine in 22 young, 21 older sedentary and 10 older trained individuals. Analyses of co‐variance were used to examine age, sex and training status differences and to explore the explanatory power of integrated baroreflex gain and its mechanical and neural components. Training status and sex influenced neither resting sympathetic outflow nor sympathetic baroreflex gain components. Older subjects had a smaller mechanical component and a strong tendency towards a greater neural component of the sympathetic baroreflex during both pressure falls and pressure rises. Opposing age‐related changes in mechanical and neural components resulted in a smaller integrated gain during pressure falls, but a greater integrated gain during pressure rises in older subjects. Thus, in older individuals, compromised sympathetic activation to pressure falls was owing to the stiffening of barosensory vessels, whereas the more sensitive sympathoinhibition to pressure rise was due to an increased neural control. Enhanced neural control with age, however, did not contribute the increased resting sympathetic outflow, which indicates that these two changes are probably driven by distinct neural mechanisms.