Steven Truijen

Risk factors for delirium in intensive care patients: a prospective cohort study

IntroductionDelirium is a common complication in the intensive care unit. The attention of researchers has shifted from the treatment to the prevention of the syndrome necessitating the study of associated risk factors.MethodsIn a multicenter study at one university hospital, two community hospitals and one private hospital, all consecutive newly admitted adult patients were screened and included when reaching a Glasgow Coma Scale greater than 10. Nurse researchers assessed the patients for delirium using the NEECHAM Confusion Scale. Risk factors covered four domains: patient characteristics, chronic pathology, acute illness and environmental factors. Odds ratios were calculated using univariate binary logistic regression.ResultsA total population of 523 patients was screened for delirium. The studied factors showed some variability according to the participating hospitals. The overall delirium incidence was 30%. Age was not a significant risk factor. Intensive smoking (OR 2.04), daily use of more than three units of alcohol (OR 3.23), and living alone at home (OR 1.94), however, contributed to the development of delirium. In the domain of chronic pathology a pre-existing cognitive impairment was an important risk factor (OR 2.41). In the domain of factors related to acute illness the use of drains, tubes and catheters, acute illness scores, the use of psychoactive medication, a preceding period of sedation, coma or mechanical ventilation showed significant risk with odds ratios ranging from 1.04 to 13.66. Environmental risk factors were isolation (OR 2.89), the absence of visit (OR 3.73), the absence of visible daylight (OR 2.39), a transfer from another ward (OR 1.98), and the use of physical restraints (OR 33.84).ConclusionsThis multicenter study indicated risk factors for delirium in the intensive care unit related to patient characteristics, chronic pathology, acute illness, and the environment. Particularly among those related to the acute illness and the environment, several factors are suitable for preventive action.

Monitoring of Physical Activity After Stroke: A Systematic Review of Accelerometry-Based Measures

OBJECTIVE To assess the clinimetric properties and clinical applicability of different accelerometry-based measurement techniques in persons with stroke. DATA SOURCES A systematic search of literature was performed using a specific search strategy by means of different electronic databases until October 2008 (PubMed, EMBASE, CINAHL, Cochrane Library of Clinical Trials). STUDY SELECTION A first selection was made by means of title and abstract. A second selection was performed by means of predefined inclusion criteria: (1) accelerometry in stroke population, (2) application of accelerometry in patients with stroke including clinimetric properties. The exclusion criteria were (1) dysphagia, (2) new engineering techniques or software alterations, (3) secondary sources, and (4) Case studies. DATA EXTRACTION The clinimetric properties and applicability of accelerometry were described based on the included publications. DATA SYNTHESIS Twenty-five articles (4 randomized controlled trials) were included. The information of the publications was divided into (1) gait, cadence, and ambulatory activity; (2) upper-extremity activity; and (3) topics related to stroke other than upper or lower extremity. Accelerometry was shown to be valid and had good test-retest reliability in a large number of settings. Numerous studies demonstrated correlations between accelerometry and common stroke scales. Trunk movements were measured as an outcome of disturbed gait. The vertical asymmetry index especially was able to differentiate between persons with stroke and healthy controls. Persons with stroke showed less ambulatory activity, measured as steps per day, than sedentary controls. Triaxial accelerometry was able to distinguish between varying activity levels. Upper-extremity use was lesser in persons with stroke. It was impossible to calculate a minimal clinical difference for arm use by a uniaxial accelerometer. Evidence was presented that finger-tapping and sit-to-stand measured by accelerometers could be used to define recovery from stroke. CONCLUSIONS The literature concerning accelerometry incorporated into stroke research is young, limiting the ability to draw consistent conclusions. Nonetheless, the available evidence suggests that accelerometers yield valid and reliable data about the physical activity of patients with stroke. Future research is necessary to investigate clinimetric properties like predictive value and responsiveness further before implementing accelerometry in clinical trials as an outcome for change.

Clinical assessment of balance: Normative data, and gender and age effects

The purpose of this study was to provide age specific normative data of clinical gait and balance tests and to determine to what extent gender contributes to differences in postural control. Standing balance and walking performance was tested in 318 asymptomatic adults. The logistic regression, using both 10- and 30-second time limits as a dichotomization point, revealed a significant age effect for standing on foam with eyes closed, tandem Romberg with eyes closed (TR-EC), and one leg stance (eyes open and closed). The actual effect of decline was different for each test. Both tandem gait and dynamic gait index showed a ceiling effect up to 60 years of age, with a rapid decline of performance for subjects in their seventies. Linear regression equations indicated that for both men and women, timed up and go test (TUG) times increased with age, but even older subjects should perform the TUG in 10 seconds or less. Women performed significantly poorer on the TUG and TR-EC (30-second time limit).

Diffuse noxious inhibitory control is delayed in chronic fatigue syndrome: an experimental study.

Abstract Deficient endogenous pain inhibition, e.g. Diffuse noxious inhibitory controls (DNIC), or hormonal abnormalities like hypocortisolism, could be responsible for chronic widespread pain in Chronic Fatigue Syndrome (CFS). Thirty‐one CFS‐patients with chronic pain and 31 healthy controls were subjected to spatial summation of thermal noxious stimuli by gradual immersion (ascending or descending) of the arm in warm water (46 °C). They rated pain intensity every 15 s. Every immersion took 2 min, alternated with 5 min rest. Before and after immersion, salivary cortisol was assessed. Overall pain ratings were higher in CFS‐patients, but the evolution was not different between patients and controls, during both ascending and descending immersion. Pain intensity and immersed surface were only correlated during the descending session in both patients (r = .334) and controls (r = .346). When comparing the first and the last 15 s of every emersion, it was found that pain inhibition starts slower for CFS‐patients in comparison to healthy subjects. Both pre‐ or post‐values and cortisol response did not differ between controls and patients. The drop in cortisol was significantly correlated to pain intensity in CFS (r between .357 and .402). In addition to the hyperalgesia in CFS, DNIC react slower to spatial summation of thermal noxious stimuli. We found no evidence for hypocortisolism in CFS, and the cortisol response to nociception was not different in CFS compared to healthy subjects. In conclusion, delayed pain inhibition may play a role in chronic widespread pain in CFS but further research is required.

Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study

Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli, maladaptive illness beliefs, inappropriate attitudes, and movement dysfunctions. Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance. This single-case study (A-B-C design) with six patients with chronic whiplash associated disorders (WAD) was aimed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms, daily functioning, pain beliefs, and behavior. Periods A and C represented assessment periods, while period B consisted of the intervention (pain neurophysiology education). Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.

Reduced pressure pain thresholds in response to exercise in chronic fatigue syndrome but not in chronic low back pain: an experimental study.

OBJECTIVE The aims of this study were to examine: (i) baseline pressure pain thresholds in patients with chronic fatigue syndrome and those with chronic low back pain compared with healthy subjects; (ii) the change in mean pain threshold in response to exercise; and (iii) associations with exercise-induced increase in nitric oxide. PARTICIPANTS Twenty-six patients with chronic fatigue syndrome suffering of chronic pain, 21 patients with chronic low back pain and 31 healthy subjects. METHODS Participants underwent a submaximal aerobic exercise protocol on a bicycle ergometer, preceded and followed by venous blood sampling (nitric oxide) and algometry (hand, arm, calf, low back). RESULTS Patients with chronic fatigue syndrome presented overall lower pain thresholds compared with healthy subjects and patients with chronic low back pain (p < 0.05). No significant differences were found between healthy subjects and patients with chronic low back pain. After submaximal aerobic exercise, mean pain thresholds decreased in patients with chronic fatigue syndrome, and increased in the others (p < 0.01). At baseline, nitric oxide levels were significantly higher in the chronic low back pain group. After controlling for body mass index, no significant differences were seen between the groups at baseline or in response to exercise. Nitric oxide was not related to pain thresholds in either group. CONCLUSION The results suggest hyperalgesia and abnormal central pain processing during submaximal aerobic exercise in chronic fatigue syndrome, but not in chronic low back pain. Nitric oxide appeared to be unrelated to pain processing.

Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers. A prospective study

Dancers experience significant more low back pain (LBP) than non-dancers and are at increased risk of developing musculoskeletal injuries. Literature concerning the relationship between joint hypermobility and injury in dancers remains controversial. The purpose of this study was therefore to examine whether lumbopelvic movement control and/or generalized joint hypermobility would predict injuries in dancers. Four clinical tests examining the control of lumbopelvic movement during active hip movements were used in combination with joint hypermobility assessment in 32 dancers. Occurrence of musculoskeletal injuries, requiring time away from dancing, was recorded during a 6-month prospective study. Logistic regression analysis was used to predict the probability of developing lower limb and/or lumbar spine injuries. Twenty-six injuries were registered in 32 dancers. Forty-four percent of the dancers were hypermobile. A logistic regression model using two movement control tests, correctly allocated 78% of the dancers. The results suggest that the outcome of two lumbopelvic movement control tests is associated with an increased risk of developing lower extremities or lumbar spine injuries in dancers. Neither generalized joint hypermobility, evaluated with the Beighton score, nor a history of LBP was predictive of injuries. Further study of these interactions is required.

A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: an observational study in non-intubated patients

BackgroundSeveral reports indicate a high incidence of intensive care delirium. To develop strategies to prevent this complication, validated instruments are needed. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is widely used. A binary result diagnoses delirium. The Neelon and Champagne (NEECHAM) Confusion Scale recently has been validated for use in the ICU and has a numeric assessment. This scale allows the patients to be classified in four categories: non-delirious, at risk, confused, and delirious. In this study, we investigated the results of the NEECHAM scale in comparison with the CAM-ICU.MethodsA consecutive sample of 172 non-intubated patients in a mixed ICU was assessed after a stay in the ICU for at least 24 hours. All adult patients with a Glasgow Coma Scale score of greater than 9 were included. A nurse researcher simultaneously assessed both scales once daily in the morning. A total of 599 paired observations were made.ResultsThe CAM-ICU showed a 19.8% incidence of delirium. The NEECHAM scale detected incidence rates of 20.3% for delirious, 24.4% for confused, 29.7% for at risk, and 25.6% for normal patients. The majority of the positive CAM-ICU patients were detected by the NEECHAM scale. The sensitivity of the NEECHAM scale was 87% and the specificity was 95%. The positive predictive value and the negative predictive value were 79% and 97%, respectively. The diagnostic capability in cardiac surgery patients proved to be lower than in other patients.ConclusionIn non-intubated patients, the NEECHAM scale identified most cases of delirium which were detected by the CAM-ICU. Additional confused patients were identified in the categorical approach of the scale. The NEECHAM scale proved to be a valuable screening tool compared with the CAM-ICU in the early detection of intensive care delirium by nurses.

Scapular-focused treatment in patients with shoulder impingement syndrome: a randomized clinical trial

The purpose of this clinical trial is to compare the effectiveness of a scapular-focused treatment with a control therapy in patients with shoulder impingement syndrome. Therefore, a randomized clinical trial with a blinded assessor was used in 22 patients with shoulder impingement syndrome. The primary outcome measures included self-reported shoulder disability and pain. Next, patients were evaluated regarding scapular positioning and shoulder muscle strength. The scapular-focused treatment included stretching and scapular motor control training. The control therapy included stretching, muscle friction, and eccentric rotator cuff training. Main outcome measures were the shoulder disability questionnaire, diagnostic tests for shoulder impingement syndrome, clinical tests for scapular positioning, shoulder pain (visual analog scale; VAS), and muscle strength. A large clinically important treatment effect in favor of scapular motor control training was found in self-reported disability (Cohen’s d = 0.93, p = 0.025), and a moderate to large clinically important improvement in pain during the Neer test, Hawkins test, and empty can test (Cohen’s d 0.76, 1.04, and 0.92, respectively). In addition, the experimental group demonstrated a moderate (Cohen’s d = 0.67) improvement in self-experienced pain at rest (VAS), whereas the control group did not change. The effects were maintained at three months follow-up.

Effect of Long-Term Whole Body Vibration Training on Visceral Adipose Tissue: A Preliminary Report

Aim: To determine the effect of whole body vibration (WBV), combined with caloric restriction, on weight, body composition and metabolic risk factors in overweight and obese adults. Methods: A randomized, controlled study with a 6-month intervention period and a 6-month ‘no intervention’ follow-up. 61 of the 79 participants completed the study. Data were collected at baseline and at 3, 6 and 12 months in the control group (CONTROL), the diet only group (DIET), the diet plus fitness group (FITNESS) and the diet plus WBV group (VIBRATION). Results: Weight decreased significantly in all three intervention groups. Only FITNESS and VIBRATION managed to maintain a weight loss of 5% or more in the long term. Visceral adipose tissue (VAT) changed most in VIBRATION: –47.8 ± 41.2 and –47.7 ± 45.7 cm2 after 6 and 12 months respectively compared to CONTROL (–3.6 ± 20.5 or +26.3 ± 30.6 cm2), DIET (–24.3 ± 29.8 or –7.5 ± 28.3 cm2) and FITNESS (–17.6 ± 36.6 or –1.6 ± 33.3 cm2) (p < 0.001). Conclusions: Combining aerobic exercise or WBV training with caloric restriction can help to achieve a sustained long-term weight loss of 5–10%. These preliminary data show that WBV training may have the potential to reduce VAT more than aerobic exercise in obese adults, possibly making it a meaningful addition to future weight loss programs.