Patient Immobilization Research Articles

A Case of Stercoral Perforation Detected on CT Requiring Proctocolectomy in a Heroin-Dependent Patient.

Stercoral perforation of the colon is rare but carries with it significant morbidity and mortality. Stercoral perforation usually occurs in elderly, immobile patients with chronic constipation. In this manuscript, we report the case of stercoral perforation in a patient due to chronic heroin dependence. We report the case of a 56-year-old male patient with stercoral perforation, diagnosed by computed tomography, secondary to heroin dependence, requiring proctocolectomy and an end ileostomy. There are very few reports in the literature describing cases of stercoral perforation and questions have been asked about the importance of preoperative cross-sectional imaging. In our case, the diagnosis of stercoral perforation was made only on CT. Although this is not the first such case to be reported, it is significant as preoperative CT imaging was influential not only in determining the aetiology of the abdominal distension seen on the plain film, but also in detecting the pneumoperitoneum which was not evident clinically or on plain radiographs.

An obstruction not to forget: Pseudo-obstruction (Ogilvie syndrome): Single center experience.

Purpose:Colonic pseudo obstruction disease commonly seen in the elderly, immobile patient group can cause serious mortality and morbidity. Our objective in this retrospective study is to share our clinical experience by evaluating patients with Ogilvie syndrome who were followed and treated in our clinic.Methods:Eleven cases with the diagnosis of Ogilvie syndrome followed up and treated between September 2010 and April 2013 were evaluated retrospectively. All the patients that had no symptoms of acute abdominal pain were initiated conservative treatment. Colonoscopic decompression was attempted for patients whose clinical pictures were not recovered. Patients underwent operation if they developed peritoneal irritation symptoms during these procedures and of their number of white blood cells seriously increased during the follow-up period.Results:A total of 11 patients were treated for Ogilvie syndrome. 6 of the patients underwent surgical treatment, and 5 were treated medically. Mortality developed in two patients. The main cause of mortality was a delay in diagnosis and additional severe underlying diseases. Seven patients were given Neostigmine. Of these, 2 patients required surgery and 3 patients responded to Neostigmine.Conclusion:Ogilvie syndrome is a rare cause of ileus of the colon. It is more common particularly in old patients with additional problems. If the disease is suspected and diagnosed early, unnecessary surgical interventions can be prevented with medical treatment choices.

A Portable Remote Medical Consultation System for the Use of Distant Rural Communities

Remote medical monitoring and consultation has become indispensable in order to enhance the availability of better health-care services to the patients in remote rural areas in the country. This paper proposes an inexpensive, easy to handle Remote Medical Consultation System (RMCS) which supports the healthcare workers to carry out their services through bi-directional video and voice communication between the remote end and doctor’s end as well as automated measuring of medical parameters that can be controlled from both ends. RMCS is consisted of a wearable sensors kit, a centralized hardware platform which connects to the medical sensors and devices and a software platform with database for operating and managing the system. RMCS is capable of remotely measuring patient’s blood pressure, heart rate, body temperature, electrocardiogram (ECG), heart sounds and the system’s platform supports to add-on more medical sensors or devices. The key aspect of the system is that it reduces most of the complexity in operation and facilitates the doctors to monitor and diagnose the patients in real-time. RMCS was essentially developed to eliminate the issues of low quality healthcare services in rural areas and to assist in monitoring immobilized patients.

Effect of an Exercises Programme on Reducing Musculoskeletal Complications for Stroke Immobilized Patients

Stroke is a leading cause of disability. Aim: the first assess patient’s knowledge and practice regarding musculoskeletal complications resulting from immobility. The second evaluate the effect of applying for an exercise programme on stroke immobilized patients’ knowledge and practice. Patient methods: 60 patients conducted at neurological departments at Assiut University Hospital. . Tools: Data collected by using three tools; Tool Ι: Patient's health needs assessment sheet: part 1; A- included Sociodemographic patient characteristics, B- socio-demographic scale, according to Fahmy and Al-sherbeny (1983), part 2; assessment of the past and present health history, part 3; patient’s Assessment for the musculoskeletal complications, Part 4: Assessment of patient's knowledge and practice regarding musculoskeletal complications resulting from immobility and importance of these exercises, Tool II- Musculoskeletal assessment sheet: Part 1; by Ashworth scale ,1964, Part 2; Scandinavian stroke scale,1991. Results: The incidences of musculoskeletal complications in the study sample were lesser than the control group and having higher mean score knowledge regarding stroke. Conclusions: providing a successful physical exercise programme for stroke patients was much more effective on the outcome of patients than those patients in the control group who received routine hospital care. Also, the mean score level of knowledge of the study group patients in the time of follow-up was higher than the mean score level of knowledge of control group patients who didn’t receive the exercise programme. Recommendations: the exercise programme should be applying early as possible as from at the time of admission to the hospital.

Deep Vein Thrombosis Prophylaxis Evaluation in Intensive Care Unit

Background: One of the main causes of morbidity in hospitalized patients, and especially in the intensive care unit (ICU), is venous thromboembolism (VTE). The best way to deal with VTE is prophylaxis. Rational prophylaxis should be provided after risk factor anal- ysis. Dierent prophylaxis regimens are pharmacological and physical. Pharmacological prophylaxis regimens consist of heparin and enoxaparin that are given subcutaneously. Objectives: The current study aimed to investigate appropriate administration of deep vein thrombosis (DVT) prophylaxis in ICU in an educational hospital. Methods: Caprini risk assessment model was employed to evaluate patients' risk factors. Immobile patients (for three days) with at least one thrombotic risk factor were selected. The Caprini scores were identified from patients' medical record. Three groups were identified after obtaining the scores: patients at low, medium and high risks. For each group, appropriate prophylaxis regimen was recommended. Results: A total of 52 patients were evaluated, about 88.46% of the subjects had DVT prophylaxis indication; 10.71% received physical prophylaxis and 89.29% of them received pharmacological prophylaxis. For two-thirds of the patients with pharmacological pro- phylaxis enoxaparin was administered and for the other part heparin. Totally, 32.61% of the subjects received correct prophylaxis, 17.39% received inadequate prophylactic doses and 6.52% received higher doses. Totally, 67.39% of the subjects did not receive correct prophylaxis. Conclusions: According to the collected data, appropriate DVT prophylaxis was not prescribed. It is required to pay serious atten- tion to this medication error. It is suggested to invest on educating medical teams about DVT prophylaxis, which is highly demanded.

Emergency Department Geriatric Assessment and Short-Term Mortality in Hospitalized Elderly Medical Patients

We studied which elements of an emergency department geriatric assessment (EDGA) are associated with a short-term mortality in hospitalized elderly medical patients. This was a retrospective cohort study. Medical charts of all consecutive elderly (aged ≥ 75 years) patients who had undergone an EDGA and had been admitted to internal medicine departments of a tertiary medical center between April 2010 and June 2011 were reviewed. The study group included patients who died within 3 months, and the control group included patients who survived during this time. A regression analysis was used to study which of the following elements of an EDGA were independently associated with a 3-month mortality: caregiver support, independence in activities of daily living, immobility, incontinence, cognitive decline, recurrent falls, and the number of medications. The final cohort included 368 patients: 236 (64.1%) women; the mean age was 84.3 ± 5.3 years. Overall, 61 (16.6%) patients died within 3 months. Dead patients were significantly more dependent, more immobile, and more incontinent compared with those who survived ( p < 0.0001 for all). A regression analysis showed that only immobility was independently associated with a 3-month mortality (odds ratio 1.9; p = 0.001). A 3-month cumulative survival was significantly higher in ambulant patients relative to cane/walker users, in cane/walker users relative to patients who needed assistance, and in patients who needed assistance relative to totally immobile patients ( p < 0.0001). Immobility documented during an EDGA at the time of admission is associated with 3-month mortality in hospitalized elderly medical patients.

A phase II trial to evaluate single-dose stereotactic body radiation therapy (SBRT) prior to surgery for early-stage breast carcinoma: SIGNAL (stereotactic image-guided neoadjuvant ablative radiation then lumpectomy) trial

Background Breast-conserving therapy has become a preferred option in the treatment of early breast cancer. Current breast-conserving therapy includes 3–5 weeks of external beam radiotherapy to the whole breast, sometimes followed by a 1–2-week boost to the tumor bed. However, the duration of the radiation regimen can be prohibitive for the elderly, infirm or immobile patients, those patients who live far from the cancer center, or those who have difficulty taking an extended leave of absence. We propose to treat these patients with a single dose of radiation preoperatively, thereby shortening the total treatment time.

Short- and Long-Term Safety of PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Introduction: Irregular drug plasma levels due to impaired gastric emptying may contribute to motor complications observed in patients with Parkinson's disease (PD) treated with oral medication. One treatment for PD uses percutaneous endoscopic gastrostomy with jejunal extension tube (PEGJ) to continuously deliver levodopa-carbidopa intestinal gel (LCIG, known in the US as carbidopa-levodopa enteral suspension [CLES]) directly to the jejunum for 16 hours, thereby bypassing the stomach and avoiding fluctuating drug plasma levels. We assessed short- and long-term safety of the PEG-J procedure and device used to deliver LCIG in mobile patients with PD from our most recent clinical trial data cut. Methods: All patients received a 15 French Freka PEG tube and a 9 French Freka jejunal extension tube, placed during the same endoscopy. The ideal jejunal tube tip position was distal to the ligament of Treitz. PEG-J procedure- and device-related treatment-emergent adverse events (AEs) reported during 4 phase 3 LCIG studies (including an ongoing open-label extension study into which all others filtered) were integrated and evaluated. AEs and serious AEs (SAEs) in patients treated with LCIG were included in this analysis at the March 2014 data cut-off date. Results: A total of 395 patients were included in this analysis. The median (range) exposure to PEG-J was 986 (1-1972) days; 165 patients were exposed for ≥1095 days, 130 patients were exposed for ≥1260 days, and 70 patients were exposed for ≥1460 days. The incidence of SAEs was highest in the first week and declined rapidly thereafter (Figure 1). Over the long-term, procedure/device-associated AEs occurred in 387 (94%) patients and SAEs occurred in 68 (17%) patients (Table 1), although single events may have been coded to >1 preferred term. Procedure/device-associated AEs led to discontinuation in 19 (4.8%) patients; those that led to discontinuation in >1 patient included complication of device insertion (10 patients; 2.5%), abdominal pain (4 patients, 1.0%), abdominal discomfort (2 patients, 0.5%), and peritonitis (2 patients, 0.5%).Figure 1Table 1: Overall Procedure/Device-associated Adverse EventsConclusion: The overall safety profile of LCIG via PEG-J is comparable to published data in immobile patients (Itkin M et al, Gastroenterology, 2011;141:742-65). Incidence of SAEs declined after the first week post-procedure. The low discontinuation rate of LCIG treatment via PEG-J demonstrates that this treatment can be maintained for long-term use in this mobile patient population with advanced PD.

Tracheal Intubation with a McGrath® Series 5 Video Laryngoscope by Novice Personnel in a Cervical-immobilized Manikin

BackgroundPrehospital tracheal intubation may be performed by novice intubators in cervical immobilized patients. However, most indirect laryngoscopes require special training. The McGrath® Series 5 video laryngoscope is similar to the Macintosh laryngoscope in shape and usage, yet still confers the advantages of having indirect laryngoscopes. ObjectiveThis study compared tracheal intubation by novice users, using the McGrath® Series 5 video laryngoscope vs. the Macintosh laryngoscope in a cervical immobilized manikin. MethodsThirty-eight nurses intubated the trachea of a manikin using a McGrath® Series 5 video laryngoscope and a Macintosh laryngoscope, in random order. Then they repeated the procedure in a manikin with a cervical collar. Success rate, time to success, number of intubation attempts, dental clicks, and difficulty score were compared between the two laryngoscopes. ResultsFirst-attempt success rate was higher for the McGrath® Series 5 compared to the Macintosh laryngoscope in cervical immobilizations (84.2% vs. 47.7%, respectively; p = 0.019). However, overall intubation success rate with and without the cervical collar was no different. Tracheal intubation using the McGrath® Series 5 was faster than the Macintosh laryngoscope regardless of the presence of a cervical collar. McGrath® Series 5 required fewer trials, had fewer dental clicks, and was easier to use than the Macintosh laryngoscope. ConclusionsMcGrath® Series 5 video laryngoscope may be better than a standard Macintosh laryngoscope for novice intubators intubating the trachea in cervical immobilization, due to the higher first-attempt success rate, faster intubation time, fewer dental clicks, lower number of intubation attempts, and overall ease of use.

ICU progressive mobility

In Brief Immobile patients are at increased risk for ventilator-associated pneumonia, atelectasis, muscle mass loss, and hemodynamic instability.

The Clots in Legs Or sTockings after Stroke (CLOTS) 3 trial: a randomised controlled trial to determine whether or not intermittent pneumatic compression reduces the risk of post-stroke deep vein thrombosis and to estimate its cost-effectiveness.

Venous thromboembolism (VTE) is a common cause of death and morbidity in stroke patients. There are few data concerning the effectiveness of intermittent pneumatic compression (IPC) in treating patients with stroke. To establish whether or not the application of IPC to the legs of immobile stroke patients reduced their risk of deep vein thrombosis (DVT). Clots in Legs Or sTockings after Stroke (CLOTS) 3 was a multicentre, parallel-group, randomised controlled trial which allocated patients via a central randomisation system to IPC or no IPC. A technician blinded to treatment allocation performed compression duplex ultrasound (CDU) of both legs at 7-10 days and 25-30 days after enrolment. We followed up patients for 6 months to determine survival and later symptomatic VTE. Patients were analysed according to their treatment allocation. We enrolled 2876 patients in 94 UK hospitals between 8 December 2008 and 6 September 2012. patients admitted to hospital within 3 days of acute stroke and who were immobile on the day of admission (day 0) to day 3. age < 16 years; subarachnoid haemorrhage; and contra-indications to IPC including dermatitis, leg ulcers, severe oedema, severe peripheral vascular disease and congestive cardiac failure. Participants were allocated to routine care or routine care plus IPC for 30 days, or until earlier discharge or walking independently. The primary outcome was DVT in popliteal or femoral veins, detected on a screening CDU, or any symptomatic DVT in the proximal veins, confirmed by imaging, within 30 days of randomisation. The secondary outcomes included death, any DVTs, symptomatic DVTs, pulmonary emboli, skin breaks on the legs, falls with injury or fractures and duration of IPC use occurring within 30 days of randomisation and survival, symptomatic VTE, disability (as measured by the Oxford Handicap Scale), quality of life (as measured by the European Quality of Life-5 Dimensions 3 Level questionnaire) and length of initial hospital stay measured 6 months after randomisation. We allocated 1438 patients to IPC and 1438 to no IPC. The primary outcome occurred in 122 (8.5%) of 1438 patients allocated to IPC and 174 (12.1%) of 1438 patients allocated to no IPC, giving an absolute reduction in risk of 3.6% [95% confidence interval (CI) 1.4% to 5.8%] and a relative risk reduction of 0.69 (95% CI 0.55 to 0.86). After excluding 323 patients who died prior to any primary outcome and 41 who had no screening CDU, the primary outcome occurred in 122 of 1267 IPC participants compared with 174 of 1245 no-IPC participants, giving an adjusted odds ratio of 0.65 (95% CI 0.51 to 0.84; p = 0.001). Secondary outcomes in IPC compared with no-IPC participants were death in the treatment period in 156 (10.8%) versus 189 (13.1%) (p = 0.058); skin breaks in 44 (3.1%) versus 20 (1.4%) (p = 0.002); and falls with injury in 33 (2.3%) versus 24 (1.7%) (p = 0.221). Among patients treated with IPC, there was a statistically significant improvement in survival to 6 months (hazard ratio 0.86, 95% CI 0.73 to 0.99; p = 0.042), but no improvement in disability. The direct cost of preventing a DVT was £1282 per event (95% CI £785 to £3077). IPC is an effective and inexpensive method of reducing the risk of DVT and improving survival in immobile stroke patients. Further research should test whether or not IPC improves survival in other groups of high-risk hospitalised medical patients. In addition, research into methods to improve adherence to IPC might increase the benefits of IPC in stroke patients. Current Controlled Trials ISRCTN93529999. The start-up phase of the trial (December 2008-March 2010) was funded by the Chief Scientist Office of the Scottish Government (reference number CZH/4/417). The main phase of the trial was funded by the National Institute for Health Research Health Technology Assessment programme (reference number 08/14/03). Covidien Ltd (Mansfield, MA, USA) lent its Kendall SCD™ Express sequential compression system controllers to the 105 centres involved in the trial and donated supplies of its sleeves. It also provided logistical help in keeping our centres supplied with sleeves and training materials relevant to the use of their devices. Recruitment and follow-up were supported by the National Institute for Health Research-funded UK Stroke Research Network and by the Scottish Stroke Research Network, which was supported by NHS Research Scotland.

Which stroke patients gain most from intermittent pneumatic compression: further analyses of the CLOTS 3 trial.

The CLOTS 3 trial showed that intermittent pneumatic compression (IPC) reduced the risk of DVT and improved survival after stroke. To provide additional information which may help clinicians target IPC on the most appropriate patients by exploring the variation in its effects on subgroups defined by predicted prognosis. A multicentre, parallel group, randomized trial enrolled immobile acute stroke patients and allocated them to IPC or no IPC. The primary outcome was proximal DVT at 30 days. Secondary outcomes at six-months included survival, disability, quality of life, and hospital costs. We stratified patients into quintiles according to their predicted prognosis at randomization, based on the Six Simple Variable model. Between December 2008 and September 2012, we enrolled 2876 patients in 94 UK hospitals. Patients with the best predicted outcome had the lowest absolute risk of proximal DVT (6·7%) and death by six-months (9·3%). Allocation to IPC had little effect on DVT, survival, disability, quality of life, hospital length of stay, or costs. In patients with the worst predicted outcomes, the overall risk of DVT and death was 16·0% and 51·3%, respectively. IPC reduced DVT (odds reduction 34%) and improved survival 17% and significantly increased length of stay and hospital costs. In the three intermediate quintiles, IPC reduced the odds of DVT (35-43%) and improved survival (11-13%). Disability and quality of life at six-months depended on baseline severity but was not influenced significantly by IPC. IPC appears to reduce the risk of DVT and probably improves survival in all immobile stroke patients, other than the fifth with the best prognosis. It therefore seems reasonable to recommend that IPC should be considered in all immobile stroke patients, but that the final decision should be based on a judgment about the individual's prognosis. In some, their prognosis for survival with an acceptable quality of life will be so poor that use of IPC might be considered futile, while at the other end of the spectrum, patients' risk of DVT, and of dying from VTE, may not be high enough to justify the modest cost and inconvenience of IPC use.

Whole-body ferromagnetic detector systems in clinical MRI

In spite of technical and organizational measures, ferromagnetic objects still find their way into the magnetic resonance imaging (MRI) room and can cause severe injuries. A detailed patient education and MRI safety training for personnel are necessary to avoid MRI incidents with ferromagnetic objects. Whole body ferromagnetic detection systems should increase patient safety and minimize risks for personnel and MRI equipment in the clinical routine. In a clinical MRI setting, a screener system used for outpatients and inpatients (n = 400) identified unknown ferrous objects in 2 % of the cases. In two of these cases patients were found to be in possession of unknown foreign ferrous objects. Furthermore, a door guard system only used for outpatients (n = 2500) detected unknown ferromagnetic objects in 0.3 % of the cases. The number of ferrous objects that are unknowingly brought into the scanner room can be reduced with a whole body ferromagnetic detection system. For an optimal benefit of the system a ferrous-free environment and perfectly ferrous-free clothing for the medical personnel are necessary. In the clinical routine, the benefit of the system is limited particularly for immobile patients who have to remain in a horizontal position. A whole body ferromagnetic detection system can complement but not replace patient education and MRI safety training.

Transcranial direct current stimulation of the motor cortex in waking resting state induces motor imagery.

This study investigates if anodal and cathodal transcranial direct current stimulation (tDCS) of areas above the motor cortex (C3) influences spontaneous motor imagery experienced in the waking resting state. A randomized triple-blinded design was used, combining neurophysiological techniques with tools of quantitative mentation report analysis from cognitive linguistics. The results indicate that while spontaneous motor imagery rarely occurs under sham stimulation, general and athletic motor imagery (classified as athletic disciplines), is induced by anodal tDCS. This insight may have implications beyond basic consciousness research. Motor imagery and corresponding motor cortical activation have been shown to benefit later motor performance. Electrophysiological manipulations of motor imagery could in the long run be used for rehabilitative tDCS protocols benefitting temporarily immobile clinical patients who cannot perform specific motor imagery tasks - such as dementia patients, infants with developmental and motor disorders, and coma patients.

Pelvic pressure ulcer reconstructions by pedicled muscle flaps

Introduction: Pelvic region is the most predisposed topographic area of the body to pressure ulcers in immobile patients. This communication presents the experience of the authors and set to discussion the value of the pedicled muscle flaps in the management of pressure ulcers stage III and IV. Material and Methods: The study was conducted during the period from May 2006 to December 2014. A total of 11 muscle based flaps were applied on 5 male and one female patients with deep pressure ulcers in the pelvic region. Musculus gluteus maximus (MGM), musculus gracilis (MG), musculus hamstring (MH), musculus vastus lateralis femoris (MVLF) and musculus rectus abdominis (MRA) were designed as monocomponent muscle or compound skin-muscle flaps in accordance with the wound characteristics. Results: The patients were followed-up from 1 month to 6 years. All flaps were vital. Small area partial skin necrosis of the MRA flap and MH advancement flap required secondary surgical procedures within a month after the reconstruction. Four recurrences through variable periods were observed in one patient, operated on by different muscle flaps. Conclusion: Pressure ulcers are a frequent complication in immobile patients. Surgery is the most effective treatment method for wounds at stages III and IV. Patient’s general condition and wound status should be taken into consideration when planning the reconstruction. The vitality and volume of the muscle flaps are the main advantages of that alternative for surgical treatment of pelvic pressure sores.

Assessments of the associations of thrombus localization with accompanying disorders, risk factors, D-dimer levels, and the red cell distribution width in pulmonary embolism

OBJECTIVE:Pulmonary embolisms occur as a wide spectrum ranging from clinically asymptomatic thrombi to massive thrombi that lead to cardiogenic shock. The purpose of this study was to determine the associations of thrombus localization with risk factors, accompanying disorders, D-dimer levels and the red blood cell distribution width in patients with pulmonary embolism.MATERIAL AND METHODS:In 148 patients diagnosed with pulmonary embolism, the presence and anatomical localization of the thrombus were assessed via computed tomographic pulmonary angiography. The accompanying disorders, risk factors, serum D-dimer levels, and red blood cell distribution width of the patients were retrospectively evaluated. ClinicalTrials.gov: NCT02388841.RESULTS:The mean age of the patients was 54±16.0 years, and 48 patients were ≥65 years of age. The most frequent accompanying disorders were chronic obstructive pulmonary disease (22%) and malignancy (10.1%), and the most frequent risk factors were recent operation (14.1%) and immobilization (18.2%). Thrombi were most frequently observed in the right pulmonary artery (37.8%). In 31% of the patients, the thrombus was localized to the main pulmonary arteries. Immobile patients exhibited a higher proportion of thrombi in the main pulmonary arteries than mobile patients. The mean D-dimer level and the mean red blood cell distribution width in the patients with thrombi in the main pulmonary arteries were higher than those in the patients with thrombi in more distal pulmonary arterial branches.CONCLUSION:Significant associations of proximally localized thrombi with immobilization, the D-dimer levels, and the red blood cell distribution width were observed.

PHS42 - Clinical and economic analysis of simple contact dermatitis due to Urinary incontinence and pressure Ulcers of immobilized patients with Urinary incontinence

PHS42 - Clinical and economic analysis of simple contact dermatitis due to Urinary incontinence and pressure Ulcers of immobilized patients with Urinary incontinence

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Nursing staff induced repositionings and immobile patients' spontaneous movements in nursing care.

The aim of this study was to investigate nursing staff induced repositionings and the patients' spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients' spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients' spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients' spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients.

Modelling Volume of Tissue Activated for Deep Brain Stimulation

s / Brain Stimulation 8 (2015) 395e411 405 rehabilitation of their motor system. We investigate if transcranial direct current stimulation (tDCS) of the motor cortex elevates the degree and intensity of spontaneous motor imagery in resting states in comparison with a sham-tDCS condition. We report on tDCS-inducedmotor imagery inwaking resting state as well as REM sleep, a state of consciousness that has been associated with motor learning and rehearsal. Our model of motor imagery could be used to design rehabilitation protocols especially for such temporarily immobile clinical patients who cannot perform certain motor imagery tasks, such as dementia patients, patients with psychological disorders, infants with developmental and motor disorders, and coma patients.