Residual Impairments Research Articles

Peripheral neuropathy in leprosy and its consequences.

Leprosy causes a 'mononeuritis multiplex' of immunological origin that results in autonomic, sensory and motor neuropathy. When detected and treated early, primary impairments may be reversible. However, 11-51% of patients do not recover. In addition, 33-56% of newly registered patients already have clinically detectable impairments, often no longer amenable to drug treatment. Among new patients, 6-27% present with secondary impairments, such as wounds, contractures and shortening of digits. All patients with impairments should be taught methods to prevent further impairment and subsequent disability (POID). As the result of impairments, many people experience limitation of activities of daily living, which can be partially overcome with the help of assistive devices, training, and surgery. As a result of these limitations, because of visible impairments, or simply because of the diagnosis 'leprosy', many people are restricted in their participation in society. Many overcome activity limitations and participation restrictions without assistance, despite residual impairments. However, some require intervention, such as physical or occupational therapy, reconstructive surgery or temporary socioeconomic assistance. Information on these issues is not collected routinely, and the few tools that exist to measure the severity or extent of impairment have not been widely used, nor have they been used to generate cohort-based statistics. There are no agreed indicators for monitoring POID activities or rehabilitation interventions. Work in the general field of rehabilitation has resulted in the ICIDH-2, which provides a conceptual framework for rehabilitation and the entire area of 'consequences of health conditions'. Although experience to date is very limited, the conceptual framework appears appropriate to leprosy. Data on the prevalence and incidence of primary and secondary impairments have been reported from several countries, the link between impairments and activity limitations has been investigated, and a few studies of the magnitude of the need for rehabilitation have been reported. Research priorities include studies of methods to improve detection of autonomic, sensory and motor neuropathy; trials of alternative drugs or regimens for treating neuropathy; studies of the use of various POID-monitoring systems that may be derived from these; studies of the design and use of instruments to assess limitations of activities and restrictions on participation; assessments of needs for rehabilitation and the development of methods to do these; studies of the efficacy of various types of rehabilitation interventions for particular conditions; and studies of the cost-effectiveness of such interventions.

Decreased c-fos expression in experimental neonatal hydrocephalus: evidence for reduced neuronal activation

Although neonatal hydrocephalus often results in residual neurological impairments, little is known about the cellular mechanisms responsible for these deficits. The immediate early gene, fos (c-fos), functions as a “third messenger” to regulate protein synthesis and is a good marker for neuronal activation. To identify functional changes in neurons at the cellular level, the authors quantified fos RNA expression and localized fos protein in the H-Tx rat model of congenital hydrocephalus. Tissue samples from sensorimotor and auditory regions were obtained from hydrocephalic rats and age-matched, normal litter mates at 1, 6, 12, and 21 days of age (four-six animals in each group) and processed for immunohistochemical analysis of fos and Northern blot analysis of RNA. At 12 days of age, hydrocephalic animals exhibited significant decreases in the ratio of fos immunoreactive cells to Nissl-stained neurons from both cortical regions, but no statistical differences were noted in fos expression. At 21 days of age, both the ratio of fos immunoreactive cells to Nissl-stained neurons and fos expression decreased significantly. The number of fos-positive neurons decreased in all cortical layers but was most prominent in layers V through VI. This decrease did not appear to be caused by neuronal death because examination of Nissl-stained sections revealed many viable neurons within the areas where fos immunoreactivity was absent. These results suggest that progressive neonatal hydrocephalus reduces the capacity for neuronal activation in the cerebral cortex, primarily in those neurons that provide corticofugal projections, and that this impairment may begin during relatively early stages of ventriculomegaly.

Effects of anxiolytics on memory

Drugs used in the treatment of anxiety disorders can produce impairments of cognitive functions. This article provides an overview and summary of research on the effects of anxiolytics upon human memory. Research with the benzodiazepines has shown that they produce a differential pattern of memory deficits whereby episodic memory is dose-dependently impaired but other memory systems are preserved relatively intact. Other anti-anxiety drugs have received relatively little research attention in terms of their memory effects. Recent studies imply that beta-blockers may produce poor memory particularly for emotionally valent information and that, at higher doses, buspirone may have detrimental effects on verbal recall. Studies with anxious patients suggest that tolerance does not fully develop to the amnestic effects of benzodiazepines over repeated use. Further, residual memory impairments appear to persist for a time beyond cessation of use of these drugs. The importance is stressed of assessing the effects of novel anxiolytics on a wide range of memory functions in clinical populations as well as in healthy volunteers. Copyright (C) 1999 John Wiley & Sons, Ltd.

Return to Work as an Integrative Outcome Measure Following Traumatic Brain Injury

In recent years we have witnessed the growing recognition of the centrality of work involvement in the successful rehabilitation of brain injured patients. Evidence from studies conducted at Loewenstein Rehabilitation Hospital (LRH) and from other studies, points to a strong and consistent positive association between employment and social integration, leisure activities, enhanced self-esteem, and perceived quality of life. Patients surviving severe traumatic brain injury (TBI) often suffer from residual impairments in motor control, communication skills, cognition, and social behaviour. These distinctly hamper their capability to return to work and to continue working for an extended period of time. Comprehensive and integrated rehabilitation programmes, such as those employed in LRH, were proven to be effective in returning patients to stable employment. This was demonstrated in the results of our recent follow-up study of 334 severe TBI patients, which indicated that 55.7% were gainfully employed 8-13 years post-discharge from LRH.

Neonatal Hydrocephalus: Mechanisms and Consequences

Although hydrocephalus is a multifactorial disorder, the processes responsible for neurologic impairment can be classified into primary and secondary mechanisms. Primary mechanisms include mechanical compression and stretching of brain parenchyma, ischemia and anoxia, cerebral edema, and blood brain barrier dysfunction. These processes lead to secondary mechanisms, which include cytologic and cytoarchitectural alterations of neurons, reduced size and numbers of cerebral microvessels, axonal degeneration and demyelination, and so on. Shunting studies suggest that neuronal cell death may not play a major role until severe stages of hydrocephalus and that some impairments in connectivity can be reversed. Relatively early shunting may alleviate many of the pathologic features of hydrocephalus, but residual impairments in neurotransmitter levels and dependence on anaerobic respiration leave the treated hydrocephalic brain vulnerable to subsequent insults.

Construct validity and sensitivity of an instrument commonly used to assess the clinical effectiveness of rehabilitative care

Objectives to examine the construct validity and sensitivity of the Barthel Index (BI) and, thus, to assess its utility as an outcome measure in stroke rehabilitation. Design comparison of BI scores with qualitative assessment of functional status for a cohort of patients recovering from a first stroke. Setting re-analysis of data arising in an acute hospital setting (care of the elderly and medical units) as a result of a nursing and midwifery audit initiative, funded by the Welsh Office. Participants 23 patients with discharge BI scores greater than or equal to 16/20. (12 men, 11 women. Age range 55–89.) Main outcome measure within subject comparison of BI scores, with numbers and types of impairment and/or disability as defined by the International Classification of Impairment, Disability and Handicap. Results for this cohort of patients there was no direct relationship between BI score and numbers of identified impairments and disabilities. Patients with similar BI scores had different patterns of impairment. Patients with similar change scores had different patterns of improvement. Patients with maximum BI scores on discharge had residual impairments and disabilities. Conclusions the construct that BI measures is not clearly defined. Therefore, the meaning of BI scores, in terms of patient functional ability, is unclear, and its construct validity is questionable. Its sensitivity is not demonstrated as it has a definite ceiling effect. There is a need to approach outcome measurement for complex areas, such as stroke rehabilitation, in a way that clearly specifies the construct being studied and allows individual progress and support needs to be assessed.

Simplified functional splinting after extensor tenorrhaphy

The medical records of 22 patients who had a total of 61 simple or complex lacerations of finger, thumb, and wrist extensor tendons repaired in zones V-VIII (thumb zones TIII-TV) were reviewed. By 7 days after surgery, custom-molded splints were applied to hold the patients' wrists extended (approximately 30 degrees) and the metacarpophalangeal (MP) joints flexed slightly (20 degrees-30 degrees), leaving the interphalangeal (IP) joints free. If thumb tenorrhaphies were done, the thumb carpometacarpal and MP joints were included and splinted in neutral (0 degree extension) position. Patients performed active JP joint range of motion (ROM) exercises as instructed. At a mean follow-up period of 4.5 months (range, 1.5-12 months), there were no residual impairments that interfered with patients' activities of daily living or prevented their return to preinjury employment status; 19 of 22 patients (86%) had good or excellent results, based on objective criteria of active motion. There were no tenorrhaphy failures. The results support the concept of functional splinting techniques, which allow early active IP joint ROM while protecting the repaired tendons, thus resulting in less joint stiffness than older methods of static splinting without being as complicated and labor-intensive as dynamic splinting.

Stroke Transition after Inpatient Rehabilitation

This article describes a 3-year study testing the efficacy of a system of home-based, case-managed care for stroke survivors returning to the community following inpatient poststroke rehabilitation. The Stroke Transition after Inpatient Rehabilitation (STAIR) study was a randomized, controlled trial of a postdischarge management strategy carried out in a group of 55 stroke patients, aged 65 or older, who did not have serious residual cognitive or language impairments and returned to the community following inpatient rehabilitation with the assistance of a primary caregiver. The program was shown to facilitate improvement in the general social activity level of the patients in the experimental group at 6 months compared to the control, and there was a trend for this effect to persist at 1 year. Strong relationships were identified between residual disability, social activity level, patients' perceptions of efficacy, and caregiver stress.

Successful pregnancy in a neurologically impaired woman with Wilson's disease

Patients with treated Wilson's disease and no residual impairments should have successful pregnancies. We report a case of a neurologically impaired patient with Wilson's disease who had a successful pregnancy with no complications. This is the first case to document that compliance with penicillamine therapy as low as 500 mg/day avoids placental and fetal copper accumulation. (Am J Obstet Gynecol 1997;176:712-4.)

Long-Term Prevalence of Impairments and Disabilities after Multiple Trauma

The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n = 69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.

Long-term outcomes after lower extremity trauma.

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

Partial Recovery from Visual Object Agnosia: A 10 Year Follow-Up Study

We describe a young woman, J.R., who sustained a very severe head injury in 1981 at the age of 17 years. She was assessed in 1982 and found to have visual agnosia. Since then J.R. has been assessed on several occasions over a period of ten years. Her agnosia for real objects has resolved and she has improved on the identification of other classes of stimuli. However, she still has some problems with the identification of line drawings, photographs and model animals. Her drawing from memory remains particularly poor and she has difficulty with visual imagery. We consider her residual deficits in the light of Farah's (1990) theoretical framework; this proposes that associative agnosia could be due to a disconnection syndrome, a loss of stored visual representations or to the loss of knowledge of how to perceive objects. J.R.'s residual impairments appear to be mainly due to a loss of access to visual representations in the absence of visual input.

Epidemiology of acute childhood encephalitis: Aichi Prefecture, Japan, 1984–1990

The case records for 256 patients with acute encephalitis, including meningoencephalitis, acute encephalopathy and Reye syndrome, were obtained from 36 departments of pediatrics in large hospitals through questionnaires which were sent in 1990–1992. The incidence rate per 100,000 child years was 3.3, and was more frequent in children aged 0–4 years (rate 6.6) than 5–15 years (rate 2.0), with statistical significance. The disease in the 105 etiologically diagnosed patients was due to measles virus (24), herpes simplex (21), rubella (24), and other agents (36), including two cases of human herpesvirus 6. A third of the infants with measles encephalitis were first seen at less than 18 months of age. Eighteen cases of rubella encephalitis occurred during an epidemic of rubella in Aichi Prefecture, 1987–1988. The short-term outcome (mean length of follow-up: 2 years 3 months) of encephalitis was death in 20 cases (7.8%) and sequelae in 58 (24%). Eleven patients died within 7 days and five by the 8–14th day from onset. Thirty-six children had multiple residual impairments, including twelve who were severely handicapped. The prognosis for both life and sequelae was significantly poor for herpes simplex encephalitis in etiologically diagnosed patients. We stress the importance of an increase in the vaccination rate and the establishment of an early diagnostic system.

Residual impairments and work status 15 years after penetrating head injury

We investigated the relationship of neurologic, neuropsychological, and social interaction impairments to the work status of a large sample of penetrating head-injured patients wounded some 15 years earlier during combat in Vietnam. Extensive standardized testing of neurologic, neuropsychological, and social functioning was done at follow-up on each head-injured patient (N = 520), as well as on a sample of uninjured controls (N = 85). Fifty-six percent of the head-injured patients were working at follow-up compared with 82% of the uninjured controls. Seven systematically defined impairments proved to be most correlated with work status. These were post-traumatic epilepsy, paresis, visual field loss, verbal memory loss, visual memory loss, psychological problems, and violent behavior. These disabilities had a cumulative and nearly equipotent effect upon the likelihood of work. We suggest that a simple summed score of the number of these seven disabilities can yield a residual "disability score" which may prove to be a practical tool for assessing the likelihood of return to work for patients in this population and perhaps in other brain-injured populations. These findings may also help to focus rehabilitation efforts on those disabilities most likely to affect return to work.

Rehabilitation needs after haemorrhagic brain injury: are they similar to those after traumatic brain injury?

A retrospective survey of 78 patients with spontaneous haemorrhagic brain injury admitted to a regional neurorehabilitation centre over a three-year period is described. Residual neuropsychological impairments and the need for assistance in activities of daily living (ADL) were assessed. Little difference was found in terms of impairment or extent of disability between the 53 subarachnoid haemorrhage and 25 intracerebral haemorrhage survivors who comprised the study population. This population is compared to the findings in traumatically brain-injured patients managed in the same unit. Although there were some neuropsychological differences between the two groups, these were not reflected in the degree of dependence in ADL, which was remarkably similar. The length of stay for haemorrhagic brain injury patients on the unit was longer than that of the head injured. Haemorrhagic brain injury therefore, represents a major demand on rehabilitation services and similar provisions should be made for them as are advocated for the traumatically brain injured.

Risk factors for heterotopic ossification in children and adolescents with severe traumatic brain injury.

Previous reports on the incidence of heterotopic ossification (HO) in children and adolescents with traumatic brain injury (TBI) have ranged from 3% to 20%. These studies mention HO briefly or address patient cohorts with coma more than three months. We reviewed the medical records of 90 children younger than 19 years old, who were comatose more than 24 hours after TBI. Mean followup was 33.1 months (range = 2 to 128 months). Incidence of HO was 14.4% (n = 13). One to five sites were involved, with hip and knee most frequent, followed by shoulder, elbow, and nonjoint sites. Children with HO were older than 11 years (relative risk [RR] = 18.85, confidence interval [CI] = 3.7, 95.7), had a greater length of coma (RR = 7.22, CI = 1.4, 37.1), and had a greater associated risk for poor functional outcome (RR = 2.89, CI = 1.02, 7.9) compared to those without RO. Multiple limb fractures showed a trend toward association with increased incidence of HO. Other factors, including gender, history of skull fracture, brain CAT scan findings, and presence of spasticity, were not predictive of HO. Eleven children were treated with etidronate, four with nonsteroidal antiinflammatory drugs, and one with surgery. Only three children had residual functional impairments attributed to the presence of HO.

Assisted survival, aging, and rehabilitation needs: comparison of older dialysis patients and age-matched peers.

In Western societies a growing number of older persons have their lives extended by medical or surgical intervention. Older persons who suffer kidney failure and are maintained by chronic dialysis therapy are a good example. We compared 349 persons aged 60 years or older, who were on chronic dialysis, with 354 persons similar in age, race, gender, and geographic residence who were not undergoing dialysis. Recent health problems and demographic characteristics were included as control variables in all analyses. Older persons on dialysis reported more functional disability (as measured by ADL-mobility difficulty), less frequent walking for exercise, decreased ability to do the things they would like to do, and lower levels of perceived mastery over their lives. They were also more likely to report a need for health-related aids or services. The residual impairments of disabled elderly persons challenge rehabilitation professionals to address quality of life issues.

Recovery and plasticity in child-onset aphasics: Ultimate outcome at adulthood

Abstract The long-term outcome of linguistic and nonlinguistic functions was investigated for three closely followed, child-onset aphasic subjects at the time of their adulthood. Despite the early restoration of functional communication ability, the results of our investigation revealed that linguistic recovery was not complete and that syntactic processing difficulties, limitation of lexical-semantic abilities as well as written language processing difficulties were present. All three showed poorer performance in spontaneous speech measures, such as production of complex syntactic structure and efficiency of production, when compared to controls matched for lexical-semantic ability. The case histories suggested that the influence of residual linguistic impairments was not limited to the area of academic achievement but had broad generalizing effects on the subjects personalities and social development. Examination of the relationship between lesion site and linguistic difficulty in individual subjects sh...

Impairment after severe blunt head injury: the results from a consecutive series of 100 patients.

Three scales, assessing the degree of brain impairment after severe blunt head injury in neurophysical and neuropsychological functions as well as overall organic functioning, are described. A consecutive series of 100 severe blunt head injured patients was followed up 6 years post-trauma and the scales were used to measure the residual impairments and determine the level of recovery for 82 subjects in the series. No subject made a complete neurophysical and neuropsychological recovery, 92% of the series was classified as suffering clinically significant impairments and in half the series the moderate or severe impairments were consistent with a poor level of recovery. The impairments of a large proportion (42%) of the series, however, were classified as mild. Although most subjects demonstrated impairments in both neurophysical and neuropsychological functions, 43% of the series suffered isolated impairments in either the neurophysical or neuropsychological areas. There was strong agreement between the overall organic impairment profile and the subjects' classifications on the Glasgow Outcome Scale.

Should the elderly be resuscitated following out-of-hospital cardiac arrest?

purpose: Elderly and younger patients who were successfully resuscitated and hospitalized following out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. patients and methods: The study consisted of 214 consecutive patients, divided into two age groups: elderly (more than 70 years, n = 112) and younger (less than 70 years, n = 102). Hospital charts and paramedic run data were retrospectively reviewed for each patient and findings were compared between the two age groups. results: Prior to cardiac arrest, 47 of 112 (42 percent) elderly patients had a history of heart failure, compared with 19 of 102 (18 percent) younger patients, and were more commonly taking digitalis (51 percent versus 29 percent) and diuretics (47 percent versus 26 percent). Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33 percent versus 16 percent). At the time of cardiac arrest, 83 percent of younger patients demonstrated ventricular fibrillation, compared with 71 percent of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71 percent versus 53 percent), the length of hospitalization and stay in intensive care units were not significantly different between the age groups. The number of neurologic deaths was similar in both age groups, as were residual neurologic impairments. Only five elderly patients and six younger patients required placement in extended-care facilities. Calculated long-term survival curves demonstrated similar survival in both age groups, with approximately 65 percent of hospital survivors alive at 24 months after hospital discharge. conclusion: Resuscitation of elderly patients in whom out-of-hospital cardiac arrest occurs is reasonable and appropriate, according to the findings of this study. Even though elderly patients are more likely than younger patients to die during hospitalization, the hospital stay of the elderly is not longer, the elderly do not have more residual neurologic impairments, and survival after hospital discharge is similar to that in younger patients.