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Arch Phys Med Rehabil

Aspiration in patients with acute stroke.

Daniels SK. Brailey K. Priestly DH. Herrington LR. Weisberg LA. Foundas AL.
Speech Pathology Service, VA Medical Center, New Orleans, LA 70146, USA.
OBJECTIVES: To determine the frequency and clinical predictors of aspiration within 5 days of acute stroke. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Consecutive stroke patients (n = 55) with new neurologic deficit evaluated within 5 days of acute stroke. MAIN OUTCOME MEASURES: Comparison of features identified on clinical swallowing and oromotor examinations and occurrence of aspiration (silent or overt) evident on videofluoroscopic swallow study (VSS). RESULTS: Aspiration occurred in 21 of 55 patients (38%). Whereas 7 of 21 patients (33%) aspirated overtly, 14 (67%) aspirated silently on VSS. Chi-square analyses revealed that dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow were significantly related to aspiration and were predictors of the subset of patients with silent aspiration. Logistic regression revealed that abnormal volitional cough and cough with swallow, in conjunction, predicted aspiration with 78% accuracy. CONCLUSIONS: Silent aspiration appears to be a significant problem in acute stroke patients because silent aspiration occurred in two thirds of the patients who aspirated. The prediction of patients at risk for aspiration was significantly improved by the presence of concurrent findings of abnormal volitional cough and cough with swallow on clinical examination.

Bowel care practices in chronic spinal cord injury patients.

Kirshblum SC. Gulati M. O'Connor KC. Voorman SJ.
Kessler Institute for Rehabilitation, West Orange, NJ 07052, USA.
OBJECTIVE: To determine current characteristics of bowel care practices of chronic spinal cord injury (SCI) patients. DESIGN: Prospective interview and examination of 100 SCI patients injured for more than 1 year. SETTING: Freestanding rehabilitation outpatient SCI center. PARTICIPANTS: One hundred chronic SCI patients. RESULTS: The following bowel program characteristics were found: alternate-day programs were most common; most subjects performed their programs in the morning; and tetraplegic subjects performed their programs less often, used suppositories more often, required greater assistance, and took longer to complete their programs. CONCLUSIONS: Bowel dysfunction in chronic SCI need not be associated with complications in the majority of cases.

Avascular necrosis of bilateral knees secondary to corticosteroid enemas.

Year 1998
Braverman DL. Lachmann EA. Nagler W.
Department of Rehabilitation Medicine, The New York Hospital-Cornell Medical Center, New York, USA.
Avascular necrosis (AVN) is a devastating adverse effect of corticosteroid therapy rarely reported in the setting of inflammatory bowel disease. We describe a 48-year-old woman with 6 weeks of progressive bilateral knee pain resulting in the inability to ambulate. Her symptoms developed suddenly, 9 months after treatment with hydrocortisone enemas for ulcerative proctitis. On physical examination, the patient had knee tenderness, decreased range of motion, and flexion contractures. Magnetic resonance imaging showed multiple bony infarcts in bilateral distal femora and proximal tibias, consistent with advanced AVN. Initial therapy included pain management, serial casting, gentle flexibility and strengthening, and limited mobility training. The rehabilitation efforts led to functional improvement. Ultimately, bilateral total knee arthroplasties were recommended to treat her advanced AVN. This is the first reported case of AVN secondary to hydrocortisone enemas. We review the literature and discuss the pathophysiology and management of corticosteroid-induced AVN.

Successful prosthetic fitting of a 73-year-old hip disarticulation amputee patient with cardiopulmonary disease.

Year 1998
McAnelly RD. Refaeian M. O'Connell DG. Powell GD. Walsh NE.
Department of Rehabilitation Medicine, University of Texas Health Science Center, and Warm Springs and Baptist Rehabilitation Hosptial, San Antonio 78284-7798, USA.
Patients with hip disarticulation (HD) require high energy expenditure for successful prosthetic ambulation. Thus, older patients are rarely fitted with an HD prosthesis. To our knowledge there are no reports of gait analysis following successful prosthetic fitting of an elderly HD amputee patient with systemic cardiopulmonary disease. We report the case of successful prosthetic ambulation in a 73-year-old man with HD secondary to histiosarcoma and a medical history significant for stable angina, chronic obstructive pulmonary disease, and diabetes mellitus. The patient underwent gait training with an endoskeletal prosthesis and achieved ambulation to 400 feet with bilateral forearm crutches. Vicon kinematic gait analysis revealed a cadence of 44 steps/min (112 steps/min normal), and double support time of 47% (26% normal). Oxygen rate during ambulation (VO2) was 11.0 mL/kg/min at velocity of .35 m/sec, compared with published figures for ambulation in those with HD of 10.73 mL/kg/min at velocity of .93 m/sec. At 1-year follow-up, the patient continued to walk into church with the prosthesis. We conclude that a trial fitting of an HD prosthesis should be considered on an individual basis in elderly amputee patients.

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