Biomedical subjects

D D Cardenas

Publications and source records attributed to D D Cardenas.

At least 19 recordsLinked to original sources

PubMed2006

Phase 2 trial of sustained-release fampridine in chronic spinal cord injury.

STUDY DESIGN: Double-blind, randomized, placebo-controlled, parallel-group clinical trial. OBJECTIVE: Assess safety and efficacy of sustained-release fampridine in subjects with chronic spinal cord injury. SETTING: A total of 11 academic rehabilitation research centers in the United States. METHODS: A total of 91 subjects with motor-incomplete spinal cord injury (SCI), randomized to three arms: fampridine, sustained release, 25 mg b.i.d. (Group I), 40 mg b.i.d. (Group II), and placebo (Group III) for 8 weeks. OUTCOME MEASURES: Patient diary questionnaire, Ashworth score, American Spinal Cord Injury Association International Standards, International Index of Erectile Function, bladder and bowel management questionnaires, and Clinician and Subject Global Impressions (Clinician Global Impression of change, Subject Global Impression (SGI)). Safety was evaluated from adverse events, physical examinations, vital signs, electrocardiograms, and laboratory tests. RESULTS: In total, 78% of the subjects completed the study. More (13/30) discontinued from Group II than Group I (4/30) and Group III (3/31). The most frequent adverse events across groups were hypertonia, generalized spasm, insomnia, dizziness, asthenia, pain, constipation, and headache. One subject in Group II experienced a seizure. SGI changed significantly in favor of Group I (P=0.02). Subgroup analysis of subjects with baseline Ashworth scores >1 showed significant improvement in spasticity in Group I versus III (P=0.02). CONCLUSIONS: Group I showed significant improvement in SGI, and potential benefit on spasticity. The drug was well tolerated. Group II showed more adverse events and discontinuations.

4-Aminopyridine↗

PubMed2005

Chronic pain in individuals with spinal cord injury: a survey and longitudinal study.

STUDY DESIGN: Cross-sectional and longitudinal postal survey. OBJECTIVES: To (1) compare the severity of pain in persons with spinal cord injury (SCI) to national norms, (2) examine the association between pain and measures of (a) psychological functioning, (b) community integration and (c) pain interference with daily activities, and (3) examine the change in the prevalence and intensity of pain over time. SETTING: Community. METHODS: A total of 147 adults with SCI were surveyed twice, 2-6 years apart. Main outcome measures included presence/absence of pain in general and at specific body sites, 0-10 numerical rating scale of average pain intensity, modified Brief Pain Inventory Pain Interference scale, SF-36 Bodily Pain scale, SF-36 Mental Health scale, Community Integration Questionnaire. RESULTS: Pain was more severe, on average, in this sample of patients with SCI than it is in normative samples. The presence of pain was associated with trends towards poorer psychological functioning and social integration, and the intensity of pain was associated with interference with a number of important basic activities of daily living. Little systematic change was found in pain over a 2-6-year-period, although there was evidence that the prevalence of shoulder pain increases over time. CONCLUSION: The current findings underscore the serious nature of pain in persons with SCI and provide additional support for the need to identify effective treatments for SCI-related pain.

Chronic Disease↗

PubMed2001

Chronic pain associated with spinal cord injuries: a community survey.

OBJECTIVE: To investigate, in a community sample of people with spinal cord injuries (SCIs), chronic pain prevalence, associated factors, sites, characteristics, interference with daily functioning, treatments received, and treatment helpfulness. DESIGN: Postal survey. SETTING: Community. PARTICIPANTS: Three hundred eighty-four individuals aged over 17 years with SCIs. MAIN OUTCOME MEASURES: Chronic Pain Grade questionnaire, Short-Form McGill Pain Questionnaire, pain sites, and treatments. RESULTS: Current pain was reported by 79% of respondents and was significantly more common in less highly educated persons, and individuals not employed or in school. Most common locations of current pain were the back (61%), hips and buttocks (61%), and legs and feet (58%). Upper extremity pain was experienced by 76% after the injury and by 69% currently. Individuals with tetraplegia were significantly more likely to have neck and shoulder pain than were those with paraplegia. On average, respondents reported a high level of pain intensity and a moderate level of pain interference with activities, and rated treatments received for pain as being only somewhat helpful. CONCLUSION: Most individuals with SCI experience chronic pain that is refractory to medical treatment. Further research is needed to delineate the causes of, and optimal treatments for, the various pain problems in this population.

Activities of Daily Living↗

PubMed2001

A bibliography of cost-effectiveness practices in physical medicine and rehabilitation: AAPM&R white paper.

Cost-effectiveness studies attempt to determine the ratio of costs to outcomes of a particular intervention or treatment and to compare a standard intervention with an alternative intervention to determine if the alternative is more cost effective. The goal is to establish priorities for the resources allocation and to decide among alternative interventions for the same medical condition. The global process of rehabilitation does not usually lend itself to cost-effective analysis (due to the complex set of treatments provided) but rather to specific interventions and specific aspects of outcome. The American Academy of Physical Medicine and Rehabilitation has published a cost effectiveness annotated bibliography on the Internet (http://www.aapmr.org/memphys/cebfinala.htm) that identifies 132 studies in the literature that meet specified criteria and are related to the field of rehabilitation. This White Paper attempts to interpret and synthesize the studies in that bibliography that relate to stroke, spinal cord injury (SCI), orthopedic conditions, pain syndromes, amputations, and traumatic brain injury (TBI). Most studies support the cost effectiveness of care for stroke and SCI in dedicated units or centers rather than in a general medical unit. Studies also support back programs and revascularization procedures in limb ischemia. Studies in TBI underscore the significant financial resources for the care of these patients as well as the potential benefit from rehabilitation services even in the most severely injured. Further high quality research in this area is needed.

Academies and Institutes↗

PubMed2001

Women in physical medicine and rehabilitation. Leadership issues.

Academic medical centers share the triple missions of education, research, and clinical care, particularly in vulnerable populations. They are well positioned to have a significant impact on reducing health disparities between patients from diverse backgrounds, both now and in future generations. A key component to realizing this goal lies in increasing the number of women in academic medicine. Women bring a fresh perspective to the investigative process, often targeting gender is a better way of providing preventive services, and patient satisfaction studies have shown that many patients prefer women physicians.

Academic Medical Centers↗

PubMed2001

Bladder management in women with neurologic disabilities.

Women with neurologic disabilities can experience an array of bladder disorders. There are many aspects of lower urinary tract management that are specific to women. Treatments should be based on urodynamic findings, and individualized for each woman's physical and cognitive abilities.

Behavioral Medicine↗

PubMed1999

Immobilization hypercalcemia treatment with pamidronate disodium after spinal cord injury.

OBJECTIVE: To review the use of pamidronate to treat immobilization hypercalcemia after acute spinal cord injury (SCI) in 9 cases. DESIGN: Retrospective case series. SETTING: Two inpatient rehabilitation programs, one pediatric and one adult, in the Northwest Regional Spinal Cord Injury System. PATIENTS: Patients with acute SCI who developed immobilization hypercalcemia that was treated with pamidronate. RESULTS: Nine patients (7 men, 2 women), ages 15 to 41 yrs, with SCI (8 tetraplegia, 1 paraplegia) were treated using pamidronate between 1994 and 1998. A single dose of 60 mg of pamidronate resolved the hypercalcemia or its symptoms in 7 (78%) patients within days. One patient required a second dose (90 mg) and one patient required three additional doses (the fourth at 90 mg) to achieve resolution of the hypercalcemia or symptoms. Side effects were mild and included drug-related fever in one patient and transient asymptomatic hypocalcemia in four patients. CONCLUSION: Pamidronate was effective in treating immobilization hypercalcemia caused by SCI. Its advantages include its effectiveness, the duration of treatment, ease of administration, and elimination of the need for long-term intravenous saline or daily medications.

Acute Disease↗

PubMed1999

Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis.

OBJECTIVE: To analyze the incidence, risk factors, and trends of long-term secondary medical complications in individuals with traumatic spinal cord injury. DESIGN: Data were reviewed from the National SCI Statistical Center on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and 1998. SETTING: Multicenter Regional SCI Model Systems. MAIN OUTCOME MEASURES: Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi. RESULTS: Pressure ulcers were the most frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5), and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common method of bladder management among patients with paraplegia but became less common at later postinjury visits. CONCLUSIONS: Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury, tetraplegia, older age, concomitant illness, and violent injury.

Adolescent↗

PubMed1999

Upper extremity pain after spinal cord injury.

OBJECTIVE: Patients with spinal cord injury (SCI) may complain of upper extremity (UE) pain. The purpose of this study was to determine the frequency and severity of UE pain as well as its association with functional activities. Types of treatments that SCI patients received for UE pain and the benefits of these treatments were also identified. STUDY DESIGN AND METHODS: A questionnaire of demographic variables and measures of UE pain intensity, location, treatment, and interference with functional activities was mailed to 170 persons with SCI. Data was analyzed by descriptive and comparative statistics. RESULTS: Of the 130 persons who responded, 76 (58.5%) (38 paraplegic, 38 tetraplegic patients) reported UE pain: 71% had shoulder pain, 53% wrist pain, 43% hand pain, and 35% elbow pain. Pain interfered with transfers in 65% (36/55) of the patients who were doing them. Of ten functional activities, pain was more likely to be associated with pressure reliefs, transfers, and wheelchair mobility. Sixty-three per cent sought medical treatment for pain, and of those, 90% received either physical therapy, pharmacological treatment or massage. Although only 27% had wheelchair or home modification or joint protection education, these approaches were helpful for almost all and very helpful or extremely helpful in 26.6% and 63.6% of the patients, respectively. CONCLUSION: UE pain is a common problem in individuals with SCI and has impact on daily activities. UE pain prevention and management programs are needed for SCI patients.

Adult↗

PubMed1999

Chronic pain problems in individuals with spinal cord injuries.

Chronic pain problems are common in individuals with spinal cord injuries (SCI); however, many questions about the prevalence, nature, and impact of such problems remain unanswered. Questionnaires were mailed to individuals on an SCI newsletter mailing list to investigate chronic pain problem prevalence, sites, characteristics, interference with daily functioning, associated factors, treatments received, and treatment helpfulness. Completed questionnaires were received from 164 individuals over age 17 with SCI. Unpleasant, but not painful, sensations were currently experienced by 75%, and 80.5% reported currently experiencing one or more pain problems. Among all 164 respondents, 62% reported experiencing high intensity pain in the previous week. Respondents indicated that they had received a variety of treatments for pain, but the only treatment reported to be helpful on average for the sample was opiate medication. Among respondents reporting current pain problems, most reported more than one problem (16.7% reported one, 25.8% reported two, 16.7% reported three, and 40.9% reported more than three). These findings indicate that chronic pain is a serious secondary problem in individuals with SCI and underscore the need for further research aimed at delineating the causes of, and optimal treatments for, the various pain problems in this population.

Adolescent↗

PubMed1998

Management of focal dystonia of the extensor hallucis longus muscle with botulinum toxin injection: a case report.

Recently botulinum toxin has been used with increasing frequency as a safe and effective treatment for many previously refractory conditions associated with excessive muscle activity. The indications for use of botulinum toxin injection continue to expand. This report describes the case of an 83-year-old woman with a history of diabetes mellitus and lumbar spinal stenosis who developed a severe focal dystonia of the left great toe, such that the toe maintained the extended position. Functionally, the resultant deformity prevented the patient from wearing shoes. In addition, the patient had significant pain in the left great toe. Under needle electromyographic localization, 50 units of botulinum toxin were injected into the left extensor hallucis longus muscle. Two weeks after the injection the patient was symptom free and could place her left foot into a shoe. Seven months later, she remained symptom free. This case illustrates that localized injection of botulinum toxin to a specific lower limb muscle can effectively result in decreased muscle activity and functional improvement.

Aged↗

PubMed1998

Factors associated with contractures in acute spinal cord injury.

The purpose of this study was to examine the occurrence of contractures in acute SCI and clarify possible contributing factors such as early versus late admission, level of injury, completeness of the lesion, pressure ulcers, spasticity, co-existent head injury, extremity fractures, heterotopic ossification (HO), peripheral nerve injury, and shoulder pain. The records of all patients (n = 482) admitted between 1990 and 1995 with acute SCI to a model SCI system were reviewed. Of 482 patients 44 (9%) (33 male, 11 female) developed contractures during their initial hospitalization. There were 30 tetraplegic and 14 paraplegic patients. Thirty-four patients had complete and 10 patients had incomplete lesions. The percentage of occurrence of contractures among patients admitted to the model system on the day of injury was 7.6% and among those admitted between 2 and 60 days of the injury was 15% (P = 0.05). Patients with a pressure ulcer (14.1%) were significantly more likely to have a contracture than patients without a pressure ulcer (7.1%) (P = 0.05). Contractures were also more common in patients with spasticity requiring medication; 12.7% of patients with spasticity compared to 7.8% without spasticity, had contractures (P < 0.05). Patients with a co-existent or suspected head injury (15%) were more likely to have contractures than patients without it (7.4%)(P < 0.05). Eighteen patients with a contracture had HO, extremity fracture, peripheral nerve injury or reflex sympathetic dystrophy. In conclusion, this study is one of the first to demonstrate a significant association of contractures in acute SCI with pressure ulcers and co-existent head injury and reaffirms the importance of early admission to a coordinated SCI center in the prevention of contractures.

Acute Disease↗

PubMed1998

Limb-salvage in reconstruction of recalcitrant pressure sores using the inferiorly based rectus abdominis myocutaneous flap.

Pressure sore closure is frequently a reconstructive challenge. This challenge is particularly evident in cases of multiply recurrent sores. In such settings, there are often opportunities to manage the recurrent wounds either by repeated advancement of previous flaps or by design of alternative ones. However, these interventions are not always feasible, and limb amputation with total thigh flap closure must be considered. A review of operative experience with seven such complex pressure sores in seven patients is presented. Each patient had previously suffered a permanent thoracic-level spinal cord injury. Prior attempts at wound closure were unsuccessful. Despite consideration of all described locoregional flaps, no limb-sparing procedure could be designed satisfactorily. As an alternative to either hip disarticulation and total thigh flap coverage or distant free-tissue transfer, we reconstructed the debrided ulcer beds with inferiorly based rectus abdominis myocutaneous flaps. Six of the seven wounds healed primarily, whereas one required repeated debridement and the addition of a gracilis muscle flap to achieve complete closure. Postoperative follow-up has ranged from 6 to 45 months. Each patient has returned to his baseline preoperative activity level with no clinical compromise of abdominal wall function. All wounds have healed. Successful application of the inferiorly based vertical rectus abdominis myocutaneous flap for cases of both recalcitrant ischial and trochanteric pressure sores is demonstrated and its consideration is advocated if no reconstructive options short of extremity amputation and total thigh flap coverage exist for such challenging sores.

Activities of Daily Living↗

PubMed1998

Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine.

Despite improvements in surgical repair of pressure sores, recurrence rates greater than 80 percent are reported, thus indicating that this difficult problem is not yet solved. Recurrence results in additional hospitalizations and increased medical expenses. Because associated general clinical and social issues are numerous for these patients, our physical medicine and rehabilitation colleagues are active participants in their perioperative medical care. In addition, the Department of Physical Medicine and Rehabilitation also directs a complete postreconstruction rehabilitation and education program for them. The results of surgically repaired pressure sores for patients managed in this collaborative fashion have not been previously reported. Pressure sore patients at the Harborview and University of Washington Medical Centers are evaluated by plastic surgery colleagues together with the Department of Physical Medicine and Rehabilitation. Patients believed to be candidates for complete postoperative rehabilitation are offered surgical repair and constitute this study cohort. Individuals who cannot cooperate with our protocol are treated nonoperatively and are not included in this study. A retrospective analysis of all 158 patients (mean age 34.5 years) operated on for 268 grade III and IV pressure sores between October of 1977 and December of 1989 was performed. Following surgical debridement and reconstruction, patients receive their principal medical care from the Department of Physical Medicine and Rehabilitation service while the Plastic Surgery Department manages the surgical wounds. Graduated patient mobilization is initiated in accord with a mutually agreed upon standardized protocol. New or primary sores numbered 174 (65 percent), and recurrent or secondary sores numbered 94 (35 percent). Mean patient follow-up was 3.7 years. The overall pressure sore recurrence rate (recurrence at the same site) was 19 percent, and the overall patient recurrence rate (previous patient developing a new sore) was 25 percent. Recurrence rates of 22 and 15 percent were noted for primary and secondary pressure sores, respectively. On most recent examination, 131 patients (83 percent) had intact pelvic and perineal skin. These results support a collaborative approach to the management of high-grade pressure sore patients. Our protocol of mutual patient evaluation followed by surgical reconstruction and postoperative rehabilitation yields notably low recurrence rates of both primary and secondary sores. In addition, the high percentage of patients who manifest long-term maintenance of skin integrity demonstrates the excellent education in personal skin and self-care that this approach provides. Not only do patients enjoy successful and durable reconstructive results, but additional hospitalizations and health care expenses implicit to pressure sore recurrence are consequently diminished. This collaborative clinical effort remains our standard of care.

Adult↗

PubMed1997

Management of traumatic optic neuropathy with coexistent spinal cord injury: a case report.

Traumatic optic neuropathy (TON) causes blindness of varied severity and occurs infrequently as a complication of closed head injury. A case is presented of TON that occurred in a patient who suffered complete T4 paraplegia from a motorcycle accident but in whom no severe head injury took place. In this case, high-dose intravenous methylprednisolone was begun for the spinal cord injury and repeated 24 hours later for the TON. Vision improved from near total blindness to 20/400 in the left eye (OS) and 20/130 in the right eye (OD). Two weeks later, however, the patient's vision suddenly worsened. Magnetic resonance imaging (MRI) using fat suppression confirmed a lesion along the optic nerve consistent with TON. A third course of methylprednisolone again led to improved vision. The steroids were then tapered orally over 2 weeks and the patient had no further relapses. Moderate to severely impaired vision of 20/ 400 OS and 20/130 OD continues to interfere with the patient's function and spinal cord rehabilitation program. It was concluded that a steroid taper was important in maintaining initial visual gains in this case. Awareness of TON and careful attention to the patient's clinical course can minimize deficit and maximize functional outcomes.

Activities of Daily Living↗

PubMed1997

Social and functional variables associated with urinary tract infections in persons with spinal cord injury.

OBJECTIVE: Urinary tract infections (UTIs) and their complications remain a major source of morbidity and mortality after spinal cord injury (SCI). There has been much investigation into the physiological changes in persons with SCI and how these predispose to the development of UTIs, but other potentially influential variables are not so well understood. The purpose of this study is to examine behavioral, social, and functional factors and their relationship with UTIs. Our hypothesis is that lower UTI frequency will be associated with higher functional abilities, increased productivity, and higher life satisfaction scores. DESIGN: Respondents to a mailed questionnaire reported information on demographics, bladder management methods, functioning, productivity, and life satisfaction. PATIENTS: A volunteer sample from a list of all people with SCI previously treated at a university medical center rehabilitation medicine SCI inpatient service and/or outpatient SCI clinic from 1991 through 1994. RESULTS: There were 81 (35%) responses to 229 received mailings. Mean reported UTIs were 1.37 (SD = 2.66) per year and 4.77 (SD = 6.70) over a 3-year period. UTIs per year and total UTIs over 3 years were negatively associated with functioning and productivity (number of hours worked per week), but were not associated with life satisfaction scores. CONCLUSION: As a result of this study there is an improved understanding of social and functional variables and how these may correlate with UTI incidence in this population. Further research into these variables is warranted.

Adult↗

PubMed1997

Charcot spine as a late complication of traumatic spinal cord injury.

Charcot spine, also known as neuropathic spinal arthropathy, is a late complication of traumatic spinal cord injury that can produce pain and further disability. We report five cases of Charcot spine occurring in patients with previous traumatic spinal cord injury that we have identified at our institution from 1985 to 1994. All patients had complete paraplegia with levels of neurologic injury ranging from T7 to T12. Common presenting symptoms included back pain, loss of spasticity, change in bladder function, and audible noises with motion. The diagnosis of Charcot spine was made from 6 to 31 years after original spinal cord injury. In four cases where a surgical fusion had been performed, the Charcot joint developed within two spinal segments below the caudal end of the fusion. Radiological studies, especially plain films and computed tomography, were helpful in making the diagnoses. Immobilization of the affected joint is an essential element of treatment. Surgical repair and stabilization were performed in four patients and has been recommended to the other patient. Early diagnosis and proper treatment is important in preventing the progression of this disorder.

Adult↗

PubMed1997

Reducing the period of immobilization following pressure sore surgery: a prospective, randomized trial.

The cost to care for a patient with pressure sores can be exorbitant. One part of this expense results from the prolonged postoperative immobilization. Published protocols report 3 to 8 weeks of immobilization; however, there are no studies that establish longer periods to be superior. To justify our 3-week protocol, we conducted a prospective, randomized trial of 2 versus 3 weeks of postoperative immobilization. Each patient was randomized preoperatively to either 2 or 3 weeks of postoperative immobilization. A total of 42 patients with a diagnosis of paraplegia, tetraplegia, or multiple sclerosis and a solitary pressure sore were enrolled over 5 years. The complication rates in the two groups (9 of 23, or 39 percent, for the 2-week group and 9 of 19, or 47 percent, for the 3-week group) were not statistically different (p < 0.493). However, the time to mobilization was significantly reduced in the 2-week group (16.1 +/- 6.1 versus 22.9 +/- 4.9 days, p < 0.0003), as was the time to achieve sitting (21.2 versus 28.9 days, p < 0.0026). In summary, 2 weeks of postoperative immobilization following surgery is adequate for uncomplicated solitary pressure sores.

Humans↗