1998 APTA Presidential Address: My dream is a wish. American Physical Therapy Association.
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Curriculum↗
Biomedical subjects
J K Richardson
Publications and source records attributed to J K Richardson.
Rural residents' use of cardiac rehabilitation programs.
The goal of this study was to identify the factors that influence the use of cardiac rehabilitation services by rural residents. The Andersen-Newman framework, which consists of three determinants of health services utilization (predisposing, enabling, and need factors), was used to direct this research. The three data collection points were at time of discharge from the hospital, two weeks post discharge, and one week following the date that the cardiac rehabilitation program would have been completed. Packets for the three data collection points were unique and contained instruments to assess various factors influencing the use of health services. The sample (N = 254) were adults living in rural areas who had experienced a cardiac event and received treatment at one of four hospitals in two western states and who provided useable data on all three questionnaires. Findings indicated that 72 (28%) of the participants attended some portion of a rehabilitation program, and only 43 (17%) completed the full 36-week program. Four predisposing factors, one enabling factor, and two need factors were significant in explaining the number of cardiac rehabilitation sessions attended. Further research is needed to validate these factors and to identify others which may influence the use of cardiac rehabilitation by rural residents. Likewise, it is essential to examine alternate ways to meet the rehabilitative needs of rural cardiac clients.
Adult↗
A familial predisposition toward lumbar disc injury.
STUDY DESIGN: A retrospective case-control study was performed. OBJECTIVES: To test the hypothesis that there is a familial predisposition to lumbar disc pain and injury. SUMMARY OF BACKGROUND DATA: The few studies that have addressed this question have suggested that a familial predisposition is present, but the techniques used for identifying discogenic pain and accounting for potentially confounding extrinsic factors make it difficult to formulate a clear conclusion. METHODS: Immediate relatives of index patients who had surgically proven lumbar disc herniations (disc/case subjects) or repetitive upper extremity overuse syndromes (upper extremity/control subjects) were given a questionnaire that had been tested previously and found to reliably identify discogenic lower back pain. The prevalence of lumbar disc pain and injury was determined in the two groups of patients; logistic regression was used to control for demographic factors and activities known to increase risk for lumbar disc injury. RESULTS: The questionnaire was returned by 60 (59%) of 102 disc subjects and 41 (50%) of 81 upper extremity subjects. Sixteen (28%) disc subjects and one (2%) of the upper extremity subjects met questionnaire criteria for discogenic lumbar pain; seven (12%) disc subjects and no upper extremity subjects had received surgical therapy for lumbar disc pain. Logistic regression analysis identified familial grouping and a history of lifting as the only variables associated with a positive response on the questionnaire. Information obtained from index patients about their nonresponding relatives' history of significant back pain suggested similar findings. CONCLUSIONS: There is a familial predisposition toward lumbar disc pain and injury. This information may be helpful in occupational counseling or for targeting specific populations with preventative, interventional strategies.
Adult↗
A cane reduces loss of balance in patients with peripheral neuropathy: results from a challenging unipedal balance test.
OBJECTIVE: To test the hypothesis that use of a cane in the nondominant hand during challenging balance tasks would significantly decrease loss of balance in patients with peripheral neuropathy while transferring from bipedal to unipedal stance on an unsteady surface. DESIGN: Nonrandomized control study. SETTING: Tertiary-care institution. PARTICIPANTS: Eight consecutive patients with peripheral neuropathy (PN) and eight age- and gender-matched controls (C) with a mean (SD) age of 65 (8.2) years. METHODS: Subjects were asked to transfer their weight onto their right foot, despite a rapid +/- 2 degrees or +/- 4 degrees frontal plane tilt of the support surface at 70% of weight transfer, and balance unipedally for at least 3 seconds. The efficacy of their weight transfer was evaluated over 112 consecutive randomized and blocked trials by calculating loss of balance as failure rates (%FR) with and without visual feedback, and with and without use of a cane in the nondominant (left) hand. Results were analyzed using a 2 x 2 x 2 x 2 x 2 repeated-measures analysis of variance (rm-ANOVA) and post hoc t tests. RESULTS: The rm-ANOVA showed that the FR of the PN subjects (47.6% [18.1%]) was significantly higher than C (29.2% [15.2%], p = .036). Removing visual feedback, simulating the dark of night, increased the FR fourfold (p = .000). Use of a cane in the contralateral nondominant hand significantly reduced the FR (p = .000), particularly in the PN group (cane x disease interaction: p = .055). Post hoc t tests showed that with or without visual feedback, the cane reduced the FR of the PN group fourfold and enabled them to perform more reliably than matched controls not using a cane (p = .011). An inversion perturbation resulted in a higher FR than an eversion perturbation (p = .007). The PN group employed larger mean peak cane forces (21.9% BW) than C (13.6% BW) in restoring their balance (p = .000). CONCLUSION: Use of a cane by PN patients significantly reduced their risk of losing balance on unstable surfaces, especially under low-light conditions.
Aged↗
Moderate peripheral neuropathy impairs weight transfer and unipedal balance in the elderly.
OBJECTIVE: To quantitatively assess the performance of elderly with and without moderate, electrodiagnostically confirmed peripheral neuropathy (PN) on tasks of weight shifting and maintenance of unipedal balance. PATIENTS AND METHODS: A case control study with PN subjects selected from a computerized data bank of all patients who had undergone electrodiagnostic studies at a university-based referral center. Control subjects of similar age and same gender were selected from the same source. Clinical examination included neurological and gross motor components. Quantitative evaluation included testing while the subjects stood with a force plate under each foot. Center of reaction (CR) excursions and ground reaction forces were quantified in: (1) six trials as subjects transferred their weight from bipedal stance to unipedal stance, on command, and attempted to maintain it for at least 3 seconds; and (2) in two additional trials in which subjects held unipedal stance for as long as possible. RESULTS: No subjects in either group had difficulty with level gait, a 180-degree turn, or required examiner assistance during an eyes-closed Romberg test. Biomechanical testing revealed that although the PN group used the same time to transfer their weight onto one foot as the C group, they achieved a significantly (1) lower rate of success in reliably maintaining 3 seconds of unipedal stance (.12 vs .58, p = .021), and (2) shorter mean maximum unipedal stance time (3.8 vs 32.3sec, p < .001). Furthermore, the PN group experienced greater difficulty in maintaining unipedal stance, as evidenced by significantly greater fluctuations in their ground reaction forces. CONCLUSIONS: The demonstrated impairment in reliability of unipedal stance in elderly with PN likely contributes to their known high rate of falls. Furthermore, unipedal stance testing serves to sharpen the physical examination by verifying the functional significance of impaired distal sensation-a common finding in the elderly.
Aged↗
Peripheral neuropathy: an often-overlooked cause of falls in the elderly.
Peripheral neuropathy is common in the elderly and results in impairments in distal proprioception and strength that hinder balance and predispose them to falls. The loss of heel reflexes, decreased vibratory sense that improves proximally, impaired position sense at the great toe, and inability to maintain unipedal stance for 10 seconds in three attempts all suggest functionally significant peripheral neuropathy. Physicians can help their patients with peripheral neuropathy to prevent falls by teaching them and their families about peripheral nerve dysfunction and its effects on balance and by advising patients to substitute vision for the lost somatosensory function, correctly use a cane, wear proper shoes and orthotics, and perform balance and upper extremity strengthening exercises.
Accidental Falls↗
Hip, knee, and foot pain during pregnancy and the postpartum period.
BACKGROUND: Although much has been written about low back pain during pregnancy, there are few studies regarding leg, foot, and hip pain. The purpose of this study was to investigate the prevalence and characterize the nature of lower extremity pain in women of child-bearing age and to assess the impact of recent pregnancy on these symptoms. METHODS: In this case-control study, 107 consecutive postpartum women (case subjects) and 91 nulliparous women (controls) completed a questionnaire regarding hip, knee, and foot pain and potentially influencing factors. RESULTS: Postpartum subjects had more symptoms of leg and foot pain than did the controls (56% vs 37%; odds ratio [OR]=2.3; 95% confidence interval [CI], 1.2 to 4.7). A significant majority of pain (82%, P<.05) began during the second and third trimesters. Postpartum subjects also had a significantly higher prevalence of hip pain (38% vs 23%; OR=3.2; 95% CI, 1.4 to 7.0) and foot pain (31% vs 22%; OR=2.2; CI, 1.1 to 4.5). History of previous pain complaints also were found to be risk factors for lower extremity pain during pregnancy for case subjects and in the past year for controls. There was a trend toward older age as a risk factor as well. Multiple pain complaints were more common among case subjects than among controls. CONCLUSIONS: Lower extremity pain is common in women of childbearing age. Pregnant and postpartum women are more likely to develop new lower extremity symptoms than are nulliparous women. The timing of symptom onset in mid- to late pregnancy may suggest that biomechanical factors play a larger role than hormonal influences. Regular exercise appears to be neither protective against nor a risk factor for lower extremity pain during pregnancy.
Adolescent↗
Peripheral neuropathy effect on ankle inversion and eversion detection thresholds.
A servo-controlled foot platform was used to quantify, in upright stance, the thresholds for sensing ankle inversion and eversion movements in seven geriatric patients with peripheral neuropathy (PN) confirmed by nerve conduction studies and seven age- and gender-matched (C) controls with normal nerve conduction function. The PN group had a 4.6-fold larger (p = 0.0026) threshold (mean [SD] 1.37 [1.74]degrees) for perceiving the presence and direction of an ankle rotation at a 75% rate of success (TH75) than did the C group (0.3[0.17]degrees). Inversion acuity was approximately twice that of eversion acuity in both groups. The PN group demonstrated better proprioceptive acuity in unipedal stance than in bipedal stance, whereas no such difference was found in the C group. Semiquantitative clinical tests of PN group proprioception at the ankle performed in the seated position failed to demonstrate significant differences from controls save in one case; however, the results of such tests at the toe were abnormal in all patients. In the geriatric population, PN is associated with deficits in ankle proprioception known theoretically to hamper maintenance of unipedal balance. It is significant that these deficits are associated with a clinically demonstrable loss of position sense at the toe but not the ankle.
Aged↗
Peripheral neuropathy: a true risk factor for falls.
BACKGROUND: Several studies have recently linked peripheral nerve dysfunction in the elderly with postural instability and falls. Many causes of peripheral neuropathy (PN) have the potential for associated comorbidities, which could themselves be the true cause of these falls. This study tested the hypothesis that PN is not a cause of falls but just a marker for a comorbidity (e.g., central nervous system dysfunction) that is the true cause of falls in this elderly population. METHODS: Twenty subjects with an electromyographically documented axonal peripheral neuropathy affecting the lower extremities were identified (PN group) and matched by age and sex with 20 subjects with normal lower extremity electrodiagnostic studies (C group). A focused history and physical examination designed to identify factors other than PN which might cause falls was performed, and a history of falls or postural instability over the previous year was obtained. RESULTS: PN was found to be significantly associated with the self-report of falls (11/20, 55% vs 2/20, 10%; odds ratio 17.0, 95% CI = 2.5, > 100) and postural instability (7/9, 77% vs 0/0, 0%; odds ratio 13.0, 95% CI = 1.5, > 100) over the previous year. There was no significant difference between the two groups in total number of other risk factors known to be associated with falls, (23 PN group vs 18 C group). The PN group did take a significantly greater number of medications known to be associated with falls (10 PN group vs 1 C group, p < .01), but the usage pattern among fallers and nonfallers within the PN group suggests that medications were not the primary cause of the falls. The PN subjects who fell demonstrated significantly worse vibratory sense at the ankle and finger (p < .05), and significantly decreased unipedal stance time (3.1 sec vs 9.1 sec, p < .05) than the PN subjects who did not fall. CONCLUSIONS: No associated factors or comorbidities explained the high rate of falls in elderly persons with PN, suggesting that PN is a true risk factor for falls in the elderly. Relatively greater impairment in vibratory sense and ability to maintain unipedal stance may identify those within the PN group who are at a higher risk for falls.
Accidental Falls↗
Information effect on the perception of pain during electromyography.
Pain during the performance of electromyography (EMG) is an important clinical problem because pain distresses the patient and can interfere with diagnostic accuracy. We hypothesized that anxiety and pain perception associated with EMG would decrease if patients received written material describing the EMG before examination. Forty-two subjects received written material and 30 did not. Information before the test significantly decreased pain perception for women during the nerve conduction studies (p = .008), but not during the needle examination. A similar effect was not identified for the men. Other results indicate that women perceive the test as more painful than do men, older subjects perceive more pain and experience greater anxiety than do younger subjects, and all subjects perceive greater pain during the performance of (concentric, bipolar) needle electromyography than during the nerve conduction studies.
Adult↗
Psychotic behavior after right hemispheric cerebrovascular accident: a case report.
A 64-year-old man developed hallucinations, delusions, and agitation after a right hemispheric cerebrovascular accident (CVA) in the occipital, inferior temporal, and parietal regions of the posterior cerebral artery. A review of the literature suggests that psychotic behavior is rare after CVA, but when such behavior does occur, the lesion is usually in the right hemisphere. Two clinical presentations are seen. One presentation involves patients free of chronic disease who develop episodic psychotic behavior at a time remote from their CVA. Electroencephalogram often demonstrates epileptogenic foci, and these patients often improve with anticonvulsant medication. Another presentation involves patients with one or more chronic diseases, often resulting in brain atrophy, who display continuous abnormal behavior soon after their CVA; these patients respond variably to antipsychotic agents.
Brain↗
The relationship between electromyographically documented peripheral neuropathy and falls.
OBJECTIVE: To determine if the presence of an electromyographically demonstrated peripheral polyneuropathy involving the lower extremities is associated with falls. DESIGN: Case control study. SETTING: A University-based referral center. PATIENTS: Twenty-five patients with an axonal peripheral polyneuropathy affecting the lower extremities, demonstrated by electromyography more than 8 and less than 16 months before, and 25 age- and sex-matched controls who had normal electromyographic studies of the lower extremities during the same time period, were identified from a computer record of all electromyography results during the year prior to the study, using diagnostic codes and demographic data. Twenty-eight pairs were identified, 25 of whom completed the study. MAIN OUTCOME MEASURES: Number of falls and resultant injuries during the year before the interview, and number of previously identified risk factors for falling, based on interview. RESULTS: Peripheral neuropathy was found to be significantly associated with falling (14/25, 56% vs 2/25, 8%--odds ratio 23.0, 95% confidence interval 2.5, > 100) and repetitive falling (10/25, 40% vs 1/25, 4%--odds ratio, 95% confidence interval 1.4, > 100). There was a trend toward increased injury requiring medical attention (5/25, 20% vs 0/25, 0%), but it did not reach statistical significance. Previously identified risk factors were not significantly more common in the peripheral neuropathy group. CONCLUSION: An electromyographically identified peripheral neuropathy is strongly associated with and may be a risk factor for falls.
Accidental Falls↗
Rocker-soled shoes and walking distance in patients with calf claudication.
Calf claudication is the major clinical manifestation of peripheral vascular occlusive disease in a significant number of patients. Although claudication causes substantial patient disability, most patients are treated conservatively because of the risks of surgical therapy and the uncertain efficacy of drug therapy. It was hypothesized that rocker-soled shoes would decrease the work of the plantar flexors and therefore increase walking distance in patients with calf claudication. To test this hypothesis, walking distances in patients with calf claudication using rocker-soled shoes and a placebo shoe insert were compared. Rocker-soled shoes significantly increased both the total distance walked and the distance at which patients were initially bothered by symptoms by 77m (37%, p less than .0005) and 89m (91%, p = .003), respectively. It was concluded that rocker-soled shoes may reduce disability in patients with calf claudication by increasing walking distance.
Aged↗
Sudden, unexpected death due to "pineal apoplexy".
A 20-year-old woman had a minute vascular malformation in the wall of a glial cyst of the pineal body. Bleeding into the cyst lumen caused rapid expansion of the pineal body, resulting in compression of the midbrain and her sudden, unexpected death.
Adult↗
Esophagopleural fistula after pneumonectomy.
Rupture of the esophagus into the space left after pneumonectomy is a rare and often fatal complication. Esophagopleural fistulas occurred in three patients following pneumonectomy. After previous methods failed, two patients were successfully treated by using a one-stage procedure which included (1) suture closure of the fistula, (2) buttressing the repair with a viable, pedicled, two-rib intercostal-muscle flap, and (3) performing an extensive thoracoplasty with a continuous drip infusion of neomycin. Such a procedure offers the maximum opportunity for successful treatment of this catastrophic lesion.
Esophageal Fistula↗