Outcomes following inpatient rehabilitation of lower limb amputees

Introduction: Lower-limb amputations are a serious adverse consequence of lifestyle related chronic conditions and a serious concern among the aging population in Australia. Lower limb amputations have severe personal, social and economic impacts on the individual, healthcare system and broader community. This study aimed to address a critical gap in the research literature by investigating the physical functioning and social characteristics of lower limb amputees at discharge from tertiary hospital inpatient rehabilitation. Method: A cohort study was implemented among patients with lower limb amputations admitted to a Geriatric Assessment and Rehabilitation Unit for rehabilitation at a tertiary hospital. Conventional descriptive statistics were used to examine patient demographic, physical functioning and social living outcomes recorded for patients admitted between 2005 and 2011. Results: A total of 423 admissions occurred during the study period, 313 (74%) were male. This sample included admissions for left (n = 189, 45%), right (n = 220, 52%) and bilateral (n = 14, 3%) lower limb amputations, with 15 (3%) patients dying whilst an inpatient. The mean (standard deviation) age was 65 (13.9) years. Amputations attributed to vascular causes accounted for 333 (78%) admissions; 65 (15%) of these had previously had an amputation. The mean (SD) length of stay in the rehabilitation unit was 56 (42) days. Prior to this admission, 123 (29%) patients were living alone, 289 (68%) were living with another and 3 (0.7%) were living in residential care. Following this amputation related admission, 89 (21%) patients did not return to their prior living situation. Of those admitted, 187 (44%) patients were discharged with a lower limb prosthesis. Conclusion: The clinical group is predominately older adults. The ratio of males to females was approximately 3:1. Over half did not return to walking and many were not able to return to their prior accommodation. However, few patients died during their admission.

The process and patterns of combining the use of traditional Chinese medicine and Western medicine in Taiwanese people with cancer

Objective: The nature of contemporary cancer therapy means that patients are faced with difficult treatment decisions about surgery, chemotherapy and radiotherapy. For some, this process may also involve consideration of therapies that sit outside the biomedical approach to cancer treatment, in our research, traditional Chinese medicine (TCM). Thus, it is important to explore how cancer patients in Taiwan incorporate TCM into their cancer treatment journey. This paper aims to explore of the patterns of combining the use of TCM and Western medicine into cancer treatment journey in Taiwanese people with cancer. Methods: The sampling was purposive and the data collected through in-depth interviews. Data collection occurred over an eleven month. The research was grounded in the premises of symbolic interactionism and adopted the methods of grounded theory. Twenty four participants who were patients receiving cancer treatment were recruited from two health care settings in Taiwan. Results: The study findings suggest that perceptions of health and illness are mediated through ongoing interactions with different forms of therapy. The participants in this study had a clear focus on “process and patterns of using TCM and Western medicine”. Further, ‘different importance in Western medicine and TCM’, ‘taken for granted to use TCM’, ‘each has specialized skills in Western medicine and TCM’ and ‘different symptoms use different approaches (Western medicine or TCM)’ may explicit how the participants in this study see CAM and Western medicine. Conclusions/Implications for practice: The descriptive frame of the study suggests that TCM and Western medicine occupy quite distinct domains in terms of decision making over their use. People used TCM based on interpretations of the present and against a background of an enduring cultural legacy grounded in Chinese philosophical beliefs about health and healthcare. The increasingly popular term of 'integrative medicine' obscures the complex contexts of the patterns of use of both therapeutic modalities. It is this latter point that is worthy of further exploration.

Timed Up and Go Tests in cardiac rehabilitation : reliability and comparison with the 6-minute walk test

PURPOSE: To test the reliability of Timed Up and Go Tests (TUGTs) in cardiac rehabilitation (CR) and compare TUGTs to the 6-Minute Walk Test (6MWT) for outcome measurement. METHODS: Sixty-one of 154 consecutive community-based CR patients were prospectively recruited. Subjects undertook repeated TUGTs and 6MWTs at the start of CR (start-CR), postdischarge from CR (post-CR), and 6 months postdischarge from CR (6 months post-CR). The main outcome measurements were TUGT time (TUGTT) and 6MWT distance (6MWD). RESULTS: Mean (SD) TUGTT1 and TUGTT2 at the 3 assessments were 6.29 (1.30) and 5.94 (1.20); 5.81 (1.22) and 5.53 (1.09); and 5.39 (1.60) and 5.01 (1.28) seconds, respectively. A reduction in TUGTT occurred between each outcome point (P ≤ .002). Repeated TUGTTs were strongly correlated at each assessment, intraclass correlation (95% CI) = 0.85 (0.76–0.91), 0.84 (0.73–0.91), and 0.90 (0.83–0.94), despite a reduction between TUGTT1 and TUGTT2 of 5%, 5%, and 7%, respectively (P ≤ .006). Relative decreases in TUGTT1 (TUGTT2) occurred from start-CR to post-CR and from start-CR to 6 months post-CR of −7.5% (−6.9%) and −14.2% (−15.5%), respectively, while relative increases in 6MWD1 (6MWD2) occurred, 5.1% (7.2%) and 8.4% (10.2%), respectively (P < .001 in all cases). Pearson correlation coefficients for 6MWD1 to TUGTT1 and TUGTT2 across all times were −0.60 and −0.68 (P < .001) and the intraclass correlations (95% CI) for the speeds derived from averaged 6MWDs and TUGTTs were 0.65 (0.54, 0.73) (P < .001). CONCLUSIONS: Similar relative changes occurred for the TUGT and the 6MWT in CR. A significant correlation between the TUGTT and 6MWD was demonstrated, and we suggest that the TUGT may provide a related or a supplementary measurement of functional capacity in CR.

Practice and Procedure : Workers Compensation and Rehabilitation Act 2003 (Qld) ss 131 and 237(1)

In Jacobs v Woolworths Limited [2010] QSC 24 Jones J was required to determine whether a worker who had lodged an application for compensation for an injury outside the time prescribed under the Workers Compensation and Rehabilitation Act 2003 (Qld) (“the Act”) was precluded from seeking common law damages for that injury. This determination depended upon the proper construction of s 131 of the Act, and what was to be understood by the words “worker who has not lodged an application for compensation for the injury” for the purpose of s 237(1)(d).

Rates of attendance at a smoking cessation clinic within a cardiac rehabilitation service

Objectives: Smoking cessation has been shown to be an important intervention for preventing cardiovascular events and improving the health of patients with heart disease. However, unaided quit attempts in these patients often leads to high rates of failure and a return to smoking. Outpatient smoking cessation clinics using face-to-face counseling, ongoing behavioral support, advice on smoking pharmacotherapy and objective monitoring, have been found to be one of the most effective interventions for improving quit smoking rates. An outpatient smoking cessation clinic was trialed within a cardiac rehabilitation service in order to explore its effects on smoking rates for patients with or at risk of heart disease. Attendance rates to the clinic were also monitored. Methods: A descriptive exploratory design was used for this newly developed clinic. Patients who currently smoked tobacco and who had a history of either coronary artery disease, heart failure, atrial fibrillation or those seen under a chest pain assessment service were invited to an outpatient ‘Cardiac Patients Smokers Clinic’. Initially patients were offered up to 10 clinic visits over a 3 month period. Follow-up clinic visits were conducted at 3, 6 and 12 months. A portable carbon monoxide meter was used to objectively measure levels of smoking and validate smoking abstinence. Primary outcomes included rates of attendance. Results: Preliminary findings showed 24 per cent of participants (N = 6) completed all their clinic visits and remained smoke free as measured by their ongoing expired carbon monoxide readings. Clinic attendance rates appeared lowest for those with significant mental health issues such as schizophrenia or substance abuse. However, rates of attendance were improved by having an administration officer make reminder telephone calls prior to clinic visits. Conclusions: Early findings indicate the feasibility of providing a specialist smoking cessation clinic within a cardiac rehabilitation service. Further, that reminder telephone calls prior to appointments improved attendance rates in patients with heart disease to this type of clinic. However, future investigations are warranted.

Reconnection : a contemporary development in cultural landscape theory contributing to rehabilitation strategies for Australian open-cut coal mining landscapes

A value-shift began to influence global political thinking in the late 20th century, characterised by recognition of the need for environmentally, socially and culturally sustainable resource development. This shift entailed a move away from thinking of ‘nature’ and ‘culture’ as separate entities – the former existing to serve the latter – toward the possibility of embracing the intrinsic worth of the nonhuman world. Cultural landscape theory recognises ‘nature’ as at once both ‘natural’, and a ‘cultural’ construct. As such, it may offer a framework through which to progress in the quest for ‘sustainable development’. This study makes a contribution to this quest by asking whether contemporary developments in cultural landscape theory can contribute to rehabilitation strategies for Australian open-cut coal mining landscapes. The answer is ‘yes’. To answer the research question, a flexible, ‘emergent’ methodological approach has been used, resulting in the following outcomes. A thematic historical overview of landscape values and resource development in Australia post-1788, and a review of cultural landscape theory literature, contribute to the formation of a new theoretical framework: Reconnecting the Interrupted Landscape. This framework establishes a positive answer to the research question. It also suggests a method of application within the Australian open-cut coal mining landscape, a highly visible exemplar of the resource development landscape. This method is speculatively tested against the rehabilitation strategy of an operating open-cut coal mine, concluding with positive recommendations to the industry, and to government.

Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

Performance of elite seated discus throwers in F30s classes : part I: does whole body positioning matter?

Background: Studies on the relationship between performance and design of the throwing frame have been limited and therefore require further investigation. Objectives: The specific objectives were to provide benchmark information about performance and whole body positioning of male athletes in F30s classes. Study Design: Descriptive analysis. Methods: A total of 48 attempts performed by 12 stationary discus throwers in F33 and F34 classes during seated discus throwing event of 2002 International Paralympic Committee Athletics World Championships were analysed in this study. The whole body positioning included overall throwing posture (i.e. number of points of contact between the thrower and the frame, body position, throwing orientation and throwing side) and lower limb placements (i.e. seating arrangements, points of contact on the both feet, type of attachment of both legs and feet). Results: Three (25%), five (42%), one (8%) and three (25%) athletes used from three to six points of contact, respectively. Seven (58%) and five (42%) athletes threw from a standing or a seated position, respectively. A straddle, a stool or a chair was used by six (50%), four (33%) or two (17%) throwers, respectively. Conclusions: This study provides key information for a better understanding of the interaction between throwing technique of elite seated throwers and their throwing frame.

Load bearing improves the limits of agreement for repeated in vivo measures of the speed of sound in human Achilles tendon

Axial acoustic wave propagation has been widely used in evaluating the mechanical properties of human bone in vivo. However, application of this technique to monitor soft tissues, such as tendon, has received comparatively little scientific attention. Laboratory-based research has established that axial acoustic wave transmission is not only related to the physical properties of equine tendon but is also proportional to tensile load to which it is exposed (Miles et al., 1996; Pourcelot et al., 2005). The reproducibility of the technique for in vivo measurements in human tendon, however, has not been established. The aim of this study was to evaluate the limits of agreement for repeated measures of the speed of sound (SoS) in human Achilles tendon in vivo. Methods: A custom built ultrasound device, consisting of an A-mode 1MHz emitter and two regularly spaced receivers, was used to measure the SoS in the mid-portion of the Achilles tendon in ten healthy males and ten females (mean age: 33.8 years, range 23-56 yrs; height: 1.73±0.08 m; weight: 68.4±15.3 kg). The emitter and receivers were held at fixed positions by a polyethylene frame and maintained in close contact with the skin overlying the tendon by means of elasticated straps. Repeated SoS measurements were taken with the subject prone (non-weightbearing and relaxed Achilles tendon) and during quiet bipedal and unipedal stance. In each instance, the device was detached and repositioned prior to measurement. Results: Limits of agreement for repeated SoS measures during non-weightbearing and bipedal and unipedal stance were ±53, ±28 and ±21 m/s, respectively. The average SoS in the non-weightbearing Achilles tendon was 1804±198 m/s. There was a significant increase in the average SoS during bilateral (2122±135 m/s) (P < 0.05) and unilateral (2221±79 m/s) stance (P < 0.05). Conclusions: Repeated SoS measures in human Achilles tendon were more reliable during stance than under non-weightbearing conditions. These findings are consistent with previous research in equine tendon in which lower variability in SoS was observed with increasing tensile load (Crevier-Denoix et al, 2009). Since the limits of agreement for Achilles tendon SoS are nearly 5% of the changes previously observed during walking and therapeutic heel raise exercises, acoustic wave transmission provides a promising new non-invasive method for determining tendon properties during sports and rehabilitation related activities.

Achilles tendinopathy modulates force frequency characteristics of eccentric exercise

Introduction Previous research has demonstrated that ground reaction force (GRF) recorded during eccentric ankle exercise is characterised by greater power in the 8-12Hz bandwidth when compared to that recorded during concentric ankle exercise. Subsequently, it was suggested that vibrations in this bandwidth may underpin the beneficial effect of eccentric loading in tendon repair. However, this observation has been made only in individuals without Achilles tendinopathy. This research compared the force frequency characteristics of eccentric and concentric exercises in individuals with and without Achilles tendinopathy., Methods Eleven male adults with unilateral mid-portion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Kinematics and GRF were recorded while the participants performed a common eccentric rehabilitation exercise protocol and a concentric equivalent. Ankle joint kinematics and the frequency power spectrum of the resultant GRF were calculated. Results Eccentric exercise was characterised by a significantly greater proportion of spectral power between 4.5 and 11.5Hz when compared to concentric exercise. There were no significant differences between limbs in the force frequency characteristics of concentric exercise. Eccentric exercise, in contrast, was defined by a shift in the power spectrum of the symptomatic limb, resulting in a second spectral peak at 9Hz, rather than 10Hz in the control limb. Conclusions Compared to healthy tendon, Achilles tendinopathy was characterised by lower frequency vibrations during eccentric rehabilitation exercises. This finding may be associated with changes in neuromuscular activation and tendon stiffness which have been shown to occur with tendinopathy and provides a possible rationale for the previous observation of a different biochemical response to eccentric exercise in healthy and injured Achilles tendons., (C)2012The American College of Sports Medicine

The potential contributions of traditional Chinese medicine to emergency medicine

BACKGROUND: Despite the fact that traditional Chinese medicine (TCM) has been developed and used to treat acute and urgent illness for many thousands of years. TCM has been widely perceived in western societies that TCM may only be effective to treat chronic diseases. The aim of this article is to provide some scientific evidence regarding the application of TCM in emergency medicine and its future potential. METHODS: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) were searched using the terms: Traditional Chinese Medicine/ Chinese Medicine, Emergency Medicine, China. In addition, three leading TCM Journals in China were searched via Oriprobe Information Services for relevant articles (published from 1990—2012). Particular attention was paid to those articles that are related to TCM treatments or combined medicine in dealing with intensive and critical care. RESULTS: TCM is a systematic traditional macro medicine. The clinical practice of TCM is guided by the TCM theoretical framework – a methodology founded thousands of years ago. As the methodologies between TCM and Biomedicine are significantly different, it provides an opportunity to combine two medicines, in order to achieve clinical efficacy. Nowadays, combined medicine has become a common clinical model particular in TCM hospitals in China. CONCLUSIONS: It is evident that TCM can provide some assistance in emergency although to combine them in practice is stillits infant form and is mainly at TCM hospitals in China. The future effort could be put into TCM research, both in laboratories and clinics, with high quality designs, so that TCM could be better understood and then applied in emergency medicine.

Use of thermal imaging in sports medicine research : a short report

The assessment of skin temperature (Tsk) in athletic therapy and sports medicine research is an extremely important physiological outcome measure.Various methodsof recording Tsk, including thermistors, thermocouples and thermocrons are currently being used for research purposes. These techniques are constrained by their wires limiting the freedom of the subject, slow response times, and/or sensors falling off. Furthermore, as these products typically are directly attached to the skin and cover the measurement site, their validity may be questionable.This manuscript addresses the use and potential benefits of using thermal imaging (TI) in sport medicine research.Non-contact infrared TI offers a quick, non-invasive, portable and athlete-friendly method of assessing Tsk. TI is a useful Tsk diagnostic tool that has potential to be an integral part of sport medicine research in the future. Furthermore, as the technique is non-contact it has several advantages over existing methods of recording skin temperature

Cost effectiveness of patient education for the prevention of falls in hospital : economic evaluation from a randomized controlled trial

Background Falls are one of the most frequently occurring adverse events that impact upon the recovery of older hospital inpatients. Falls can threaten both immediate and longer-term health and independence. There is need to identify cost-effective means for preventing falls in hospitals. Hospital-based falls prevention interventions tested in randomized trials have not yet been subjected to economic evaluation. Methods Incremental cost-effectiveness analysis was undertaken from the health service provider perspective, over the period of hospitalization (time horizon) using the Australian Dollar (A$) at 2008 values. Analyses were based on data from a randomized trial among n = 1,206 acute and rehabilitation inpatients. Decision tree modeling with three-way sensitivity analyses were conducted using burden of disease estimates developed from trial data and previous research. The intervention was a multimedia patient education program provided with trained health professional follow-up shown to reduce falls among cognitively intact hospital patients. Results The short-term cost to a health service of one cognitively intact patient being a faller could be as high as A$14,591 (2008). The education program cost A$526 (2008) to prevent one cognitively intact patient becoming a faller and A$294 (2008) to prevent one fall based on primary trial data. These estimates were unstable due to high variability in the hospital costs accrued by individual patients involved in the trial. There was a 52% probability the complete program was both more effective and less costly (from the health service perspective) than providing usual care alone. Decision tree modeling sensitivity analyses identified that when provided in real life contexts, the program would be both more effective in preventing falls among cognitively intact inpatients and cost saving where the proportion of these patients who would otherwise fall under usual care conditions is at least 4.0%. Conclusions This economic evaluation was designed to assist health care providers decide in what circumstances this intervention should be provided. If the proportion of cognitively intact patients falling on a ward under usual care conditions is 4% or greater, then provision of the complete program in addition to usual care will likely both prevent falls and reduce costs for a health service.

Exercise-based cardiac rehabilitation for the 21st century

Exercise-based cardiac rehabilitation (CR) is efficacious in reducing mortality and hospital admissions; however it remains inaccessible to large proportions of the patient population. Removal of attendance barriers for hospital or centre-based CR has seen the promotion of home-based CR. Delivery of safe and appropriately prescribed exercise in the home was first documented 25 years ago, with the utilisation of fixed land-line telecommunications to monitor ECG. The advent of miniature ECG sensors, in conjunction with smartphones, now enables CR to be delivered with greater flexibility with regard to location, time and format, while retaining the capacity for real-time patient monitoring. A range of new systems allow other signals including speed, location, pulse oximetry, and respiration to be monitored and these may have application in CR. There is compelling evidence that telemonitored-based CR is an effective alternative to traditional CR practice. The long-standing barrier of access to centre-based CR, combined with new delivery platforms, raises the question of when telemonitored-based CR could replace conventional approaches as the standard practice.