The loss of a limb results in major disability and psychological trauma to the affected individual. Amputees of dysvascular origin usually have multiple co-morbidities and their complicated post-operative course frequently leads to a prolonged hospitalisation or a subsequent amputation in a higher level of the limb. The integrated comprehensive approach by a interdisciplinary team in post-operative management starts immediately after a limb amputation to assure successful surgical and functional outcomes. The programme comprises a variety of medical and rehabilitation aspects: to control acute medical co-morbidities, evaluate and alleviate different types of pain, optimal wound care, condition the residual limb to be well-fitted with a prosthesis, address patient’s functional goals and achieve maximal independence in mobility and self care, coach ideal coping skills and provide psychosocial support, and educate patient and family about risk factor modulation and residual limb care. Aggressive oedema control and early mobilisation became standardised practice in post-amputation care in view of a number of advantages.
Lower extremity - Surgery

The assessment of disability including activities of daily living (ADL) is important as a clinical tool to document functional recovery as well as to assess the effectiveness of medical and rehabilitation interventions. Disability assessment is also important epidemiologically, in developing social policies, planning disability resources and in medical research and education. In this article, we review the definitions, history and advances in the field of disability assessment. We then describe the general principles of disability assessment in adults with a further detailed focus on six basic ADLs: feeding, bathing, dressing, toileting, transfers and mobility. We use a practical framework of an independent category and four dependent categories corresponding to an increasing level of assistance for each ADL. Finally we summarise the inherent problems and difficulties in disability assessment and emphasise the important role of rehabilitation in improving functional outcomes including the basic ADLs.

The assessment of disability including activities of daily living (ADL) is important as a clinical tool to document functional recovery as well as to assess the effectiveness of medical and rehabilitation interventions. Disability assessment is also important epidemiologically, in developing social policies, planning disability resources and in medical research and education. In this article, we review the definitions, history and advances in the field of disability assessment. We then describe the general principles of disability assessment in adults with a further detailed focus on six basic ADLs: feeding, bathing, dressing, toileting, transfers and mobility. We use a practical framework of an independent category and four dependent categories corresponding to an increasing level of assistance for each ADL. Finally we summarise the inherent problems and difficulties in disability assessment and emphasise the important role of rehabilitation in improving functional outcomes including the basic ADLs.

OBJECTIVE: To evaluate the usefulness of various magnetic resonance imaging (MRI) findings in the prognosis of neurological recovery in paraplegics with thoracolumbar fracture using association analysis with clinical outcomes and electrodiagnostic features. METHODS: This retrospective study involved 30 patients treated for paraplegia following thoracolumbar fracture. On axial and sagittal T2-weighted MRI scans, nerve root sedimentation sign, root aggregation sign, and signal intensity changes in the conus medullaris were independently assessed by two raters. A positive sedimentation sign was defined as the absence of nerve root sedimentation. The root aggregation sign was defined as the presence of root aggregation in at least one axial MRI scan. Clinical outcomes including the American Spinal Injury Association impairment scale, ambulatory capacity, and electrodiagnostic features were used for association analysis. RESULTS: Inter-rater reliability of the nerve root sedimentation sign and the root aggregation sign were kappa=0.67 (p=0.001) and kappa=0.78 (p<0.001), respectively. A positive sedimentation sign was significantly associated with recovery of ambulatory capacity after a rehabilitation program (chi2=4.854, p=0.028). The presence of the root aggregation sign was associated with reduced compound muscle action potential amplitude of common peroneal and tibial nerves in nerve conduction studies (chi2=5.026, p=0.025). CONCLUSION: A positive sedimentation sign was significantly associated with recovery of ambulatory capacity and not indicative of persistent paralysis. The root aggregation sign suggested the existence of significant cauda equina injuries.
Action Potentials ; Cauda Equina ; Conus Snail ; Electrodiagnosis ; Humans ; Magnetic Resonance Imaging* ; Neural Conduction ; Paralysis ; Paraplegia ; Prognosis ; Rehabilitation ; Retrospective Studies ; Spinal Injuries ; Tibial Nerve

INTRODUCTIONRehabilitation improves functional outcomes, but there is little data on the profiles and outcomes of patients undergoing inpatient rehabilitation in Singapore. The aims of this paper were to document the clinical characteristics and functional outcomes, using the Functional Independence Measure (FIM), of all patients admitted to an inpatient rehabilitation unit in a tertiary teaching hospital, and to identify and analyse factors significantly associated with better discharge functional scores and higher functional gains.

MATERIALS AND METHODSIn this prospective cohort study over a 4-year period, clinical and functional data for 1502 patients admitted consecutively to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measures were the discharge total FIM scores, FIM gain and FIM efficiency. Multiple linear regression analysis was used to identify independent variables associated with better discharge FIM scores and FIM gain.

RESULTSThe mean age was 61.3 +/- 15.0 years and 57.2% of the patients were male. Stroke (57.9%) followed by spinal cord injury (9.7%) were the most common diagnoses. The average rehabilitation length of stay was 21.5 +/- 19.0 days. The mean admission total FIM score was 70.3 +/- 23.2 and the mean discharge total FIM score was 87.3 +/- 23.0, with this gain being highly significant (P <0.001). The mean FIM gain was 17.0 +/- 13.4 and FIM efficiency was 0.95 +/- 0.90 points/day. Factors associated with better functional outcomes were higher admission motor and cognitive FIM scores, male gender, a longer rehabilitation length of stay and the use of acupuncture. Factors associated with poorer functional outcomes were older age, clinical deconditioning, ischaemic heart disease, depression, pressure sores and the presence of a domestic worker as a caregiver.

CONCLUSIONSThe FIM is an easy-to-use, standardised and robust general measure of functional disability. Multiple demographic, clinical and socio-cultural variables are associated with the primary functional outcomes and should be taken into account in rehabilitation and discharge planning. Nevertheless, rehabilitation improves functional outcomes across a wide range of diagnoses. Further research should be aimed at evaluating long-term disability postdischarge from inpatient rehabilitation and translating these findings into improving rehabilitation and healthcare resource utilisation.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Databases, Factual ; Female ; Humans ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; Prospective Studies ; Recovery of Function ; Regression Analysis ; Rehabilitation ; Singapore ; Treatment Outcome

OBJECTIVE: To investigate the intra-rater and inter-rater reliability and usefulness of the Korean version of the Scale for the Assessment and Rating of Ataxia (K-SARA) in ataxic stroke patients. METHODS: The original SARA was translated into Korean, back translated to English, and compared to the original version. Stroke patients (n=60) with ataxia were evaluated using the K-SARA by one physiatrist and one occupational therapist. All subjects were rated twice. We divided the subjects into 5 groups by Functional Ambulation Category (FAC) and 3 groups based on the ataxia subscale of the National Institutes of Health Stroke Scale (NIHSS). The mean K-SARA scores representing each group of FAC and the ataxia subscale of NIHSS were compared. RESULTS: The test-retest correlation coefficient of the K-SARA was 0.997 by the therapist and 1.00 by the physiatrist (p<0.001). The inter-rater correlation coefficient of the K-SARA was 0.985 (p<0.001). The ataxia subscale of NIHSS did not correlate with K-SARA. There was a significant difference in the mean K-SARA score by FAC (p<0.001). CONCLUSION: K-SARA is a reliable and valid measure of ataxia in stroke patients in Korea.
Ataxia* ; Humans ; Korea ; National Institutes of Health (U.S.) ; Rehabilitation ; Stroke* ; Walking

The postoperative infectious spondylitis has been reported to occur among every 1% to 12%. It is difficult to early diagnose in some cases. If the diagnosis is delayed, it can be a life-threatening condition. We report a 32-year-old male patient with postoperative infectious spondylitis. He had surgical treatments for traumatic intervertebral disc herniations in L3-4 and L4-5. Three weeks after surgery, he complained for fever and paraplegia. Cervicothoracic magnetic resonance imaging showed the collapsed T2 and T3 vertebral body with changes of bone marrow signal intensity. Moreover, it showed anterior and posterior epidural masses causing spinal cord compressions which suggested infectious spondylitis. After the use of antibiotics and surgical decompressions T2-T3, his general conditions were improved and muscle power of lower extremities began to be gradually restored. However, we could not identify the exact organisms that may be the cause of infectious spondylitis. It could be important that the infectious spondylitis, which is presented away from the primary operative level, should be observed in patients with fevers of unknown origin and paraplegia.
Adult ; Anti-Bacterial Agents ; Bone Marrow ; Decompression, Surgical ; Fever ; Humans ; Intervertebral Disc Displacement ; Intervertebral Disc* ; Lower Extremity ; Magnetic Resonance Imaging ; Male ; Muscles ; Paraplegia ; Spinal Cord Compression ; Spondylitis*

OBJECTIVE: To investigate the factors affecting rehabilitation outcomes in children with congenital muscular torticollis (CMT). METHODS: We retrospectively reviewed the medical records of 347 patients who were clinically suspected as having CMT and performed neck ultrasonography to measure sternocleidomastoid (SCM) muscle thickness. Fifty-four patients met the inclusion criteria. Included were demographic characteristics as well as measurements of cervical range of motion (ROM), SCM muscle thickness, and the abnormal/normal (A/N) ratio, defined as the ratio of SCM muscle thickness on the affected to the unaffected side. RESULTS: Subjects were divided into three groups depending on degree of cervical ROM (group 1A: ROM>60, n=12; group 1B: 60> or =ROM>30, n=31; group 1C: ROM< or =30, n=11), the SCM muscle thickness (Th) (group 2A: Th<1.2 cm, n=23; group 2B: 1.2< or =Th<1.4 cm, n=18; group 2C: Th> or =1.4 cm, n=13), and the A/N ratio (R) (group 3A: R<2.2, n=19; group 3B: 2.2< or =R<2.8, n=20; group 3C: R> or =2.8, n=15). We found that more limited cervical ROM corresponded to longer treatment duration. The average treatment duration was 4.55 months in group 1A, 5.87 months in group 1B, and 6.50 months in group 1C. SCM muscle thickness and the A/N ratio were not correlated with treatment duration. CONCLUSION: Infants with CMT who were diagnosed earlier and had an earlier intervention had a shorter duration of rehabilitation. Initial cervical ROM is an important prognostic factor for predicting the rehabilitation outcome of patients with CMT.
Child ; Humans ; Infant ; Medical Records ; Muscles ; Neck ; Prognosis ; Range of Motion, Articular ; Retrospective Studies ; Torticollis ; Treatment Outcome

OBJECTIVE: To determine the relation between postvoid residual (PVR) and the occurrence of urinary tract infection (UTI) in stroke patients. METHOD: One hundred and eighty-eight stroke patients who were admitted to an inpatient rehabilitation unit and who did not have UTI on admission (105 males, 83 females, mean age 67.1 years) were included in this study. The PVR was measured 3 times within 72 hours after admission. Mean PVR, demographic variables, K-MMSE (Korean Mini-Mental State Examination), initial K-MBI (Korean Modified Barthel Index), Foley catheter indwelling time and stroke type were defined and the relation to the occurrence of UTI was analyzed. RESULTS: UTI occurred in 74 patients (39.4%) during admission to the rehabilitation unit. There were significant differences between the UTI and non-UTI groups in K-MMSE, K-MBI, Foley catheter indwelling time (p<0.01). However, age, gender, stroke location and type were not associated. The occurrence of UTI was 4.87 times higher in the patients with a mean PVR over 100 ml than in those with a mean PVR <100 ml. The mean PVR was 106.5 ml in the UTI group, while it was 62.7 ml in the non-UTI group (p<0.01). PVR was not associated with age. CONCLUSION: The UTI rate is higher when the mean PVR is over 100 ml irrespective of gender and age. Close monitoring of PVR and appropriate intervention is needed to reduce the occurrence of UTI in stroke patients.
Catheters ; Female ; Humans ; Inpatients ; Male ; Stroke ; Urinary Tract ; Urinary Tract Infections

A 50-year-old man with liver cirrhosis and esophageal varix for 3 years was diagnosed with hematemesis and treated for a bleeding varix. However, bleeding recurred 11 days later, and he developed drowsiness with left hemiparesis. His left upper and lower extremity muscle strengths based on the manual muscle test at the onset were grade 2/5 and 1/5, respectively. The Babinski sign was positive. His serum ammonia level was elevated to 129.9 microg/dL (normal, 20-80 microg/dL). Magnetic resonance imaging revealed restriction on diffusion and T2-hyperintensities with decreased apparent diffusion coefficient values in the bilateral frontoparietooccipital cortex. The effect was more severe in the right hemisphere and right parietooccipital cortices, which were compatible with hepatic encephalopathy. Although the patient's mental status recovered, significant left-sided weakness and sensory deficit persisted even after 6 months. Diffusion tensor tractography (DTT) performed 3 months post-onset showed decreased volume of the right corticospinal tract. We reported a patient with hepatic encephalopathy involving the corticospinal tract by DTT.
Ammonia ; Diffusion Tensor Imaging ; Diffusion* ; Esophageal and Gastric Varices ; Hematemesis ; Hemorrhage ; Hepatic Encephalopathy* ; Humans ; Liver Cirrhosis ; Lower Extremity ; Magnetic Resonance Imaging ; Middle Aged ; Muscle Strength ; Paresis ; Pyramidal Tracts* ; Reflex, Babinski ; Rehabilitation ; Sleep Stages ; Varicose Veins