Practice parameter: Immunotherapy for Guillain-Barre syndrome: Report of the Quality Standards Subcommittee of the American Academy of Neurology

OBJECTIVE

To provide an evidence-based statement to guide physicians in the management of Guillain-Barré syndrome (GBS).

METHODS

Literature search and derivation of evidence-based statements concerning the use of immunotherapy were performed.

RESULTS

Treatment with plasma exchange (PE) or IV immunoglobulin (IVIg) hastens recovery from GBS. Combining the two treatments is not beneficial. Steroid treatment given alone is not beneficial.

RECOMMENDATIONS

1) PE is recommended for nonambulant adult patients with GBS who seek treatment within 4 weeks of the onset of neuropathic symptoms. PE should also be considered for ambulant patients examined within 2 weeks of the onset of neuropathic symptoms; 2) IVIg is recommended for nonambulant adult patients with GBS within 2 or possibly 4 weeks of the onset of neuropathic symptoms. The effects of PE and IVIg are equivalent; 3) Corticosteroids are not recommended for the management of GBS; 4) Sequential treatment with PE followed by IVIg, or immunoabsorption followed by IVIg is not recommended for patients with GBS; and 5) PE and IVIg are treatment options for children with severe GBS.

Concept of spastic hypertonia

This introductory article highlights the definition of spastic hypertonia, and briefly introduces the reader to the incidence and most frequent causes of spastic hypertonia. The article also discusses the functional losses caused by spastic hypertonia that will be reviewed more thoroughly in the following articles. Also discussed is the neural physiology and the locations of the structural lesions within the central nervous system that are involved in spastic hypertonia, with an emphasis on the different clinical presentations depending on the location of the lesion.

Spastic hypertonia. Appendix

This appendix reviews the most commonly used clinical methods for assessing the clinical treatment of spastic hypertonia. The definitions and rating scales shown often are accepted by the Food and Drug Administration for pharmaceutical and investigational trials to obtain a clinical indication for use in spasticity clinic.

Current concepts: diffuse axonal injury-associated traumatic brain injury

OBJECTIVES

To review the probable physical, physiologic mechanisms that result in the medical and neuropsychologic complications of diffuse axonal injury (DAI)-associated traumatic brain injury (TBI).

DATA SOURCES

Various materials were accessed: MEDLINE, textbooks, scientific presentations, and current ongoing research that has been recently reported.

STUDY SELECTION

Included were scientific studies involving TBI, particularly direct injury to the axons and glia of the central nervous system (CNS) in both in vitro and in vivo models. These studies include pathologic findings in humans as well as the medical complications and behavioral outcomes of DAI. Studies that addressed animal models of DAI as well as cellular and/or tissue models of neuronal injury were emphasized. The review also covered work on the physical properties of materials involved in the transmission of energy associated with prolonged acceleration-deceleration injuries.

DATA EXTRACTION

Studies were selected with regard to those that addressed the mechanism of TBI associated with DAI and direct injury to the axon within the CNS. The material was generally the emphasis of the article and was extracted by multiple observers. Studies that correlate the above findings with the clinical picture of DAI were included.

DATA SYNTHESIS

Concepts were developed by the authors based on the current scientific findings and theories of DAI. The synthesis of these concepts involves expertise in physical science, basic science concepts of cellular injury to the CNS, acute medical indicators of DAI, neuropsychologic indicators of DAI, and rehabilitation outcomes from TBI.

CONCLUSIONS

The term DAI is a misnomer. It is not a diffuse injury to the whole brain, rather it is predominant in discrete regions of the brain following high-speed, long-duration deceleration injuries. DAI is a consistent feature of TBI from transportation-related injuries as well as some sports injuries. The pathology of DAI in humans is characterized histologically by widespread damage to the axons of the brainstem, parasagittal white matter of the cerebral cortex, corpus callosum, and the gray-white matter junctions of the cerebral cortex. Computed tomography and magnetic resonance imaging scans taken initially after injury are often normal. The deformation of the brain due to plastic flow of the neural structures associated with DAI explains the micropathologic findings, radiologic findings, and medical and neuropsychologic complications from this type of injury mechanism. There is evidence that the types of cellular injury in TBI (DAI, anoxic, contusion, hemorrhagic, perfusion-reperfusion) should be differentiated, as all may involve different receptors and biochemical pathways that impact recovery. These differing mechanisms of cellular injury involving specific biochemical pathways and locations of injury may, in part, explain the lack of success in drug trials to ameliorate TBI.

Intrathecal baclofen for spastic hypertonia from stroke

BACKGROUND AND PURPOSE

We sought to determine whether continuous intrathecal delivery of baclofen can effectively decrease spastic hypertonia due to stroke.

METHODS

Stroke patients with >6 months of intractable spasticity were screened via a randomized, double-blind, placebo-controlled crossover design of either intrathecal normal saline or 50 microgram baclofen. Those who dropped an average of 2 points in either their affected lower extremity side Ashworth or Penn spasm frequency scores were then offered computer-controlled pump implantation for continuous ITB and followed prospectively for up to 12 months.

RESULTS

In 21 stroke patients 6 hours after the active drug bolus, the average (+/-SD) lower extremity Ashworth score on the affected extremities decreased from 3.3+/-1.2 to 1.4+/-0.7 (P<0.0001), spasm score from 1.2+/-1.2 to 0.1+/-0.3 (P=0.0224), and reflex score from 2.1+/-1.2 to 0.1+/-0.5 (P<0.0001). The average upper extremity Ashworth score on the affected extremities decreased from 2.8+/-1.1 to 1.8+/-0.8 (P<0.0001), spasm score from 0.7+/-1.0 to 0.2+/-0.4 (P=0.1544), and reflex score from 2.1+/-0.9 to 1.2+/-0.9 (P=0.0004). All active drug scores were statistically different from placebo scores at 6 hours (P<0.05). With up to 12 months of continuous infusion of ITB in 17 implanted patients, the average lower extremity Ashworth score on the affected extremities decreased from 3.7+/-1.0 to 1.8+/-1.1 (P<0.0001), the spasm score dropped from 1.2+/-1.3 to 0.6+/-1.0 (P=0.4282), and the reflex score decreased from 2.4+/-1.3 to 1.0+/-1.3 (P<0.0001). The average upper extremity Ashworth score in the affected extremities decreased from 3.2+/-1.1 to 1.8+/-0.9 (P<0.0001), the spasm score dropped from 0.7+/-1.0 to 0.3+/-0.8 (P=0.8685), and the reflex score decreased from 2.4+/-0.8 to 1.5+/-1.2 (P=0.3337). The average continuous ITB dose required to attain these effects was 268 microgram/d.

CONCLUSIONS

Intrathecal infusion of baclofen is capable of maintaining a reduction in the spastic hypertonia resulting from stroke.

Prospective assessment of tizanidine for spasticity due to acquired brain injury

OBJECTIVE

To determine if orally delivered tizanidine will control spastic hypertonia due to acquired brain injury.

DESIGN

Randomized, double-blind, placebo-controlled, crossover design, with 2 8-week treatment arms separated by a 1-week washout period at baseline. Patients were randomly assigned to receive tizanidine or a matching placebo.

SETTING

Tertiary care outpatient and inpatient rehabilitation center attached to a university hospital.

PARTICIPANTS

Seventeen persons recruited in a consecutive manner, 9 of whom had suffered a stroke and 8 a traumatic brain injury, and had more than 6 months of intractable spastic hypertonia.

INTERVENTION

Over a 6-week period, subjects were slowly titrated up to their maximum tolerated dose (up to 36 mg/d). Following a 1-week drug taper and 1-week period in which no study drug was administered, patients were then crossed over to the other study medication following an identical titration regime.

MAIN OUTCOME MEASURES

Subjects were evaluated for dose and effect throughout the trial as well as for side effects. Data for Ashworth rigidity scores, spasm scores, deep tendon reflex scores, and motor strength were collected on the affected upper extremity (UE) and lower extremity (LE). Differences over time were assessed via descriptive statistics, Friedman's analysis, and Wilcoxon's signed-rank. Data are reported as the mean +/- 1 standard deviation.

RESULTS

Following 4 weeks of treatment when subjects reached their maximal tolerated dosage, the average LE Ashworth score on the affected side decreased from 2.3 +/- 1.4 to 1.7 +/- 1.1 (p <.0001). The spasm score decreased from 1.0 +/- 0.9 to 0.5 +/- 0.8 (p =.0464), while the reflex score was not statistically significant decreasing from 2.2 +/- 1.0 to 2.0 +/- 1.1 (p =.0883). The average UE Ashworth score on the affected side decreased from 1.9 +/- 1.1 to 1.5 +/- 0.9 (p <.0001). There was no significant change in the UE spasm and reflex scores. While there were positive placebo effects on motor tone, the active drug was still significantly better than placebo for decreasing LE tone (p =.0006) and UE tone (p =.0007). With a reduction in motor tone, there was an increase in motor strength (p =.0089). The average dosage at 4 weeks was 25.2mg/d.

CONCLUSION

Tizanidine is effective in decreasing the spastic hypertonia associated with acquired brain injury, which is dose-dependent. There are limitations on its use due to side effects related to drowsiness.

Intrathecal baclofen in tetraplegia of spinal origin: efficacy for upper extremity hypertonia

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To evaluate the efficacy of intrathecal baclofen (ITB) for upper extremity spastic hypertonia in tetraplegia of spinal origin.

SETTING

University of Alabama at Birmingham hospital.

METHODS

The medical records of 14 individuals with tetraplegia of spinal origin who underwent intrathecal baclofen pump placement were reviewed. The effects of intrathecal baclofen on spasm frequency, deep tendon reflexes, and tone (Ashworth scale) were assessed for the upper and lower extremities for a 1-year follow-up period.

RESULTS

There were statistically significant declines in upper extremity spasm scores (1.8 points, P=0.012), reflex scores (1.4 points, P<0.0001) and Ashworth scores (0.6 points, P<0.0001) for the 1-year follow-up period. For the lower extremities, all decreases were significant (P<0.0001). There was also a statistically significant (P<0.0001) increase in intrathecal baclofen dosage requirements during the 1-year follow-up period to maintain the reductions in spasm frequency, reflexes and tone.

CONCLUSIONS

Intrathecal baclofen is a safe and effective intervention for treating upper extremity hypertonia of spinal origin. In addition, the level of intrathecal catheter placement is felt to be of importance.

Sertraline to improve arousal and alertness in severe traumatic brain injury secondary to motor vehicle crashes

OBJECTIVE

To establish whether or not the serotonin reuptake inhibitor (SSRI) sertraline can improve arousal and alertness of patients with traumatic brain injury (TBI) and associated diffuse axonal injury (DAI). Serotonin is a major inhibitory as well an excitatory neurotransmitter, and serotonergic neurons modulate the activity of brain regions responsible for motor control, arousal, attention, and emotional regulation.

SETTING

Tertiary care inpatient rehabilitation centre directly attached to a university hospital level-one trauma centre.

DESIGN

Prospective placebo-controlled randomized trial utilizing sertraline on admission to acute rehabilitation.

DATA SET

Eleven subjects, post-high speed motor vehicle crash and post-severe TBI (GCS < or = 8) with presumed DAI randomized to receive either sertraline 100mg per day or placebo for 2 weeks. All subjects were within 2 weeks of acute injury. Outcome measures recorded were the Orientation Log (daily), Agitated Behaviour Scale (daily), and the Galveston Orientation and Amnesia Test (weekly).

RESULTS

Both placebo and active medication groups demonstrated similar rates of improvement on all three scales. There was no difference in the rates of recovery for either study group (p > 0.05, ANOVA with repeated measures). The groups did not demonstrate a statistically significant negative effect on recovery either, although the size is too small for a statistically reliable beta-effect.

CONCLUSION

This pilot study fails to establish whether the early use of sertraline may improve alertness, decrease agitation or improve cognitive recall of material. This may be due to the small size of the study group, the brief duration of treatment or by a skewed placebo group. Larger studies will be required to prove any efficacy. There were no complications with its use and sertraline did not demonstrate a detrimental effect on recovery. This indicates that sertraline may be safe to use in the treatment of psychiatric or behavioural complications attributable to TBI.

Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables

OBJECTIVE

To examine the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome 1 year after traumatic brain injury (TBI) and to assess the feasibility of multivariate path analysis as a way to discover those relationships.

DESIGN

Prospective, longitudinal.

SETTINGS

Level I trauma center, acute inpatient rehabilitation hospital.

PATIENTS

One hundred seven subjects (87 men, 20 women; mean age, 33.91 +/- 14.2 yr) who had experienced severe TBI, typically from motor vehicle crashes.

INTERVENTIONS

Acute medical and rehabilitation care.

MAIN OUTCOME MEASURES

Disability Rating Scale, Community Integration Questionnaire, and return to employment. Evaluated in acute rehabilitation, and at 6 and 12 months' postinjury.

RESULTS

Path analyses revealed that premorbid factors had significant relationships with injury severity, functional skills, cognitive status, and outcome; injury severity affected cognitive and functional skills; and cognitive status influenced outcome. No significant relationships were found between injury severity and emotional status, injury severity and outcome, emotional status and outcome, and functional skills and outcome.

CONCLUSIONS

Multivariate analysis is important to understanding outcome after TBI. Injury severity, as measured in this study, is less important to 12-month outcome than the premorbid status of the person and the difficulties (particularly cognitive deficits) exhibited at follow-up 6 months after the trauma.

Continuously infused intrathecal baclofen over 12 months for spastic hypertonia in adolescents and adults with cerebral palsy

OBJECTIVE

To determine if the continuous intrathecal delivery of baclofen will control spastic hypertonia caused by long-standing cerebral palsy (CP).

DESIGN

Case series.

SETTING

Tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital.

PATIENTS

Thirteen CP patients (average age, 25yr; range, 13--43yr) with intractable spastic hypertonia and quadriparesis (one of whom had predominate diplegia) who had not responded to oral medications including baclofen.

INTERVENTION

Patients were screened via a bolus injection of baclofen intrathecally. Those who dropped an average of 2 points on their lower extremity (LE) Ashworth scores were offered computer-controlled pump implantation for 12 months of continuous delivery of intrathecal baclofen (ITB).

MAIN OUTCOME MEASURES

Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UEs) and LEs. Differences over time were assessed via descriptive statistics and Wilcoxon's signed-rank test.

RESULTS

After 1 year of continuous ITB treatment, the average LE Ashworth score +/- standard deviation decreased from 3.4 +/- 1.2 to 1.5 +/- 0.7 (p <.0001), spasm score from 1.4 +/- 1.6 to 0.6 +/- 1.2 (p =.1024), and reflex score from 2.5 +/- 1.2 to 0.7 +/- 1.1 (p <.0001). The average UE Ashworth score decreased from 3.0 +/- 1.2 to 1.7 +/- 1.0 (p <.0001), spasm score from 1.2 +/- 1.6 to 0.2 +/- 0.6 (p =.0135), and reflex score from 2.3 +/- 0.7 to 0.5 +/- 0.9 (p <.0001). The average ITB dose required to attain these effects at 1 year was 263 +/- 91microg continuously infused per day.

CONCLUSION

Continuously infused ITB can reduce spastic hypertonia in the UEs and LEs associated with long-standing CP. This reduction in tone will allow more freedom of movement and the potential for improved function.

Cognitive and functional recovery at 6 and 12 months post-TBI

Outcome studies examining recovery from traumatic brain injury (TBI) often fail to provide a clear understanding of the time course of cognitive, emotional, and behavioural recovery. The present study represents an effort to prospectively study individuals with TBI at fixed intervals, specifically 6 and 12 months post-injury with a window of +/- 1 month. Seventy-two individuals with new-onset TBI underwent neuropsychological evaluation and clinical interview at 6 and 12 months post-injury. Results revealed significant improvements in cognitive abilities, including memory, processing speed, language abilities, and constructional skills. There were significant gains in community integration and involvement in productive activities, but limitations in driving activities remained. Although individuals with mild-moderate TBI performed better than individuals with severe TBI, both groups demonstrated equivalent rates of recovery across domains. The results of this study provide important information regarding the time course of TBI recovery.

Neuroleptic malignant syndrome induced by haloperidol following traumatic brain injury

The use of neuroleptics in the acute management of traumatic brain injury (TBI) is controversial and may be detrimental to recovery. The following case report describes a patient developing neuroleptic malignant syndrome (NMS) secondary to the use of haloperidol given to control the patient's agitation. The patient began to exhibit symptoms consistent with NMS (high fever, dystonia, diaphoresis, tachycardia, and decerebrate posturing) shortly after administration of the haloperidol. Upon transfer to a rehabilitation hospital, the symptoms persisted. When NMS is suspected, the first intervention is to remove the offending agent; thus, the administration of haloperidol was suspended, and the patient was placed on Amantadine and propranolol. Amantadine was used to increase the availability of dopamine to the mid-brain region, and the propranolol was used to control the fever, which was believed to be central in origin. The patient was able to complete his rehabilitation with no further incidence of fever or agitation. The patient met or exceeded all short-term physical therapy goals and was able to complete most of the neuropsychological tasks presented. The patient returned home 38 days after admission to the rehabilitation hospital and was able to perform most activities of daily living. At the 6-months follow-up visit, the patient was considering entrance into an adult vocational school.

Midthoracic catheter tip placement for intrathecal baclofen administration in children with quadriparetic spasticity

OBJECTIVE

In an effort to increase the effect of intrathecal baclofen on upper-extremity spasticity, the tip of the intrathecal catheter was placed at the T6-T7 level rather than at the traditional T11-T12 level in children with spastic quadriparesis.

METHODS

Twelve children with spastic quadriparesis from varying causes had significant reductions in spasticity after a test dose of intrathecal baclofen and subsequently underwent placement of a programmable pump and intrathecal catheter tip placed at the T6-T7 level with fluoroscopic guidance. With the use of Ashworth scores for four muscle groups in both the upper and lower extremities, degrees of spasticity were determined by a physiatrist preoperatively and at 1, 3, 6, and 12 months postoperatively. Mean changes in upper- and lower-extremity Ashworth scores and baclofen dosages for the entire cohort were compared with published results in which the catheter tip had been placed at the T11-T12 level.

RESULTS

Spasticity was significantly reduced in all muscle groups (P < 0.001). The lower-extremity reduction in spasticity of 1.6 points at 3 and 12 months was greater than published reductions of 1.1 points at 3 and 12 months. The upper-extremity reduction in spasticity was noticeably greater at 3 and 12 months (1.7 and 2.0 points, respectively) than published results at 3 and 12 months (0.4 and 0.6 points, respectively). At 3, 6, and 12 months, our mean baclofen dosage remained below the dosages administered at the T11-T12 level. There were no complications related either to the positioning of the catheter higher in the spinal canal or to the administration of baclofen at the T6-T7 level.

CONCLUSION

Compared with published results, placement of the tip of the intrathecal catheter at the T6-T7 level was associated with greater relief of upper-extremity spasticity without loss of effect on the lower extremities. The mean dosages of baclofen in our study group were lower compared with mean dosages administered at the T11-T12 level. There was no morbidity related to the more rostral location of the catheter.

Antiepileptic drugs

Antiepileptics are a very important class of medications, and the number of these drugs available for clinical use has increased dramatically in the last decade. The pharmacology and indications for use in a variety of physiatric patient groups are comprehensively and systematically reviewed.

Continuously infused intrathecal baclofen for spastic/dystonic hemiplegia: a preliminary report

The objective of this study was to determine whether the continuous intrathecal delivery of baclofen will control spastic hypertonia associated with long-standing hemiplegia from acquired brain injury. Six hemiparetic patients (average age, 50 (range, 42-66) yr) with more than 6 mo of disabling lower limb spastic hypertonia on one side caused by either a unilateral traumatic brain injury or a stroke were recruited in a consecutive manner. The setting was a tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital. Patients were screened via a randomized, double-blind, placebo-controlled, crossover design to receive either an intrathecally administered bolus injection of normal saline or 50 microg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected on the affected upper limb and lower limb side. Those who dropped an average of two points on their affected lower limb side Ashworth scores were then offered computer-controlled pump implantation for continuous intrathecal administration of baclofen. Differences over time were assessed via descriptive statistics and Wilcoxon's signed-rank test. After 3 mo of treatment, the average lower limb Ashworth score on the affected side decreased from 3.7 +/- 1.0 to 1.9 +/- 0.6 standard deviation (SD) (P < 0.0001), the reflex score from 1.8 +/- 1.3 to 0.5 +/- 0.8 SD (P = 0.0208), and the spasm score from 1.3 +/- 1.2 to 0.8 +/- 1.3 SD (P > 0.05). The average upper limb Ashworth score on the affected side decreased from 3.4 +/- 0.9 to 2.1 +/- 0.9 SD (P = 0.0002), the reflex score from 2.3 +/- 0.5 to 1.7 +/- 0.5 SD (P > 0.050, and the spasm score from 0.8 +/- 1.3 to 0 +/- 0 SD (P > 0.05). The average intrathecally administered dose of baclofen that was required to attain these effects was 205.3 microg, which was continuously infused for 24 h. Continuous intrathecal infusion of baclofen is capable of maintaining a reduction in the dystonia on the hemiparetic side without significantly affecting motor strength on the normal side.

Long-term continuously infused intrathecal baclofen for spastic-dystonic hypertonia in traumatic brain injury: 1-year experience

OBJECTIVE

To determine if the long-term use of continuously infused intrathecal baclofen (ITB) over a 1-year period will control spastic-dystonic hypertonia in patients with traumatic brain injury (TBI).

SETTING

Tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital.

SUBJECTS

Persons with TBI and intractable spasticity and dystonia for more than 6 months' duration recruited in a consecutive manner.

DESIGN

TBI patients were admitted to the study after screening via a bolus injection of either intrathecal normal saline or 50 microg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Patients whose LE Ashworth scores decreased an average of 2 points were then offered implantation of a computer-controlled pump for continuous ITB. Changes over time were assessed statistically via Friedman's analysis for ordinal data and ANOVA for linear data. Differences between set points in time were also assessed via Wilcoxon signed rank.

DATA SET

Seventeen patients (average age 29+/-11 yrs) with spasticity and/or dystonia treated over 1 year via a computer-controllable intrathecal delivery system for the delivery of ITB.

RESULTS

After 1 year of continuous ITB treatment the average LE Ashworth score decreased from 3.5+/-1.3 (SD) to 1.7+/-0.9 (p < .0001), spasm score from 1.8+/-1.3 to 0.2+/-0.5 (p< .0001), and reflex score from 2.5+/-1.1 to 0.1+/-0.3 (p < .0001). The average UE Ashworth score decreased from 2.9+/-1.5 to 1.6+/-1.0 (p < .0001), spasm score from 1.2+/-1.5 to 0.2+/-0.6 (p < 0.0001), and reflex score from 2.2+/-0.5 to 1.0+/-0.8 (p < .0001). The average ITB dose required to attain these effects at 1 year was 302 microg continuously infused per day.

CONCLUSION

Continuous intrathecal infusion of baclofen is capable of maintaining a reduction in spasticity and dystonia in both the upper and lower extremities of TBI patients.

Elevated liver enzymes after nontraumatic intracranial hemorrhages

OBJECTIVE

To determine the prevalence and possible etiologies of liver enzyme abnormalities in patients with acquired brain injury and to assess the impact of these abnormalities on the rehabilitative process.

SETTING

University tertiary care rehabilitation center.

DESIGN

Retrospective study.

SUBJECTS

Fifty-six consecutive patients admitted to a brain injury unit in a 30-month period who had an intracranial hemorrhage without associated head or abdominal trauma.

MAIN OUTCOME MEASURES

Liver function tests, Functional Independence Measure (FIM) scores, exposure to hepatotoxic drugs, antiepileptic medication serum levels, history of alcohol use, medical history, length of stay, and medical costs.

RESULTS

There was an increase (from acute hospital admission to inpatient rehabilitation admission) in gamma-glutamyltransferase (GGT) levels from 42 to 147U/L (p=.0012). There was an increase in alkaline phosphatase from 83 to 125U/L (p=.0079). There was a significant relationship between the GGT level on rehabilitation admission and exposure to hepatotoxic drugs, particularly phenytoin (n=55, p=.0007). Similar findings were noted between alkaline phosphatase and phenytoin (n=55, p=.0022) and systemic steroids (n=50, p=.0277). History of alcohol use was not predictive of changes in liver function tests (p > .05). Correlation analysis revealed no detrimental effect of the elevated serum liver enzyme levels on the Rasch-converted FIM cognitive or motor admission or discharge scores or change in the scores while on rehabilitation (p > .05). All radiologic testing and hepatitis profiles were negative, and 10 of the 16 patients with follow-up laboratory tests showed improvement in their serum liver enzyme levels.

CONCLUSIONS

After nontraumatic brain injury there is a characteristic pattern of enzyme elevation that statistically relates to phenytoin exposure. No additional etiologic abnormalities were found on further workup, suggesting that further evaluation should be guided by the patient's clinical status, not laboratory value alone.

Rehabilitation outcomes of patients who have developed Guillain-Barré syndrome

The objective of this study was to determine associations between early variables (requirement for ventilator support, anemia, indicators of abnormal peripheral nerve function (proprioception, vibratory, fine touch/pinprick, deep-tendon reflexes, cranial nerve involvement, dysautonomia, electrodiagnostic findings), plasmapheresis, age, and gender) and outcome variables (length of acute hospitalization, length of inpatient rehabilitation, Functional Independence Measure (FIM) Rasch converted scores, and acute and rehabilitation charges) in Guillain Barré Syndrome (GBS). The design of the study was a retrospective case review of 39 GBS admissions (as defined by National Institute of Neurologic Disorders and Stroke clinical criteria) to an inpatient rehabilitation unit at a university tertiary care rehabilitation center during a three-year period. The average length of stay for 39 patients requiring transfer to the inpatient rehabilitation unit (40% of all acute care GBS admissions) was 34 days in acute care and 26 days in rehabilitation. The average adjusted charges for inpatient rehabilitation (1993 dollars) was $31,636.28. Those who required ventilator support before rehabilitation v those who did not had an admission mean FIM Rasch converted motor score of 26.6 v a score of 38.3 (P = 0.0469), gained only 10.3 points on their FIM Rasch converted motor score v 27.7 points (P = 0.0001), and had a mean acute length of stay of 66.2 days v 19.3 days (P = 0.0029). Patients requiring ventilator support were more likely to have dysautonomia (P = 0.0009). Thirty-one of 39 patients with GBS (79%) had anemia. No correlation was found between hematocrit or hemoglobin and motor function recovery as assessed via the Rasch transformed FIM motor scores. There was an association between autonomic dysfunction and an increased acute care length of stay (P = 0.0325) and total length of hospital stay (P = 0.0203). Cranial nerve dysfunction resulted in an increase in the acute care length of stay (P = 0.0266), the total length of hospital stay (P = 0.0123), and adjusted hospital charges while undergoing inpatient rehabilitation (P = 0.0235). For patients with GBS necessitating admission to inpatient rehabilitation, the requirement of prior ventilator support most strongly predicts an extended length of stay for inpatient rehabilitation.

Prospective assessment of continuous intrathecal infusion of baclofen for spasticity caused by acquired brain injury: a preliminary report

Twelve consecutive patients with severe spasticity and hypertonia following acquired brain injury were treated with continuous intrathecal infusion of baclofen via an implanted, programmable infusion pump-catheter system for a minimum of 3 months. In every case intrathecal baclofen therapy resulted in a statistically significant reduction in upper- and lower-extremity tone, spasm frequency, and reflexes, contributing to improved functional abilities. There were no untoward side effects or complications associated with treatment. This preliminary assessment indicates that intrathecal administration of baclofen is effective in treating the disabling spasticity caused by acquired brain injury in selected patients.

Rehabilitation of Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is the most common cause of acute neuromuscular paralysis in developed countries. GBS is a significant cause of new long-term disability for at least 1,000 persons per year in the United States, and more elsewhere. Given the young age at which GBS sometimes occurs and the relatively long life expectancies following GBS, it is likely that at least 25,000 and perhaps 50,000 persons in the US are experiencing some residual effects of GBS. Approximately 40% of patients who are hospitalized with GBS will require admission to inpatient rehabilitation. For GBS persons necessitating admission to inpatient rehabilitation, the requirement of prior ventilator support most strongly predicts an extended length of stay on inpatient rehabilitation. Other issues that affect rehabilitation are dysautonomia, cranial nerve involvement, and various medical complications associated with GBS. Deafferent pain syndrome is common in the early stages of recovery. Multiple medical complications, including deep venous thrombosis, joint contractures, hypercalcemia of immobilization, and decubitii, may develop in the early stages of recovery and interfere with the rehabilitation program. Anemia is a frequent finding in the first few months of illness but does not appear to interfere with functional recovery. Therapy should not overfatigue the motor unit, which has been associated with paradoxical weakening. Little is known of the long-term implications of the disability caused by GBS. Work similar to that performed for postpolio syndrome and spinal cord injury should be started in the rehabilitation setting.

Prospective study on the use of bolus intrathecal baclofen for spastic hypertonia due to acquired brain injury

OBJECTIVE

To determine if the intrathecal delivery of baclofen will decrease spastic hypertonia caused by brain injury.

PATIENTS

Eleven patients more than 1 year after their brain injury with disabling lower extremity spastic hypertonia.

SETTING

University tertiary care outpatient rehabilitation clinic.

DESIGN

Patients were a consecutive sample randomized in a double blind, placebo-controlled crossover study.

INTERVENTIONS

Bolus intrathecal injection of either normal saline or 50 micrograms baclofen.

MAIN OUTCOME MEASURES

Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper extremities (UE) and lower extremities (LE). Changes over time were assessed via Friedman's test. Differences between the placebo and active drug at any given time were assessed via Wilcoxon signed-rank.

RESULTS

Four hours after injection with the active drug (maximum effect) the average LE Ashworth score decreased from 4.2 +/- 0.8 (SD) to 2.2 +/- 0.6 (p = .0033), spasm score from 3.1 +/- 1.0 to 1.0 +/- 0.7 (p = .0032), and reflex score from 3.3 +/- 0.5 to 1.0 +/- 1.3 (p = .0033). The average UE Ashworth score decreased from 3.3 +/- 1.3 to 1.9 +/- 0.8 (p = .0033), spasm score from 1.8 +/- 1.3 to 0.6 +/- 1.0 (p = .007), and reflex score from 2.7 +/- 0.5 to 1.7 +/- 0.6 (p = .0111). No trend was observed over time with placebo administration. There were significant reductions in the average for LE Ashworth (p < .0001), spasm (p < .0001), and reflex (p < .0001) scores and for UE Ashworth (p < .0001) and spasm (p < .0004) scores observed over 4 hours (maximum effect) with active drug administration. No significant differences were noted between the active drug and placebo groups before administration in LE and UE Ashworth, spasm, or reflex scores. There were significant differences between the active drug and placebo groups at 4 hours after administration for LE and UE Ashworth, spasm, and reflex scores (p < or = .0272).

CONCLUSION

Intrathecal injection of baclofen is capable of reducing the spastic hypertonia associated with brain injury.

Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation

OBJECTIVE

Determine the prevalence of proximal deep venous thrombosis (DVT) among acquired brain injury patients on admission to rehabilitation and assess cost-effectiveness of routine ultrasound screening for proximal DVT in those patients.

DESIGN

Prospective study, sequential case series.

SETTING

University tertiary care rehabilitation center.

DATA SET

One hundred sixteen traumatic brain injury patients (TBI) and 48 nontraumatic brain injury patients were admitted to our brain injury (BI) unit over a 21-month period and screened for a DVT on admission to rehabilitation utilizing real time, Doppler, and color Doppler ultrasound. Patients with a previous clinically recognized and treated DVT were excluded. No patients had been treated with prophylactic anticoagulation or intermittent anticoagulation since their BI and all patients were within 4 months of the original injury.

RESULTS

Fourteen patients in total (8.5%) were found to have a DVT in the thigh or popliteal area, 9 of the 116 patients in the TBI group (7.8%), and 5 of the 48 patients in the nontraumatic BI group (10.4%). Statistically, there was no significant difference in the total number of detected proximal lower extremity DVTs between the TBI and the nontraumatic BI groups (Fisher's exact test). In the TBI group 22 patients had associated lower extremity or pelvic fractures, but this factor appeared not to be significant, because only 1 of the 22 patients was discovered to have a DVT. The average admission Glascow Coma Score (GCS) of the TBI group was 8.6 but there was no correlation with the GCS and prevalence of DVT. The additional cost of screening for and treating the additional DVTs utilizing color Doppler ultrasound is conservatively estimated to be $674.84 per patient admitted to the BI rehabilitation unit. It can be estimated the cost of saving one life is $129,527.83.

CONCLUSION

DVT screening in this patient population appears to be more cost-effective than mass screening programs for either breast cancer or colorectal cancer. The cost per year of life saved, estimated at only $2,977.65 ($129,527.83/43.5 years) for DVT screening for brain injury patients on admission to rehabilitation, is lower than those costs proposed for comparable programs with significant social support.

Influence of early variables in traumatic brain injury on functional independence measure scores and rehabilitation length of stay and charges

OBJECTIVE

To determine the relationship between early variables (initial Glasgow Coma Scale [GCS] scores, computed tomography [CT] findings, presence of skeletal trauma, age, length of acute hospitalization) and outcome variables (Functional Independence Measure [FIM] scores, rehabilitation length of stay [LOS], rehabilitation charges) in traumatic brain injury (TBI).

DESIGN

Inception cohort.

SETTING

University tertiary care rehabilitation center.

PATIENTS

91 patients with TBI.

INTERVENTIONS

Inpatient rehabilitation.

MAIN OUTCOME MEASURES

FIM, rehabilitation LOS, and rehabilitation charges.

RESULTS

Patients in the severely impaired (GCS = 3 to 7) group showed significantly lower (p = .01) mean admission and discharge motor scores (21.26, 39.83) than patients in the mildly impaired (GCS = 13 to 15) group (38.86, 55.29). Cognitive scores were also significantly lower (p < .01) in the severely impaired group on admission (26.73 vs 54.14) and discharge (42.28 vs 66.48). These findings continued to be statistically significant (p < .01) after regression analysis accounted for the other early variables previously listed. Regression analysis also illustrated that longer acute hospitalization LOS was independently associated with significantly lower admission motor (p < .01) and cognitive (p = .05) scores, and significantly higher (p = .01) rehabilitation charges. Patients with CT findings of intracranial bleed with skull fracture had longer total LOS (70.88 vs 43.08 days; p < .05), rehabilitation LOS (30.01 vs 19.68 days; p < .10), and higher rehabilitation charges ($43,346 vs $25,780; p < .05). Paradoxically, those patients in a motor vehicle crash with an extremity bone fracture had significantly higher (p = .002; p = .04 after regression analysis) FIM cognitive scores on admission (48.30 vs 27.28) and discharge (64.74 vs 45.78) than those without a fracture. Finally, data available on rehabilitation admission were used to predict discharge outcomes. The percentage of explained variance for each outcome variable is as follows: discharge FIM motor score, 69.5%; discharge FIM cognitive score, 71.2%; rehabilitation LOS, 54.1%; rehabilitation charges, 61.1%. The most powerful predictor of LOS and charges was the admission FIM motor score (p < .001), followed by CT findings (p = .02) and age (p = .04).

CONCLUSION

Information readily available on rehabilitation admission, particularly the FIM motor score, may be useful in predicting discharge FIM scores as well as utilization of medical rehabilitation resources. Earlier transfer to rehabilitation may result in higher functional status and lower rehabilitation charges, as well as lower acute hospitalization charges. The presence of extremity fractures encountered during a motor vehicle crash is associated with a more favorable outcome in TBI as evidenced by higher discharge FIM cognitive scores.

Hypotensive effects of thioridazine in an elderly patient with traumatic brain injury

Neuroleptics have been used to help control agitation, restlessness, and hostility in patients with traumatic brain injury. However, there are many reported side-effects with the use of neuroleptics after brain injury, including memory and other cognitive impairments, as well as slowed neural recovery. Alpha-1 adrenergic blockade with resultant hypotensive and sedating effects has also been reported. This is a case report of a 70-year-old gentleman with traumatic brain injury and cardiovascular disease. Thioridazine was used to control severe behavioural problems but had to be discontinued secondary to marked hypotension. This case illustrates the need for awareness of the significant alpha-1 receptor interaction of some neuroleptics, especially in the elderly population with pre-existing heart disease.

Electrophysiologic analysis of snap amplitude in orthodromic and antidromic studies

In 1966, Buchthal and Rosenfalk established that the sensory nerve action potential (SNAP) amplitude increased with increasing number of nerve fibers. Lambert and Dyck's in vitro study of the sural nerve, however, found the SNAP amplitude of a single fascicle was equivalent to the SNAP amplitude of the entire nerve. The current study confirmed Buchthal and Rosenfalk's original findings, and discovered an in vivo equivalent to Lambert and Dyck's findings. Ten subjects were used as their own controls. Orthodromic stimulation of both the index and middle fingers stimulated individually versus simultaneously revealed a significant increase in amplitude (p < 0.001). When the recording and stimulating electrodes were reversed, without physically changing the electrodes on the subject, there was no significant difference between the antidromic SNAP amplitudes recorded from separate fingers, or from both fingers simultaneously. Although in both cases the number of recorded nerve fibers approximately doubled, the effect on the SNAP amplitude was very different. This seemingly paradoxical result can be explained by electrophysiologic differences in the recording methods, without using the concept of fiber density.

Fever of central origin in traumatic brain injury controlled with propranolol

Central fevers are known to develop in traumatic brain injury (TBI) and are believed to be caused by injury involving the hypothalamus. Described are three patients admitted with very severe TBI secondary to motor vehicle accidents. Initial Glasgow Coma Score ratings were 3 or 4. Head computed tomography (CT) scans showed intraventricular hemorrhage in two cases and no focal injury or bleeding in the third. All patients had decorticate posturing and symptoms of autonomic dysfunction, manifested by tachycardia and profuse sweating. Each of these patients developed high fevers ranging from 38.9 degrees C to 40.6 degrees C during their hospitalization course. Centrally mediated fevers were indicated after fever workups failed to show an infectious or inflammatory source. Propranolol 20 to 30 mg every 6 hours reduced the temperatures at least 1.5 degree C within 48 hours. In each case, when weaning from propranolol was attempted, an increase in temperature to greater than 38.0 degrees C reoccurred within 3 days. Repeat workups for infectious or inflammatory causes of fever were negative. The fevers were reduced after a reinstitution of propranolol. The propranolol was continued until all signs of autonomic dysfunction abated. Central fevers after TBI have been reported to have been treated successfully with propranolol in two children with decerebrate posturing. Pharmacological, neurophysiological, and anatomic studies provide evidence of a significant central nervous system role in the regulation of blood pressure and temperature.

Successful treatment of immobilization hypercalcemia using calcitonin and etidronate

Hypercalcemia of immobilization may present in patients with spinal cord injury, multiple fractures, or Landry-Guillain-Barre Syndrome. It is attributed to an increase in bone resorption and diminished bone formation characterized clinically by elevated serum calcium levels, hypercalciuria, increased risk of urinary lithiasis, and renal failure. Traditional treatment methods can interfere with the intensive level of therapy provided in the comprehensive rehabilitation program. Other treatments, less disruptive of the rehabilitation milieu, are possible. Reported are six patients with hypercalcemia of immobilization who were successfully treated with combination therapy of salmon calcitonin and sodium etidronate. The patients developed hypercalcemia an average of 69 days after the onset of illness. Serum calcium levels dropped an average of 2.8mg/dL (12.3mg/dL, SD 1.33 to 9.5mg/dL, SD 0.42) within eight days after initiation of treatment. In two patients, 24 hour urine excretions of calcium decreased by 414 and 210mg/day, respectively. All patients had a reduction in serum calcium levels noted within two days of treatment, and a normal serum calcium levels within one week. Patients were usually changed to a single medication maintenance regimen, sodium etidronate, within a few days. Full therapies in the treatment gyms were given to all patients within a day of initiation of the combined treatment. These two drugs appear to have a rapid and combined effect on the treatment of hypercalcemia of immobilization, and allow full participation in a comprehensive rehabilitation program.

Voiding dysfunction in patients with spastic paraplegia: urodynamic evaluation and response to continuous intrathecal baclofen

Patients with hereditary spastic paraplegia (HSP), a degenerative central nervous system disorder characterized by progressive lower extremity spasticity, frequently experience symptoms of voiding dysfunction. Urodynamic evaluation of patients with HSP has not been reported, and the etiology of voiding dysfunction remains unexplained. We present our evaluation of three men (ages 42-62 years) with this rare syndrome. Urgency of urination was a uniform and dominant complaint, and two patients regularly experienced urge incontinence. Other symptoms included frequency (n = 3), nocturia (n = 3), and diminished force of stream (n = 1). Postvoid residual volumes were less than 25 ml in all patients. On urodynamic evaluation the two patients with urge incontinence displayed cystometric evidence of involuntary detrusor contractions. Pelvic floor EMG recordings suggested detrusor-sphincter dyssynergia (DSD). In addition, one patient exhibited markedly diminished bladder compliance (1.0 ml/cm H2O) and capacity (50 ml). All patients reported marked symptomatic improvement when treated with continuous intrathecal baclofen. Evaluation during baclofen treatment revealed increases in bladder compliance and capacity, with apparent resolution of DSD in one patient. Voiding symptoms in these patients most likely arise from a neurogenic etiology; however, a contributory role for chronic outlet obstruction from striated muscle spasticity may also exist.

Continuous intrathecal baclofen in spinal cord spasticity. A prospective study

Continuous intrathecal infusion of the well known antispastic medication baclofen was evaluated in ten consecutive patients. One year after pump implantation the average Ashworth scale for muscle tone decreased, compared with before treatment, 2.32 points (P < 0.0001), reflexes decreased 2.22 points (P < 0.0001) and the spasm score decreased 1.65 points (P < 0.0001). The average dose increased from 92.22 to 290.95 micrograms (P < 0.0001) between the 1st month of treatment and 1 yr of treatment. The dosage for all patients more than doubled (P < 0.0022) between 3 months and 1 yr postimplantation. There was no significant difference for muscle tone, reflexes or spasms at 3 months v 1 yr. Complications were not unusual and included temporary atelectasis, orthostatic hypotension with escalation of baclofen dose, loss of penile erections, postsurgical pseudo-meningoceles, catheter disruptions and exhausted pump reservoirs. One patient suffered a seizure apparently related to a rapid withdrawal from intrathecal baclofen as a result of catheter sequestration. All patients required a period of intensive inpatient rehabilitation to benefit functionally from the decreased motor tone and/or increased voluntary motor control. The procedure is expensive and close follow-up is necessary for assessing efficacy and refilling the pump. Intrathecal baclofen infusion by subcutaneous pump is useful in treating the effects of spinal spasticity resistant to oral medications. However, there appears to be accommodation to intrathecal baclofen necessitating escalating doses to maintain clinical effects.

Effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary dysfunction due to spinal cord pathology

A prospective, blinded study was done to examine the effects of acute bolus and chronic continuous intrathecal baclofen on genitourinary function in 10 patients with severe spasticity due to spinal cord pathology. Genitourinary function was assessed by symptom questionnaires and urodynamic studies performed after a bolus dose of baclofen and 6 to 12 months after continuous intrathecal baclofen. Results were compared to placebo for acute bolus testing or to pre-continuous intrathecal baclofen values. In all patients with irritative voiding and urge incontinence uninhibited bladder contractions were eliminated. Of 3 patients with an indwelling urethral catheter for incontinence due to detrusor hyperreflexia 1 was converted to intermittent self-catheterization. Whereas bladder capacity, compliance, sensation and voiding pressures were not different after continuous intrathecal baclofen, when a mean of all patients was compiled, a 72% increase in capacity and 16% improvement in compliance were observed in subjects without cervical spinal cord pathology. Detrusor-sphincter dyssynergia was abolished in 40% of the patients. Continuous intrathecal baclofen may represent a novel approach to the management of patients with a neurogenic bladder who have decreased bladder compliance and detrusor hyperreflexia not controlled by oral medications.

Pregnancy, labor and delivery post spinal cord injury

There are approximately 3,000 women of childbearing age who become spinal cord injured each year in the United States. There are few reports in the literature that address pregnancy, labor and delivery in this patient population. We are reporting on 22 women post spinal cord injury who had 33 pregnancies. There were equal numbers of paraplegic and quadriplegic women. Three pregnancies aborted, one spontaneously. The babies were near normal or normal weight with one exception. The mothers waited 5 years on average to become pregnant. Cesarean section was performed on 43% of pregnancies. Abnormal presentations occurred in over 10% of pregnancies. Indications for cesarean section included 5 that were repeats; the remainder were necessary due to bleeding (1), breech presentation (1), transverse presentation (2), lack of progress (2), onset of labor 1 day post spinal fusion, and a mother's request to have tubal ligation. Epidural anesthesia was selected for 9 deliveries; 6 of these patients had controlled autonomic hyperreflexia. Five general and 4 local anesthetics were used, and 12 patients received no anesthesia. Diagnostic ultrasound and amniocentesis were used selectively. Complications included autonomic hyperreflexia (9), frequent urinary tract infections, infected pressure sores (3, 2 resulting in below-knee amputations), seizures during and after delivery, pneumonia, bladder stones (2), episiotomy dehiscence (1), and breakdown of spinal fusion. The newborns were healthy, although one double footing breech vaginal delivery had an APGAR of 1 at 1 min, 7 at 5 min and 9 at 10 min. One premature baby, who weighed only 1600 g, was a precipitate birth at home unattended. Implications for the care of pregnant SCI women are discussed.

Heterotopic ossification of the extensor tendons in the hand associated with traumatic spinal cord injury

Heterotopic ossification (HO) occurs in spinal cord injury (SCI), most frequently in the large joints such as hips, shoulders, knees, and elbows. It always occurs below the level of neurologic lesion. In the upper extremities, HO associated with SCI usually involves the flexor side of the involved joint. HO has only been reported once to involve the hands and rarely develops parallel to the long bones. We present a 44-year-old male with C5 traumatic SCI who developed HO involving the extensor tendons of one hand. The HO was discovered four months after the SCI and involved the extensor sheaths of the second, third, and fourth digits, from the metacarpal-phalangeal joint to the proximal inter-phalangeal joint. The patient had been improving neurologically with poor to fair extension of the right wrist allowing for tenodesis finger flexion, but with the onset of HO he lost some functional grasp. Diagnosis, possible etiology, and treatment (including options of radiation therapy and surgery) are discussed.

Intrathecal baclofen in hereditary spastic paraparesis

Intrathecal baclofen has not been previously evaluated for the treatment of the disabling hypertonia associated with hereditary spastic paraparesis. Muscle tone and deep-tendon reflexes were evaluated in three patients with hereditary spastic paraparesis after a double-blind, cross-over bolus injection of intrathecal baclofen. Patients underwent placement of a subcutaneous pump for continuous infusion of intrathecal baclofen. Three months after implantation the muscle tone decreased 2.04 points (p less than .0001) and the reflex score decreased 2.25 points (p less than .001). Patients initially reported subjective weakness, but muscle testing revealed either an increase or no change in voluntary motor function. Baclofen doses of 60 to 264 micrograms per day were required for effective control of muscle tone and spasticity. Much of the disability in familial spastic paraparesis may be related to the loss of suprasegmental inhibition of spinal reflexes overwhelming the residual voluntary motor function.

Functional improvement in severe head injury after readmission for rehabilitation

Early rehabilitation has been shown to minimize complications and optimize functional outcomes in head-injured patients. Although cognitive, behavioural and vocational issues continue for years after injury, many investigations maintain that physical improvement is limited after 6 months. At 12 months after injury, expectations for physical improvement are generally limited. In addition, although repeated inpatient admissions for rehabilitation are common, gains in self-care and mobility skills during readmissions for rehabilitation have not been specifically investigated. In this retrospective study the records of 49 severely head-injured patients were evaluated. All were readmitted to an inpatient rehabilitation facility more than 12 months after injury. Barthel Index scores were obtained to evaluate physical function. Although previous studies would predict few improvements, in this study 53% (26 patients) showed improvement, and the difference between readmission and discharge Barthel scores was statistically significant (p = 0.0001). Gains were highly correlated with length of readmission, but not with age of patient, age at time of injury, length of coma, time since injury, or duration of previous rehabilitation. Patients with mid-range admission Barthel scores (21-85) demonstrated the largest gains, with 79% showing improvement. Gains averaged 11.2 points on the Barthel Index. Severely head-injured patients may show clinically significant improvement in physical function well after current standards predict a plateau.

Interdisciplinary management of hemicorporectomy after spinal cord injury

Hemicorporectomy (HCP) is infrequently used, but its effects can devastate the patient's body image, autonomic function, and physical abilities even more than a spinal cord injury of comparable level. Interdisciplinary management is of the utmost importance. This report describes the 2 year course, including four separate rehabilitation admissions, of a patient who was initially paraplegic, and then underwent a HCP for complications secondary to a cauda equina ependymoma. The patient's expectations for functional independence were established by his successful initial spinal cord rehabilitation. The HCP was performed 6 months after initial discharge secondary to infected Harrington rods and rapid spread of the tumor. Extensive use of the interdisciplinary team approach allowed comprehensive analysis and treatment of the patient's comfort, mobility, skin tolerance, and upper extremity functional abilities. Four successive prostheses were developed and modified, until all concerns were successfully addressed. The patient ultimately became completely independent at the wheelchair level. The evaluations, treatment plan, and emphasis of each discipline, including physical therapy, occupational therapy, rehabilitation nursing, therapeutic recreation, social work, vocational rehabilitation, and physiatry are summarized. Differences between the patient's course and standard spinal cord rehabilitation are detailed.

Prosthetic management of hemicorporectomy patients: new approaches

Functional outcome with hemicorporectomy prosthetic management has improved little in the last 20 years. Patient expectations for independence, comfort, and cosmesis have been disappointed with traditional bucket designs. This report describes the prosthetic management of a paraplegic patient who underwent hemicorporectomy at T12 secondary to complications from a lumbar ependymoma. Four successive prostheses were developed using foam and resin combinations, computer-assisted pressure monitoring, and interdisciplinary team feedback regarding design and fabrication. A total-contact bucket with removable liner was created, allowing management of the ileal diversion and colostomy. Prosthetic legs were attached to improve wheelchair balance and cosmesis. In his final prosthesis, the patient's function and appearance was equivalent to a well-rehabilitated midthoracic spinal cord trauma patient. Sitting tolerance exceeded 12 hours a day. Each prototype is discussed, including design, materials, fabrication process, patient acceptance and functional independence, and complications.

Spinal cord seizures: a possible cause of isolated myoclonic activity in traumatic spinal cord injury: case report

Spinal cord seizures are infrequently reported. They have been associated with intravenous dye placement, transverse myelitis and multiple sclerosis, but never with traumatic spinal cord injury (SCI). We report the case of a 48-year-old SCI male with complete C6 quadriplegia, and apparent spinal cord seizures. These seizures were characterised by myoclonus simplex activity involving the upper extremities only. The lower extremities were spared. The patient was conscious throughout the myoclonic activity and an electroencephalogram of the brain obtained during an event revealed no cortical epiliptiform activity. The seizures lasted approximately 30 seconds to a few minutes, and an acute increase in blood pressure and a decrease in pulse generally occurred 30 to 60 seconds prior to the event. Previously reported spinal cord seizures in multiple sclerosis were frequently treated with carbamazepine. In this case successful treatment was with diazepam. Spinal cord seizures may present in those with traumatic SCI. Benzodiazepines may be useful in the treatment of spinal cord seizures.

Inpatient comprehensive rehabilitation after liver transplantation

Liver transplantation has become a standard treatment for liver failure and is covered by Medicare. Transplantation has up to an 80% survival rate; however, the postoperative course can include many complications, a long hospital admission and the need for the involvement of many medical and therapeutic disciplines. Ideally, this is provided by a coordinated comprehensive rehabilitation program, but descriptions of this type of management are absent from the literature. This report describes the case of a 54-yr-old male with alcoholic cirrhosis who underwent orthotopic liver transplantation. His postoperative course was complicated, and he developed global weakness secondary to hepatic neuropathy with superimposed type II steroid-induced myopathy. Four months after the transplant he was unable to sit up in bed and was admitted to the rehabilitation unit. The patient required two subsequent admissions to the acute hospital for complications; however, close cooperation between the surgical transplant team and the rehabilitation team facilitated functional improvement and enabled discharge to home in less than 8 wk. At discharge, the patient was independent in bed mobility, transfers and self-care, and he was ambulating with contact guard. Medical issues, including evaluation, medications and possible complications in the rehabilitative phase are discussed.

Pregnancy following spinal cord injury

Each year about 2,000 women of childbearing age in the United States have a spinal cord injury. Only a few mostly anecdotal reports describe pregnancy after such an injury. In a retrospective study of 16 women with a spinal cord injury, half of whom have a complete injury and about half quadriplegia, 25 pregnancies occurred, with 21 carried to full term. The women delayed pregnancy an average of 6.5 years after their injury, with an average age at first pregnancy of 26.8 years. Cesarean section was necessary in 4 patients because of inadequate progress of labor. In 5 deliveries an episiotomy and local anesthesia were required, 7 required epidural anesthesia, including all cesarean sections, and 10 did not require anesthesia. Several complications have been identified in the antepartum, intrapartum, and postpartum periods including autonomic hyperreflexia, premature labor, pressure sores, urinary tract infections, abnormal presentation, and failure to progress. Ultrasonography and amniocentesis were used selectively. Women with spinal cord injuries can have healthy children, although there are significant risks and these women have special needs.

Rehabilitation of quadriparesis secondary to spinal cord sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder that rarely involves the spinal cord. This report describes the presentation and rehabilitative course of a 31-yr-old man with quadriparesis secondary to spinal cord sarcoidosis. The patient had insidious, progressive weakness in his arms and legs for six weeks before evaluation. Examination revealed a C4 incomplete spinal cord injury. Computed tomography demonstrated an intrinsic cord lesion from the brainstem to approximately T8. Magnetic resonance imaging (MRI) suggested the lesion was granulomatous and cervical laminectomy confirmed noncaseating granulomas. The patient was started on high dose steroids, subsequently gained strength in the distal upper extremities, and was sent for spinal cord rehabilitation. Examination revealed 3 to 4+/5 strength in the upper extremities, 2- to 3-/5 in the lower extremities. The right side was slightly stronger than the left, with proximal musculature stronger than distal. Sensory examination was intact except in the C-8 to T-2 dermatomes. The patient was dependent in self-care and mobility except for feeding. Initial progress was inhibited by severe spasticity requiring medication, but by discharge he was independent at the wheelchair level with 4/5 strength in all four extremities except for his hands, which had 3/5 strength. Sensory exam did not change. Follow-up MRI studies revealed reduction of the lesion. Review of previous cases revealed that myelopathy is the most common presenting complaint and cervical segments are most commonly involved. Survival averaged almost three years and significant gains were made in functional status. Rehabilitative course and special considerations, treatment and follow-up recommendations are discussed.

Cost-effective screening by nursing staff for urinary tract infection in the spinal cord injured patient

Screening tests for urinary tract infections (UTI) are used in the clinical laboratory setting. This study evaluated the efficacy of screening by nursing staff on the inpatient unit, instead of the clinical laboratory, in the spinal cord-injured population. Fifty-three consecutive traumatically spinal cord-injured patients had weekly urine collection, except when infected or on antibiotics. Each urine sample was tested by a nitrite and leukocyte esterase (LE) dipstick (Chemstrip LN by Bio-Dynamics) and by routine clinical laboratory culture. A total of 169 tests were completed. The correlation coefficients of the LE and the nitrite tests with the culture were 0.604 (P less than 0.001) and 0.663 (P less than 0.001), respectively. The correlation of the combined tests was 0.837 (P less than 0.001). The sensitivity, specificity and positive and negative predictive values of nitrite-LE testing by nursing staff were calculated and compared favorably with published performances of clinical laboratory staff. When measured against the culture, the combined nitrite and LE test had a sensitivity of 79%, specificity of 99% and positive and negative predictive values of 96% and 95%, respectively. The use of a protocol where laboratory culture is performed only when the dipstick test is positive, would reduce the number of cultures by 83%. After extra costs of the additional screen are added, the use of dipstick screening methods by nursing staff can reduce the cost of weekly urine screening by 73%, with a false negative rate of only 4.4%. The expense and complexity of screening for UTI is reduced, response time is minimized and laboratory cultures will have a higher probability of useful clinical information.

Traumatic spinal cord injury complicated by AIDS related complex

It is estimated that one to two million people in the US have antibodies to the human T-lymphotropic virus Type III/lymphadenopathy-associated virus (HTLV-III/LAV) and are consequently at risk for developing acquired immunodeficiency syndrome (AIDS). As the number of carriers of this infection increases, so does the expected incidence of this population for acquiring disabilities that require rehabilitative services. We report a traumatic spinal cord injured patient with resultant quadriplegia who has HTLV-III/LAV infection. Presented are the difficulties in classifying the manifestations of the HTLV-III/LAV infection in such a patient. Many of the symptoms of AIDS may be attributed to complications of recently acquired quadriplegia. This is added to the psychologic and social strains on a patient who has already lost permanent function due to quadriplegia. Implementation of educational programs to meet staff, family, and patient needs regarding their concerns and questions significantly reduced anxiety on the rehabilitation unit. Because the possible life expectancy can still be quite long, AIDS patients warrant rehabilitation programs. This necessitates that health care professionals in rehabilitation become familiar with AIDS, as they are likely to be involved in the care of patients with AIDS in the future.

Serratus anterior disruption: a complication of rheumatoid arthritis

Pathology influencing the serratus anterior muscle contributes to classical medial winging of the scapula. Serratus anterior weakness or injury interferes with regular shoulder movement as this muscle stabilizes the medial border of the scapula against the thorax and rotates the scapula upward and laterally with arm elevation. Traumatic injury to the serratus anterior muscle without electrodiagnostic evidence of neurogenic involvement has only been reported once previously. We report an unusual case of disruption of the serratus anterior as a complication of rheumatoid arthritis. Involvement of the long thoracic nerve was ruled out by electromyography and nerve conduction studies. The injury occurred during routine activities of daily living and was complicated by a recurring subscapular hematoma. Contributing factors of shoulder joint contractures and coagulation abnormalities were associated with the course and treatment of rheumatoid arthritis. Initial treatment was by joint immobilization and reversal of coagulation abnormalities. Later treatment was directed toward joint protection and gradually increasing range of motion exercises.

Immobilization hypercalcemia associated with Landry-Guillain-Barré syndrome. Successful therapy with combined calcitonin and etidronate

Two patients with immobilization hypercalcemia associated with Landry-Guillain-Barré syndrome had marked hypercalciuria (890 and 1136 mg/d [22.2 and 28.3 mmol/d]) and radiologic evidence of generalized osteopenia. Parathyroid hormone levels were either low or normal by C-terminal radioimmunoassay. Subtotal parathyroidectomy was performed in the one patient, with no improvement in serum or urinary calcium levels. A bone biopsy specimen revealed decreased cellular activity in the first patient and increased bone resorption in the second patient. Treatment with intravenous saline, furosemide, oral phosphate supplementation, mithramycin, and calcitonin alone was ineffective in lowering serum or urinary calcium levels. However, when subcutaneous calcitonin combined with oral etidronate disodium was used, a reduction in the serum calcium level was observed within two days of therapy. Within one week of the start of this combined therapy, the calcium level returned to normal and urinary calcium excretion was substantially reduced.