Potential risk factors for developing heterotopic ossification in patients with severe traumatic brain injury.

BACKGROUND: Heterotopic ossification (HO) is a frequent complication after traumatic brain injury (TBI). The current preliminary study is intended to provide additional data on the potential roles that brain injury severity, concomitant orthopaedic trauma, and specific intensive care complicating events may play in the prediction of HO in patients who have sustained severe TBI. METHODS: A prospective cohort study in patients with severe TBI. RESULTS: Ninety-seven of the 176 patients were eligible for follow-up; 13 patients (13%) developed 19 clinically relevant HOs at 1 or more sites. Univariate analysis indicated that patients with HO remained in coma longer (P < .001) and were ventilated during a longer period (P = .002). Autonomic dysregulation (relative risk = 6.11, 95% confidence interval: 2.53-14.76) and surgically treated extremity fractures (relative risk = 5.02, 95% confidence interval: 1.68-15.04) also showed significant associations with the development of HO. CONCLUSION: Prolonged coma duration and mechanical ventilation, coexistent surgically treated bone fractures and clinical signs of autonomic dysregulation should be given further consideration as potential risk factors for developing clinically relevant HO. Larger-scale studies are needed to develop a valid risk profile that takes into account the interrelationships between variables.

Speech pathology interventions in patients with neuromuscular diseases: a systematic review.

PURPOSE: A systematic review was conducted to summarize and evaluate the literature on the effectiveness of speech pathology interventions in adults with neuromuscular diseases. METHOD: Databases searched included the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, PsycINFO and PubMed. A total of 1,772 articles were independently screened on title and abstract by 2 reviewers. RESULTS: No randomized controlled trials or clinical controlled trials were found. Four other designs were included. Only one study on oculopharyngeal muscle dystrophy (OPMD) appeared to have sufficient methodological quality. There is evidence indicating that correction of head position in patients with OPMD improves swallowing efficiency (level III evidence). CONCLUSION: Despite 1,772 studies, there is only evidence of level III regarding the effectiveness of speech pathology interventions in patients with OPMD. Recommendations for future research are given.

Dysautonomia after severe traumatic brain injury.

BACKGROUND: Dysautonomia after traumatic brain injury (TBI) is characterized by episodes of increased heart rate, respiratory rate, temperature, blood pressure, muscle tone, decorticate or decerebrate posturing, and profuse sweating. This study addresses the incidence of dysautonomia after severe TBI, the clinical variables that are associated with dysautonomia, and the functional outcome of patients with dysautonomia. METHODS: A historic cohort study in patients with severe TBI [Glasgow Coma Scale (GCS) < or = 8 on admission]. RESULTS: Seventy-six of 119 patients survived and were eligible for follow-up. The incidence of dysautonomia was 11.8%. Episodes of dysautonomia were prevalent during a mean period of 20.1 days (range 3-68) and were often initiated by discomfort. Patients with dysautonomia showed significant longer periods of coma (24.78 vs. 7.99 days) and mechanical ventilation (22.67 vs. 7.21 days). Dysautonomia was associated with diffuse axonal injury (DAI) [relative risk (RR) 20.83, CI 4.92-83.33] and the development of spasticity (RR 16.94, CI 3.96-71.42). Patients with dysautonomia experienced more secondary complications. They tended to have poorer outcome. CONCLUSIONS: Dysautonomia occurs in approximately 10% of patients surviving severe TBI and is associated with DAI and the development of spasticity at follow-up. The initiation of dysautonomia by discomfort supports the Excitatory: Inhibitory Ratio model as pathophysiological mechanism.

Optimizing referral of patients with neuromuscular disorders to allied health care.

BACKGROUND AND PURPOSE: To report the predictive validity of the perceived limitations in activities and need questionnaire (PLAN-Q), a screening instrument to support neurologists to select patients with neuromuscular disorders (NMD) for referral for a one-off consultation by occupational therapist (OT), physical therapist (PT) and speech therapist (ST). METHODS: In a cross-sectional validation study, 102 patients with various NMD participated. Patients received a one-off consultation by an expert OT, PT and ST and filled out the PLAN-Q. Therapists rated the appropriateness of the one-off consultations based on need, available treatment and patient's motivation. Receiver Operation Characteristic analysis and multivariate logistic regression analysis were used to obtain a PLAN-Q based prediction model for the appropriateness of the one-off consultations. RESULTS: Probability for a one-off OT consultation increased from 64% to 78% (95% CI: 69-85%). Prior test probability for a one-off ST consultation increased from 44% to 61% (95% CI: 48-73%). Prior test probability for one-off PT consultation could not be increased. CONCLUSION: Screening patients with NMD using the PLAN-Q may assist neurologists in selecting the appropriate patients for a one-off consultation by OT and ST. Unlike our expectations the screening did not guide referral for a one-off consultation by PT.

Functional electrical stimulation by means of the 'Ness Handmaster Orthosis' in chronic stroke patients: an exploratory study.

OBJECTIVE: To gain experience with 'Ness Handmaster Orthosis' treatment in chronic stroke patients, to identify suitable patients, and to study the effects of treatment. DESIGN: Exploratory, uncontrolled trial with measurement of motor functions and muscle tone of the upper extremity prior to, during, upon completion, and six weeks after a treatment period. SETTING: A rehabilitation centre in the Netherlands. SUBJECTS: Eighteen chronic stroke patients (more than six months post stroke), who exhibited upper extremity dysfunction due to spastic paresis. INTERVENTION: A 10-week therapy programme of functional electrical stimulation by means of the 'Ness Handmaster Orthosis'. RESULTS: The results of 15 patients were available for analysis. The differences in motor score and muscle tone before and at the end of treatment were statistically significant (p = 0.008 and 0.021, respectively). The follow-up measurements showed that the effects on motor functions and muscle tone decreased after therapy completion. Stratification of the patients in two subgroups indicated that patients with initial high motor scores benefited most during the intervention period. CONCLUSION: The present study suggests that Handmaster treatment possesses therapeutic opportunities in chronic stroke patients with spastic paresis of the upper extremity.

Prediction of recovery from upper extremity paralysis after stroke by measuring evoked potentials.

Paralysis of the upper extremity is a severe motor impairment that can occur after stroke. Prediction of recovery from paralysis is difficult and is primarily based on subjective clinical evaluation. However, the integrity of the sensorimotor system can be assessed objectively and quantitatively by measuring evoked potentials. In this retrospective exploratory study, we evaluated the predictive value of motor and somatosensory evoked potentials for recovery from paralysis of the upper extremity. Motor and somatosensory evoked potentials were recorded in 29 patients who had had their first-ever infarction in the territory of the middle cerebral artery and who exhibited paralysis of the upper extremity. At follow-up, seven patients showed motor recovery. The evoked potential data were dichotomized into present or absent and related to the occurrence of motor recovery. Analysis revealed a significant association between the presence of evoked potentials early after stroke and the observed occurrence of motor recovery. These results suggest strongly that evoked potentials predict the occurrence of motor recovery of upper extremity paralysis in patients suffering from first-ever infarction in the territory of the middle cerebral artery.

Cerebral amyloid angiopathy: diagnosis by MRI and brain biopsy.

We report the case of an intellectually deteriorating 66-year-old man who presented with an epileptic seizure. CT of the brain suggested a low-grade astrocytoma, but MRI showed multiple punctate hemorrhagic lesions and a demyelination of vascular origin. Brain biopsy revealed depositions of amyloid in cortical and meningeal arteries. MRI may be of value in diagnosing cerebral amyloid angiopathy associated with leukoencephalopathy and petechial hemorrhages.