Utilization of rehabilitation services in violent versus nonviolent traumatic spinal cord injury.

BACKGROUND: Violence is the third leading cause of spinal cord injury (SCI) in the United States, and people with violence-related SCI have worse long-term outcomes compared to other traumatic SCI etiologies. Little is known, however, about the underlying reasons for these differences. Access to and utilization of rehabilitation services may differ in this population, but their outpatient care has not been previously investigated. OBJECTIVE: To evaluate differences in utilization patterns of outpatient rehabilitation services between people with violence-related SCI and other traumatic SCI etiologies. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care hospital system. PATIENTS: A total of 41 patients with violence-related SCI residing in King County at the time of injury who completed inpatient rehabilitation (IPR) in our institution were identified from the hospital trauma registry and matched with 41 control patients with nonviolent traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): The number of appointments attended, canceled, and missed during the first year after discharge from IPR were obtained by chart review for physical medicine & rehabilitation (PM&R) physicians and therapy services. RESULTS: People with violence-related SCI had decreased follow-up with outpatient rehabilitation services after IPR discharge compared to non-violent traumatic SCI, including PM&R (2.50 ± 2.44 vs. 3.76 ± 2.21 visits, ß = -1.28, p = .017), physical therapy (8.91 ± 11.02 vs. 17.57 ± 15.26, ß = -9.79, p = .009), occupational therapy (4.28 ± 7.90 vs. 10.04 ± 14.42, ß = -6.18, p = .033), and recreational therapy (0.293 ± 0.955 vs. 1.37 ± 2.86, ß = -1.07, p = .035). The rate of missed appointments was also higher among people with violence-related SCI compared to controls for PM&R (25.2% ± 28.5% vs. 9.9% ± 16.5%, ß = 14.6%, p = .014) and physical therapy (26.0% ± 32.0% vs 4.2% ± 13.2%, ß = 22.1%, p = .009). CONCLUSIONS: Individuals with violence-related SCI had fewer follow-up appointments with PM&R physicians and other allied health professionals and were more likely to miss scheduled appointments compared to other traumatic SCI etiologies. Decreased outpatient follow-up may affect long-term outcomes for people with violence-related SCI.

Stroke and breathing.

Stroke remains a leading cause of neurologic disability with wide ranging effects, including a variety of respiratory abnormalities. Stroke may influence the central control of the respiratory drive and breathing pattern, airway protection and maintenance, and the respiratory mechanics of inspiration and expiration. In the acute phase of stroke, the central control of breathing is affected by changes in consciousness, cerebral edema, and direct damage to brainstem respiratory centers, resulting in abnormalities in respiratory pattern and loss of airway protection. Common acute complications related to respiratory dysfunction include dysphagia, aspiration, and pneumonia. Respiratory control centers are located in the brainstem, and brainstem stroke causes specific patterns of respiratory dysfunction. Depending on the exact location and extent of stroke, respiratory failure may occur. While major respiratory abnormalities often improve over time, sleep-disordered breathing remains common in the subacute and chronic phases and worsens outcomes. Respiratory mechanics are impaired in hemiplegic or hemiparetic stroke, contributing to worse cardiopulmonary health in stroke survivors. Interventions to address the respiratory complications are under researched, and further investigation in this area is critical to improving outcomes among stroke survivors.

Novel and modifiable factors associated with adherence to continuous positive airway pressure therapy initiated during stroke rehabilitation: An exploratory analysis of a prospective cohort study.

OBJECTIVE/BACKGROUND: Continuous positive airway pressure (CPAP) for the treatment of sleep apnea may improve stroke recovery but is limited by poor adherence. We evaluated baseline features and psychosocial factors associated with CPAP adherence among stroke patients enrolled in a pilot study of an intensive CPAP adherence protocol initiated during inpatient rehabilitation. PATIENTS/METHODS: In a retrospective analysis of a prospective cohort study, we compared participants adherent to CPAP (≥4 h for ≥70% of nights over 3 months) to non-adherent participants. Using mixed methods, we quantitatively compared baseline demographic and stroke-related factors associated with adherence and qualitatively compared facilitators and barriers to adherence. RESULTS: There were 32 adherent and 20 non-adherent participants. Quantitative analysis revealed more severe stroke, aphasia and white race were associated with adherence. Adherent compared to non-adherent participants also had fewer early CPAP complaints, especially claustrophobia. In a thematic qualitative analysis, facilitators of adherence included improvement in sleep and stroke symptoms, confidence in CPAP use, and positive treatment expectations. Conversely, barriers to adherence included both potentially modifiable factors (lack of confidence in CPAP use, discomfort with a new health technology, and common CPAP-related complaints), and less modifiable factors (social stressors, sleep disturbance, and lack of home social support). DISCUSSION: Adherence programs for CPAP use after stroke should address modifiable barriers, with early desensitization to improve CPAP-related complaints and claustrophobia, and training to address perceived self-efficacy with CPAP. Future studies should explore individual goals and barriers associated with CPAP use among stroke survivors to improve long-term CPAP adherence. CLINICAL TRIAL REGISTRATION NUMBER: NCT02809430.

Trends and Disparities in Inpatient Rehabilitation of Adolescents: The Effect of Demographics, Injury Characteristics, and Facility Type.

BACKGROUND: Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI). OBJECTIVES: To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types. METHODS: Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software. RESULTS: SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ. CONCLUSION: Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Relationship between individual neuron and network spontaneous activity in developing mouse cortex.

Spontaneous synchronous activity (SSA) that propagates as electrical waves is found in numerous central nervous system structures and is critical for normal development, but the mechanisms of generation of such activity are not clear. In previous work, we showed that the ventrolateral piriform cortex is uniquely able to initiate SSA in contrast to the dorsal neocortex, which participates in, but does not initiate, SSA (Lischalk JW, Easton CR, Moody WJ. Dev Neurobiol 69: 407-414, 2009). In this study, we used Ca(2+) imaging of cultured embryonic day 18 to postnatal day 2 coronal slices (embryonic day 17 + 1-4 days in culture) of the mouse cortex to investigate the different activity patterns of individual neurons in these regions. In the piriform cortex where SSA is initiated, a higher proportion of neurons was active asynchronously between waves, and a larger number of groups of coactive cells was present compared with the dorsal cortex. When we applied GABA and glutamate synaptic antagonists, asynchronous activity and cellular clusters remained, while synchronous activity was eliminated, indicating that asynchronous activity is a result of cell-intrinsic properties that differ between these regions. To test the hypothesis that higher levels of cell-autonomous activity in the piriform cortex underlie its ability to initiate waves, we constructed a conductance-based network model in which three layers differed only in the proportion of neurons able to intrinsically generate bursting behavior. Simulations using this model demonstrated that a gradient of intrinsic excitability was sufficient to produce directionally propagating waves that replicated key experimental features, indicating that the higher level of cell-intrinsic activity in the piriform cortex may provide a substrate for SSA generation.