Influence of paroxysmal sympathetic hyperactivity (PSH) on the functional outcome of neurological early rehabilitation patients: a case control study.

BACKGROUND: Paroxysmal Sympathetic Hyperactivity (PSH) is a frequently observed condition among critically ill patients on intensive care units. According to different studies, PSH is associated with worse recovery and increased mortality in acute-care facilities. In this monocentric, retrospective case-control study, we investigated whether this association also applies to post-acute neurological early rehabilitation. METHODS: The study included n = 387 patients, admitted to an intensive care or intermediate care unit within 1 year (2016). Among these, 97 patients showed clinical signs of PSH. For each patient with PSH, a patient without PSH was identified, controlling for age, gender, functional and respiratory status upon admission. However, for 25 patients with PSH, there was no suitable control patient fulfilling all defined matching criteria. Primary outcome was type of discharge, dichotomized into favorable (follow-up rehabilitation) and unfavorable outcome (all others). Secondary outcome measures were functional and respiratory status, number of secondary diagnoses, duration of treatment interruptions and length of stay at discharge. RESULTS: About 25% of neurological early rehabilitation patients showed clinical signs of PSH. A young age (OR = 0.94; CI = 0.91-0.97) and less severe PSH symptoms (OR = 0.79; CI = 0.69-0.90) were independent predictors of a favorable outcome. In addition, severity of PSH symptoms was associated with weaning duration, while the occurrence of PSH symptoms alone had no influence on most secondary outcome variables. The treatment on intermediate care units proved to be longer for patients with PSH symptoms, only. CONCLUSIONS: Patients with PSH represent a large group of neurological early rehabilitation patients. Overall, we did not find PSH-related differences in most of the examined outcome measures. However, severe PSH symptoms seem to be associated with poorer outcome and longer treatment on intermediate care units, in order to prevent possible complications.

Impact of paroxysmal sympathetic hyperactivity on nutrition management after brain injury: a case series.

OBJECTIVE: To review the nutritional requirements of all new inpatient brain injury admissions presenting with Paroxysmal Sympathetic Hyperactivity (PSH) in the rehabilitation setting. METHODS: RABIU is a 25-bed Regional facility in Northern Ireland which opened in 2006. All records of patients with a single episode non-progressive acquired brain injury admitted to RABIU from 2006 until the present were reviewed for evidence of PSH. Dietetic assessment and management was examined and recorded. RESULTS: Four patients with persisting paroxysmal sympathetic hyperactivity were identified. All patients displayed dystonia and posturing and had clinically important percentage weight loss. All had nutrition and/or hydration requirements markedly above their estimated requirement for slow weight gain, despite adjustment for brain injury. All four had posture-related complications of their dystonia and nutrition. CONCLUSION: Careful monitoring of nutrition, hydration and mineral supplementation is paramount in patients presenting with paroxysmal sympathetic hyperactivity after brain injury. It is argued that morbidity may be reduced by aggressive and expert nutrition management.

Paroxysmal sympathetic hyperactivity during neurorehabilitation for severe acquired brain injury: current Scandinavian practice and Delphi consensus recommendations.

OBJECTIVES: To document current practice and develop consensus recommendations for the assessment and treatment of paroxysmal sympathetic hyperactivity (PSH) during rehabilitation after severe acquired brain injury. DESIGN: Delphi consensus process with three rounds, based on the Guidance on Conducting and REporting DElphi Studies (CREDES) guidelines, led by three convenors (the authors) with an expert panel. Round 1 was exploratory, with consensus defined before round 2 as agreement of at least 75% of the panel. SETTING: A working group within the Nordic Network for Neurorehabilitation. PANEL PARTICIPANTS: Twenty specialist physicians, from Sweden (9 participants), Norway (7) and Denmark (4), all working clinically with patients with severe acquired brain injury and with current involvement in clinical decisions regarding PSH. RESULTS: Consensus was reached for 21 statements on terminology, assessment and principles for pharmacological and non-pharmacological treatment, including some guidance on specific drugs. From these, an algorithm to support clinical decisions at all stages of inpatient rehabilitation was created. CONCLUSIONS: Considerable consensus exists in the Nordic countries regarding principles for PSH assessment and treatment. An interdisciplinary approach is needed. Improved documentation and collation of data on treatment given during routine clinical practice are needed as a basis for improving care until sufficiently robust research exists to guide treatment choices.

[The role of phototherapy in the rehabilitation of newborn babies and infants].

This review is devoted to the problems pertaining to the rational application of phototherapy in the rehabilitation of newborn babies and infants. The analysis of the classical and present-day literature sources provided materials for the development of the rationale for the use of colour-puncture therapy. The data included in this review indicate that phototherapy has positive effect on the immune and rehabilitative processes in the newborns following surgical interventions and in the breast-fed infants suffering hypoxic ischemic encephalopathy. Phototherapy is equally beneficial when the newborn babies need to be treated for cutaneous and nervous disorders or undergo a surgical operation. Moreover, it can be applied to manage endocrine disorders and diseases of the vegetative nervous system. The photo-induced changes in the skin influence the concentration of biologically active compounds in the systemic circulation. It is believed that colour-puncture therapy makes it possible to selectively affect biologically active points in the channel-meridian system of the newborn babies and infants.

Effects of long-term exercise training on cardiac baroreflex sensitivity in patients with coronary artery disease: a randomized controlled trial.

OBJECTIVE: To investigate whether a structured long-term exercise training programme in patients with coronary artery disease affects baroreflex function and cardiorespiratory efficiency. PATIENTS: Twenty-five elderly male patients with coronary artery disease. METHODS: The patients were randomized into exercise (group A) or control group (group B). Group A followed a seven-month supervised exercise programme, consisting of three sessions of aerobic interval training weekly at moderate intensity. Twenty patients completed the study (group A: 10 patients and group B: 10 patients). At the beginning and end of the study, all subjects underwent a tilt test for the baroreflex sensitivity assessment and a graded exercise treadmill test with spiroergometry for the evaluation of their cardiorespiratory efficiency. RESULTS: There were no differences between the two groups for any baseline variable. After training in group A, peak oxygen consumption, maximal treadmill tolerance time and anaerobic threshold were significantly increased by 21.9% (P < 0.001), 19.8% (P < 0.001) and 18.6% (P < 0.05), respectively. There were also significant increases in baroreflex sensitivity by 21.2% (P < 0.01), in baroreflex effectiveness index by 23.9% (P < 0.01), in event count by 45.1% (P < 0.01) and in ramp count by 13.2% (P < 0.05). Moreover, significant correlations were observed between the autonomic and cardiorespiratory parameters in group A at the end. CONCLUSION: The results suggest that long-term exercise training leads to beneficial effects on baroreflex activity and cardiorespiratory performance in coronary patients, and thus could constitute an efficient nonpharmacological intervention in this population.

Lowered cardiac sympathetic nerve performance in response to exercise in Parkinson's disease.

We examined whether cardiac sympathetic denervation influences the cardiovascular response to exercise in Parkinson's disease (PD). Sixteen patients with PD were divided into two groups, according to their cardiac uptake of (123)I-metaiodobenzylguanidine (denervated group, 10 patients with heart to mediastinum (H/M) ratio < 1.7; innervated group, six patients with H/M ratio > 1.7) and compared changes in blood pressure (BP), heart rate (HR), and cardiac contractility with 13 control subjects during ergometric exercise stress. Velocity index (VI), an indicator of cardiac contractility, was measured using impedance cardiography and recorded every minute. Exercise began at a power output of 20 W for the first 2 min and increased 10 W every 2 min to a maximal intensity of 60 W. All control subjects accomplished the procedure while six patients with PD could not continue after the first minute of 50 W loading. There were no significant differences in BP or HR change between the three groups. However, a significant reduction in VI was observed from the first minute of the 30 W workload in the denervated group compared to the control group. This lowered response continued till 50 W loading and was significantly different to the innervated group at 50 W loading. No significant VI changes were observed between the control and innervated groups throughout the exercise test. Patients with PD with reduced MIBG uptake had a lowered cardiac contractility than innervated subjects during exercise, suggesting that this response represents the impaired exercise capacity of patients with PD with cardiac sympathetic denervation.

[New lines of activity of health centres in the Russian Federation].

The first data illustrating work efficiency of health centres in this country are presented. They suggest the necessity to change both the strategy of activities and the patient population. Studies on variability of cardiac rhythms and characteristics of vegetative status in adolescents showed that the equipment used is poorly adapted to the purpose.

Effects of effortful swallowing on cardiac autonomic control in individuals with neurogenic dysphagia: a prospective observational analytical study.

Considering that neurogenic oropharyngeal dysphagia is a prevalent condition with or without cardiac disease we should contemplate issues surrounding cardiovascular difficulties during rehabilitation. This study aims to evaluate the effects of effortful swallowing maneuver (ESM) on heart rate variability (HRV) in subjects with neurogenic oropharyngeal dysphagia. We studied 22 individuals [8 Stroke and 14 Parkinson Disease (PD) subjects aged between 41 and 75 years old] with neurogenic oropharyngeal dysphagia regardless of gender. HRV was assessed under two circumstances: spontaneous swallowing versus ESM. Surface electromyography of the suprahyoid muscles was undertaken to measure the swallowing muscle excitation, which then confirmed higher muscle activity during ESM. We attained no changes in HRV between the two swallowing events [HR: spontaneous swallowing 78.68 ± 13.91 bpm vs. ESM 102.57 ± 107.81 bpm, p = 0.201; RMSSD (root-mean square of differences between adjacent normal RR intervals in a time interval): spontaneous swallowing 16.99 ± 15.65 ms vs. ESM 44.74 ± 138.85 ms, p = 0.312; HF (high frequency): spontaneous swallowing 119.35 ± 273 ms2 vs. ESM 99.83 ± 194.58 ms2, p = 0.301; SD1 (standard deviation of the instantaneous variability of the beat-to-beat heart rate): spontaneous swallowing 12.02 ± 1.07 ms vs. ESM 31.66 ± 98.25 ms, p = 0.301]. The effortful swallowing maneuver did not cause clinically significant changes in autonomic control of HR in this group of subjects with oropharyngeal dysphagia.

Paroxysmal Sympathetic Hyperactivity and Clinical Considerations for Patients With Acquired Brain Injuries: A Narrative Review.

The term "storming" has often been used colloquially to characterize patients with brain injury who showed signs and symptoms of elevated heart rate, blood pressure, respiratory rate, temperature, and motor posturing. Recently, the term paroxysmal sympathetic hyperactivity has been used as the unifying term to describe these acute episodes of elevated sympathetic hyperactivity. Various pharmaceutical and management options are available, but no single drug or protocol has been deemed superior to the others. Data on prognosis and recovery in relation to paroxysmal sympathetic hyperactivity are limited but point toward poorer functional outcome and increased mortality. Overall, the phenomenon of paroxysmal sympathetic hyperactivity requires further research to aid rehabilitative efforts so that patients can effectively participate in therapy. A review of the literature has revealed sparse information on the management of sympathetic storming within rehabilitation facilities. This narrative review seeks to provide an up-to-date synopsis and recommendations on the management of rehabilitation inpatients with paroxysmal sympathetic hyperactivity.

Association between Paroxysmal Sympathetic Hyperactivity and tracheostomy weaning in Traumatic Brain Injury.

BACKGROUND: Rehabilitation following severe Traumatic Brain Injury (TBI) often involves the use of temporary tracheostomies. Tracheostomy weaning is influenced by physiological parameters, which are abnormal in the concomitant complication of Paroxysmal Sympathetic Hyperactivity (PSH). OBJECTIVE: To investigate the association between PSH and tracheostomy weaning in severe TBI. METHODS: This was a retrospective cohort study of consecutive patients with TBI and tracheostomy admitted to a Hyper-Acute Neurorehabilitation Unit over a 34-month period. Duration of tracheostomy wean and influencing characteristics were statistically compared between those with and without PSH. RESULTS: Fifty-one patients admitted with TBI required a tracheostomy. Of these, 10 patients were also diagnosed with PSH. The mean tracheostomy wean in the PSH group was longer compared to the non-PSH group (72.3, SD 61.0 versus 30.0 days, SD 16.2). This difference was statistically significant (p = 0.007, using Mann Whitney U test). The PSH group had more respiratory and oral secretions, but this was not statistically significant (p = 0.16 and 0.29). CONCLUSIONS: This is the first study to demonstrate that PSH is associated with prolonged tracheostomy weaning in severe TBI. Awareness of this association should enable those planning rehabilitation to set realistic goals for a patient's tracheostomy weaning programme.

The influence of autonomic impairment on aerobic exercise outcome in stroke patients.

PURPOSE: To investigate whether autonomic impairment post stroke modifies the influence of early aerobic training in relation to resting heart rate, peak workload and walking performance at the subacute stage post event. METHODS: Sixty-four patients after a first ischemic stroke were included and randomly assigned either to an aerobic training or to a control group. The training period lasted 8 weeks. Heart rate variability (HRV) parameters, aerobic and functional abilities were measured. RESULTS: Early aerobic exercise significantly improved endurance and walking performance in stroke patients (p< 0.05). A significant association was found between the HRV parameters two weeks post event and heart rate at rest and peak workload at the beginning of the program. No significant interaction effects between autonomic impairment and training on outcome measures were found. CONCLUSION: Early aerobic training resulted in positive effects on peak workload and walking parameters in stroke patients. No modification effect was found between HRV parameters and exercise on those parameters.

[The vegetative status of patients after myocardial infarction, and the effectiveness of sanatorium rehabilitation].

The aim of the study was to investigate the dynamics of functional variables and the vegetative status of patients undergoing sanatorium rehabilitation with different results. The subjects, 106 patients aged 48.6 +/- 0.95, who had had myocardial infarction, were divided into 3 groups according to the dynamics of physical exercise tolerance (PET) in the course of treatment: group I, 39 patients with a significant (more than 10W) increase in PET; group II, 47 patients with no change in PET or with a small (up to 10W) increase in PET; group 3, 20 patients with a decrease in PET. An initial examination showed PET was the lowest in group 1. Group 3 patients displayed the lowest ejection fraction, the biggest end-diastolic volume and left ventricular (LV) asynergy at an initial examination, as well as higher incidence of ventricular premature beats; this group contained more patients with large-focal MI, LV aneurism, and postinfarction stenocardia. After treatment group 1 patients demonstrated an increase in the low-frequency component of the spectral parameters of cardiac rhythm variability (CRV) according to ECG at rest; active orthostatic test (AOT) revealed a moderate increase in the variables of sympathovagal balance, which could be considered to demonstrate the recovery of the impaired sympathetic reactivity. Group III patients demonstrated a decrease in the low-frequency component of the CRV spectral parameters at rest after treatment; AOT demonstrated a shift from an initial inadequate sympathetic reactivity to hyperreactivity, which might reflect a "stale" condition in these patients. The data of the study will help to plan individual physical rehabilitation programs and to control exercise tolerance in cardiological patients.

Autonomic dysfunction in multiple sclerosis: implications for exercise.

Multiple sclerosis (MS), a progressive neurological disease, can result in autonomic dysfunction. Impairments in the autonomic control of cardiovascular and thermoregulatory function during exercise have been observed in MS. Attenuated elevations in blood pressure during exercise in MS patients can negatively impact blood flow to skeletal muscle. Diminished sweating during exercise may impair heat dissipation likely limiting the exercise intensity that can be performed before detrimental core temperatures are reached. Further understanding the physiologic mechanisms of autonomic dysfunction during exercise in MS may lead to the development of novel therapeutic strategies targeted at improving quality of life in individuals with this disease.

Rehabilitation of incomplete spinal cord pathology: factors affecting prognosis and outcome.

To determine the factors affecting the outcome of patients with incomplete spinal cord lesions, a retrospective study was performed of all such patients (n = 49) admitted to the neurorehabilitation unit of the National Hospital for Neurology and Neurosurgery, London, over a 2-year period. Disability on admission and discharge as measured by the Functional Independence Measure (FIM), change in disability, presence or absence of neurological recovery, patient age, level of the lesion and length of inpatient stay were the main outcome measures. Data were complete on 39 patients. There were 20 patients with cervical myelopathy, 15 with intrinsic cord abnormalities including syrinxes, 7 with spinal cord infarcts and 7 with other conditions such as tropical spastic paraparesis and hereditary paraparesis. Age ranged from 17 to 88 years (mean 53). Mean duration of stay was 40 days and the duration was related to the diagnosis. Nineteen of the patients made some neurological improvement, while all but one improved on the FIM. This functional gain did not correlate with the patients' age, initial disability or level of the lesion, but was related to the length of stay in the unit, and neurological improvement. We conclude that the needs of patients with progressive incomplete spinal cord lesions due to neurological disease differ from those of patients with acute traumatic spinal cord lesions and are best managed in a neurological rehabilitation unit. Efficacy appears to be related to neurological recovery and the duration of rehabilitation. This study underlines the value of combined neurological and rehabilitation expertise in the management of this patient group and the need to incorporate both disciplines in planning service provision.

Early use of intrathecal baclofen in brain injury in pediatric patients.

BACKGROUND: The Food and Drug Administration (FDA) approved the use of intrathecal Baclofen for spasticity from traumatic brain injury in June of 1996 based on a Phase III clinical trial that documented efficacy in patients one year post injury. The FDA approval is only for patients who are one year post injury based on the Phase III study. We have found use of ITB in the first few months after injury very effective in a subgroup of severe traumatic brain injury (TBI) pediatric patients with spasticity, dystonia and autonomic storming following brain injury. METHOD: The author's database of over 250 patients receiving intrathecal baclofen was reviewed. Retrospective chart review was undertaken of the 6 patients identified with brain injuries over a three year period that were given ITB less than one year post injury. The patients' diagnosis included asphyxia, traumatic brain injury and stroke. The ages were one year to fourteen years of age. ITB was offered after all conventional therapy had been exhausted and the patient's spasticity remained intractable. These patients also all experienced autonomic dysfunction with severe autonomic storms. FINDINGS: All of the patients had a decrease in their spasticity of at least 2 points on the Ashworth score. The autonomic storms ceased in all 6 patients when adequate dosages of ITB were reached. The patients could be weaned from all oral and intravenous medications for tone, storming and fever. Many of the patients became much more alert and interactive when the medications were stopped. Five of the six are still using their pump for their tone one to five years post implant, the sixth had the pump stopped at the parents' request for religious reasons. INTERPRETATION: Early use of ITB can play a significant role in the rehabilitation of brain injury in children.

Malone antegrade continence enemas for autonomic dysreflexia secondary to neurogenic bowel.

A 42-year-old man with T-4 ASIA B thoracic paraplegia presented with chronic constipation, fecal incontinence, and bowel-related autonomic dysreflexia (AD) refractory to conservative bowel program. His usual toileting time lasted one to five hours. Antegrade continence enemas (ACE) were performed. The ACE technique, which requires creating a continent catheterizable appendicocecostomy, is described. Postoperatively, a daily enema was given through the stoma. The patient's toileting time was reduced to 20 minutes and his AD resolved. The role of the ACE is discussed in adult spinal cord injury (SCI).

[The dynamics of neurotic disorders with autonomic paroxysms]. / Dinamika nevroticheskikh rasstroistv s vegetativnymi paroksizmami.

Multi-dimensional investigation in the peculiarities, clinical course and possible mechanisms of neurotic disorders was performed in 115 patients. In order to study the further course of neurotic disorders and their determinants, as well as the issues of social rehabilitation and psychoprophylactic interferences, 56 patients were studied again after 6 to 8 years. For each of the symptom complexes investigated, the course had distinct features determined primarily by adaptation-compensatory capabilities of personality, and the "system of psychological defense". Most unfavorable was the course of hysterical disorders. Therapeutic policy in these patients should be grounded upon the psychotherapeutic measures aimed at finding the ways that would be psychologically adequate for changing the patients' attitudes and restoring their adaptation.

Exercise and the autonomic nervous system.

The autonomic nervous system plays a crucial role in the cardiovascular response to acute (dynamic) exercise in animals and humans. During exercise, oxygen uptake is a function of the triple-product of heart rate and stroke volume (i.e., cardiac output) and arterial-mixed venous oxygen difference (the Fick principle). The degree to which each of the variables can increase determines maximal oxygen uptake (V˙O2max). Both "central command" and "the exercise pressor reflex" are important in determining the cardiovascular response and the resetting of the arterial baroreflex during exercise to precisely match systemic oxygen delivery with metabolic demand. In general, patients with autonomic disorders have low levels of V˙O2max, indicating reduced physical fitness and exercise capacity. Moreover, the vast majority of the patients have blunted or abnormal cardiovascular response to exercise, especially during maximal exercise. There is now convincing evidence that some of the protective and therapeutic effects of chronic exercise training are related to the impact on the autonomic nervous system. Additionally, training induced improvement in vascular function, blood volume expansion, cardiac remodeling, insulin resistance and renal-adrenal function may also contribute to the protection and treatment of cardiovascular, metabolic and autonomic disorders. Exercise training also improves mental health, helps to prevent depression, and promotes or maintains positive self-esteem. Moderate-intensity exercise at least 30 minutes per day and at least 5 days per week is recommended for the vast majority of people. Supervised exercise training is preferable to maximize function capacity, and may be particularly important for patients with autonomic disorders.

Autonomic dysfunction: recognition, diagnosis, investigation, management, and autonomic neurorehabilitation.

The autonomic nervous system (ANS), through its central connections and efferent pathways, innervates every organ in the body, influences their function, and is also involved in a number of integrative systems such as those concerned with maintenance of arterial blood pressure, organ perfusion, and body temperature. Responsive functioning of the ANS is thus needed in a variety of situations; it contributes to well being, and is essential for survival. Autonomic dysfunction may occur in a number of neurological diseases and may complicate various medical disorders. This chapter will provide an outline of the scientific principles, followed by classification of autonomic disorders, an outline of the autonomic investigations, brief accounts of some of the key disorders and the pathophysiological mechanisms involved, and discussion of treatment, emphasizing the importance of non-pharmacological methods and, in particular, the role of autonomic neurorehabilitation.

Differential responses of adiposity, inflammation and autonomic function to aerobic versus resistance training in older adults.

BACKGROUND: Increased body fat, autonomic dysfunction and low-grade chronic inflammation are interrelated risk factors implicated in the etiology of several chronic conditions normally presented by older adults. OBJECTIVE: This study aims to assess the effectiveness of different training protocols on reducing body fat, improving autonomic function, and decreasing low-grade systemic inflammation in community-dwelling elderly adults. METHODS: Fifty participants (11 men, 68±5.5years) were randomly allocated into resistance or aerobic training or control groups. Evaluations were done at baseline and following the 8-month intervention period on their body composition (assessed by DXA), inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], tumor necrosis-alpha [TNF-α], interferon-gamma [IFN-γ], interleukins-6 and -10 [IL-6, IL-10]), lipoproteic profile, fasting glycemia, blood pressure, heart rate variability (HRV; frequency and time domains) and aerobic fitness (assessed by six-minute walk distance [6MWD]). A paired t-test was used to detect changes (%Δ=[(post-test score-pretest score)/pre-test score]×100) within groups, while between-group differences were analyzed using the one-way ANOVA or General Linear Models. RESULTS: A significant change (Δ%) both in total (-5.4±6.3% and -3.3±2.9%, respectively) and central body fat (8.9±11.3% and -4.8±4.5%) was observed in resistance and aerobic training groups, respectively; along with a change in resting systolic and diastolic blood pressures (-9.2±9.8% and -8.5±9.6%), heart rate (-4.6±6.5%), hs-CRP (-18.6±60.6%), and 6MWD (9.5±6.9%) in response to aerobic training. CONCLUSIONS: The present findings provide further evidence for the benefits of aerobic and resistance training on reducing body fat. Aerobic training was demonstrated to reduce hs-CRP and blood pressure in community-dwelling elderly participants with no serious medical conditions.