Delayed encephalopathy after acute carbon monoxide poisoning: a case study.

Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a relatively rare inflammatory-associated neurometabolic complication. In this article, we present a case report of a 50-year-old male patient with a history of carbon monoxide poisoning. This acute poisoning, although successfully controlled during a stay in the intensive care unit of a local hospital, later led to persistent neurological symptoms. The patient was then treated in the inpatient unit of the rehabilitation clinic, where cognitive deterioration began to develop 20 days after admission. Subsequent examination using EEG and magnetic resonance imaging confirmed severe encephalopathy later complicated by SARS-CoV-2 infection with fatal consequences due to bronchopneumonia. Because currently there are no approved guidelines for the management of DEACMP, we briefly discuss the existing challenges for future studies, especially the application of rational immunosuppressive therapy already in the acute treatment phase of CO poisoning, which could prevent the development of a severe form of DEACMP.

Botulinum Toxin for Chronic Lateral Epicondylitis (LE). / Botulinumtoxin bei chronischer Epicondylitis humeroradialis.

Lateral epicondylitis is a common disease in orthopaedic practice. Although the majority of cases do not become chronic, patients who do not respond to the initial treatment may suffer from pain in the long term and effective treatment is challenging. The off-label use of botulinum toxin is one of the common potential indications for the substance in orthopaedics and traumatology. In a literature review of 2000 - 2019, eight EBM ≥ level 3 studies evaluating the use of botulinum toxin in lateral epicondylitis were found. Five of these studies evaluated botulinum toxin versus placebo in chronic cases; two other studies compared botulinum toxin with corticosteroids in acute cases and classic Hohmann surgery in chronic cases; the eighth study compared botulinum toxin in two different injection sites and corticosteroids by classic injection. Our findings suggest that the use of this substance may be a treatment option in refractory chronic cases before surgery is indicated. The working group on botulinum toxin in O & T of the International Musculoskeletal Pain Society (IMPS/IGOST) introduced an alternative injection schedule, which combines findings from the recent clinical literature with practical experience in order to reduce the risk of side effects while ensuring treatment effectiveness. Using 2 simple tests of function and, if necessary, sonographic verification, 2 separate injection sites in the extensor carpi radialis or the extensor digitorum can be identified by palpation. The tendon level on the lateral epicondyle acts as the third injection site. With optimal use of the ampoule content, the 3 injection sites can be infiltrated individually, depending on the muscle status. On the one hand, this enables treatment to take place after a dual therapy approach and, on the other hand, the risk of overdose in a muscle with subsequent unnecessary muscle weakening can be reduced.

Specific rehabilitation exercise for the treatment of patients with chronic low back pain.

[Purpose] To evaluate the efficacy of our special rehabilitation method for patients with low back pain (LBP). [Subjects and Methods] All participants (n=33) received at least five individual 30-minute therapy sessions per week using the INFINITY method(®) and six group therapy sessions per week in a gymnasium and swimming pool, each lasting 30 minutes and including the INFINITY method(®). The treatment lasted between four to seven weeks. Plantar function using a graphic method (computer plantography), graphical quantification of postural control during static standing (posturography), and pain were measured and evaluated before and after rehabilitation therapy. The INFINITY method(®) is a special rehabilitation method for patients with musculoskeletal problems. The method focuses on stabilization and strengthening of the trunk, dorsal and abdominal muscles, including the deep stabilization system which is closely linked with diaphragmatic breathing. It teaches the central nervous system to control muscles more precisely. [Results] Plantar functions, postural control in the upright stance and pain of LBP patients were significantly improved by 4-7 weeks of rehabilitation treatment with the INFINITY method(®). There were significant differences in all measured dependent variables of the patients between before and after treatment. [Conclusion] Rehabilitation therapy with the INFINITY method(®) positively influences body stabilization and pain in patients with problems of the lumbar spine. This method presents a new improved approach (with enhanced effect) to rehabilitation therapy for LBP patients.

Quality-of-life in patients with post-traumatic hypopituitarism.

PRIMARY OBJECTIVE: Hypopituitarism is a frequent complication in patients after traumatic brain injury (TBI). Both TBI and hypopituitarism can lead to complex cognitive and affective deficits. This study was intended to examine the quality-of-life in patients with post-traumatic hypopituitarism (PTH) and to discern the effect of this endocrinological disorder on general outcome of patients after TBI including earning capacity. Research type: Retrospective analysis of clinical data. METHODS AND PROCEDURES: Ninety-seven symptomatic patients were screened after TBI for PTH. Their results were examined in the SF-36 [a standardized questionnaire for quality of life (QoL)] comparing the groups with or without PTH. After 6 months of hormone substitution (if necessary), patients were asked to repeat the SF-36. MAIN OUTCOMES AND RESULTS: Forty-six patients were diagnosed with PTH (47.5%). All patients included had a significantly lower QoL compared to the standard population. QoL was significantly worse in patients with PTH. There was no significant difference with regard to earning capacity. After hormone substitution, patients achieved better SF-36-results, albeit the difference was lacking statistical significance. CONCLUSIONS: PTH is frequent after TBI. PTH turns out to further diminish QoL, without affecting earning capacity. Hormone substitution might improve QoL in patients with PTH, but future research is needed to confirm this hypothesis.

Botulinum toxin in the treatment of post-traumatic headache - case study.

Pharmacotherapy of acute post-traumatic tension headaches consists of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). Treatment of chronic tension-type head-aches consists mainly of tricyclic antidepressants; local injection of botulinum toxin is one of the comparatively newer therapeutic options. No data on the treatment of post-traumatic headaches with botulinum toxin exist. A 62-year-old woman with a history of major traumatic brain injury five years previously developed chronic tension-type headaches of an oppressive nature. The results of treatment with oral medication were not satisfactory. The patient was treated with local injections of 22 IU Botox® into the frontalis muscle and corrugator supercilii muscle. After only five days, the headaches had improved and after ten days the patient was free of symptoms even when under stress. Sufficiently large-scale clinical studies are now required to better evaluate the effects of botulinum toxin on post-traumatic headaches.

Early rehabilitation of comatose patients after traumatic brain injury.

BACKGROUND AND PURPOSE: As a result of improvements in the rescue system and progress in intensive care therapy, an increasing number of patients have survived severe traumatic brain injury in recent years. Early and consistent administration of the correct rehabilitation programme is of crucial importance for the restoration and improvement of cerebral function, as well as social reintegration. This prospective study was conducted at the neurosurgical department of a university hospital to assess the one-year outcome of comatose patients after severe traumatic brain injury. MATERIAL AND METHODS: Twenty-seven patients were included. Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy. One-year outcome was assessed by means of the Glasgow Outcome Scale, Barthel Index, Functional Independence Measure (FIM) and need of care. RESULTS: Seven patients died, 4 remained in a vegetative state, 7 were severely disabled, 6 were moderately disabled, and 3 achieved a good recovery 12 months after injury. Median Barthel Index was 65 and median FIM score was 84. The majority of patients were still at least intermittently dependent on care. CONCLUSION: Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.

Abnormal functional MRI BOLD contrast in the vegetative state after severe traumatic brain injury.

For the rehabilitation process, the treatment of patients surviving brain injury in a vegetative state is still a serious challenge. The aim of this study was to investigate patients exhibiting severely disturbed consciousness using functional magnetic resonance imaging. Five cases of posttraumatic vegetative state and one with minimal consciousness close to the vegetative state were studied clinically, electrophysiologically, and by means of functional magnetic resonance imaging. Visual, sensory, and acoustic paradigms were used for stimulation. In three patients examined less than 2 months after trauma, a consistent decrease in blood oxygen level dependent (BOLD) signal ('negative activation') was observed for visual stimulation; one case even showed a decrease in BOLD activation for all three activation paradigms. In the remaining three cases examined more than 6 months after trauma, visual stimulation yielded positive BOLD contrast or no activation. In all cases, sensory stimulation was followed by a decrease in BOLD signal or no activation, whereas auditory stimulation failed to elicit any activation with the exception of one case. Functional magnetic resonance imaging in the vegetative state indicates retained yet abnormal brain function; this abnormality can be attributed to the impairment of cerebral vascular autoregulation or an increase in the energy consumption of activated neocortex in severe traumatic brain injury.

Health-related quality of life during the first year after severe brain trauma with and without polytrauma.

OBJECTIVE: The increasing number of patients surviving severe traumatic brain injury (sTBI) but with significant sensorimotor and neuropsychological deficits is a challenge to rehabilitation medicine. So far, most research initiatives have focused on mortality rates, physiological or economic parameters to estimate therapeutic effects of rehabilitation strategies. Investigations on health-related quality of life (HRQoL) after TBI with and without concomitant polytrauma are rare compared to other disorders. DESIGN/PATIENTS: A prospective study was conducted to investigate HRQoL using the SF-36 questionnaire in 49 patients with sTBI (Glasgow Coma Scale < 9 for more than 24 hours) with and without concomitant polytrauma 6 and 12 months after injury. RESULTS: The SF-36 score profiles 6 and 12 months after trauma were similar. Scores 12 months after trauma, however, were higher in 7/8 dimensions indicating an improvement over time. Similar observations were made for physical and mental sum scores. There was no difference in the SF-36 scoring pattern between the patients with isolated TBI and the patients with concomitant polytrauma, except for physical functioning after 12 months. CONCLUSION: While there is significant overall improvement of HRQoL over time, sTBI appears to bear major influence on post-traumatic HRQoL and outcome.

Outcome of prolonged coma following severe traumatic brain injury.

PRIMARY OBJECTIVE: To assess the outcome of severe traumatic brain injury 1 year after trauma. RESEARCH DESIGN: Prospective study conducted at the neurosurgical department of a university hospital. METHODS AND PROCEDURES: A total of 24 patients were included. Outcome was assessed by means of Glasgow outcome scale, Barthel index, Functional independence measure (FIM) and Disability rating scale (DRS). Need of care and job ability were also evaluated. EXPERIMENTAL INTERVENTIONS: Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy. MAIN OUTCOMES AND RESULTS: Six patients died, three remained in a vegetative state, six were severely disabled, six were moderately disabled and three achieved a good recovery 1 year after injury. Mean Barthel index was 68.9, mean FIM was 88.3 and mean DRS 27.7. The majority of patients still were at least intermittently dependent on care. Most of the trauma survivors were unable to work. CONCLUSIONS: Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.