Post-Acute Care for Traumatic Brain Injury Patients in Taiwan.

Background: Traumatic brain injury (TBI) can result in functional impairments. Many patients with TBI require post-acute care to improve their functional skills and allow for greater self-independence and a better quality of life. Taiwan's National Health Insurance proposed a nationwide post-acute care program in 2017 for patients with traumatic brain injury. The program's goal was to maximize patients' functional recovery and make it possible for them to return to their homes and communities. This study aimed to explore the effectiveness of such programs in Taiwan. Methods: This pilot study retrospectively evaluated a de-identified database that contained the scores of various assessments evaluated at admission and discharge. It used the data to determine the functional improvement of patients with traumatic brain injury after participating in post-acute care programs. Results: This study collected complete data from 27 patients. After an average of 45.11 days in the program, the patients showed significant improvement in the Barthel Activity Daily Living Index, the Lawton-Brody Instrumental Activity Daily Living Scale, the Mini Nutrition Assessment, the EuroQol Five Dimensions Questionnaire, the Berg Balance Scale, the Galveston Orientation and Amnesia Test, the Rancho Los Amigos Scale, the Concise Chinese Aphasia Test, and the Mini Mental State Examination. After discharge, 96% of the patients could return to their community. Conclusion: This pilot study concluded that the program significantly promoted functional recovery for patients and could help patients with traumatic brain injury return to their communities and reduce the risk of institutionalization. Thus, patients with the potential for functional recovery could receive post-acute care in regional or community hospitals immediately after being discharged from acute wards. In the future randomized controlled trials are needed to further confirm the clinical impact of this program.

Motor and bladder dysfunctions in patients with vertebral fractures at the thoracolumbar junction.

OBJECTIVE: To present the motor deficits and type of neurogenic bladder dysfunction (NBD) in patients with vertebral fractures at thoracolumbar junction. METHODS: Fifty-two patients with single level vertebra fracture over T11-L2 with onset duration of longer than 3 years were enrolled. All participants provided basic demographic data, ambulatory status and received neurologic examination and urodynamic studies. The differences in distribution of NBD types, neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cutoff value of lower extremities motor score (LEMS) in functional walker and non-walker. RESULTS: Of the 52 patients, the injured levels were 3 (5.8%) in T11, 21 (40.4%) in T12, 22 (42.3%) in L1, and 6 (11.5%) in L2 vertebrae. Eight (15.4%) patients had upper lumbar cord lesions, 26 (50.0%) had epiconus and lumbar roots lesions, 18 (34.6%) had conus medullaris or/and cauda equina lesions. Mean LEMS was 0 ± 0, 5.4 ± 7.7, 11.1 ± 10.2, and 28.0 ± 11.0 for patients with T11, T12, L1, and L2 fractures, respectively. Patients with L2 fractures had higher LEMS than other levels (p < 0.001). The cutoff value of LEMS for functional walking was set at 20, and both the sensitivity and specificity was 100%. Thirty-one (59.6%) patients had spastic NBD, 18 (35.6%) had flaccid NBD, and 3 (5.8%) had mixed type NBD. Positive prediction value of ankle spasticity for bladder and sphincter spasticity was 95.2 and 100%, respectively. CONCLUSION: Half of the patients had epiconus lesion following thoracolumbar junction fracture, and they had a clinical presentation of flaccid legs and spastic NBD. Patients with L2 fracture had higher LEMS than patients with T11, T12, and L1 fracture. Patients whose LEMS was higher than 20 could all walk functionally. Fracture at the thoracolumbar junction may cause spastic, flaccid, or mixed type NBD, and urodynamic study is an essential tool for the correct diagnosis and management. Ankle spasticity has a high positive predictive value for spastic bladder or sphincter.

Value of Doppler ultrasonography in predicting deteriorating renal function after spinal cord injury.

PURPOSE: The authors sought to study the relationship between Doppler ultrasonography and deterioration of renal function in patients with spinal cord injury. MATERIALS AND METHODS: Nineteen patients who underwent follow-up with radioisotopic renography were evaluated. Median patient age was 50 [interquartile ratio (IQR) 35-57] years, and time since injury was 4.7 (IQR 1.3-9.2) years. Following Doppler ultrasound, patients were divided into groups based on baseline renal resistive index (RRI): normal RRI (≤ 0.7), group 1 (n=14); and abnormal RRI (> 0.7), group 2 (n=5), and were followed up with radioisotopic renography 1 or more years later. Annual change in effective renal plasma flow (ERPF) was analysed. RESULTS: The 38 kidneys (two for each patient) were stratified by initial RRI, with 28 in group 1 and ten in group 2. Result of univariate generalised estimation equation (GEE) analysis for the factors affecting the change in effective renal plasma flow (ERPF) indicated that the high RRI value (RRI > 0.7) correlated with the change in ERPF. ERPF value in group 2 was significantly decreased (p=0.01) by an average of 60.33 ml/min (standard error = 23.26). CONCLUSIONS: An RRI > 0.7 is a risk factor for future renal function deterioration in patients with spinal cord injury. Thus, annual Doppler ultrasonography to assess the RRI and the degree of hydronephrosis is recommended.

Autonomic dysreflexia during urodynamic examinations in patients with suprasacral spinal cord injury.

OBJECTIVE: To investigate blood pressure (BP) and pulse rate (PR) changes during urodynamic (UD) examinations in patients with suprasacral spinal cord injury (SCI). DESIGN: A case control study. SETTING: Tertiary hospital affiliated with a medical university. PATIENTS: Control subjects (n=22) and patients with suprasacral SCI (n=120). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Systolic (SBP) and diastolic BP (DBP) and PR before and during UD studies. RESULT: Healthy subjects had an average SBP change of 9.7 ± 10.6 mm Hg and a maximal SBP increase of 21 mm Hg. Autonomic dysreflexia (AD) was defined as an SBP increase of 20mm Hg or more, and incidence rates were 36.7% overall, 42.6% in patients with injury level at or above T6, and 15.4% in patients with lesions below T6. Both SBP and DBP changes in patients with SCI showed significant negative correlations with injury levels (r=-.383 and -.315; P<.05). The BP increase was more significant in patients with SCI who had detrusor sphincter dyssynergia (DSD), especially the continuous type, or severely impaired bladder compliance than in those who did not. Most patients (75%) had no significant PR changes (within 10 beats/min) during AD responses and only 22.7% had a decrease of 10 beats/min or more. Patients younger than 50 years had a greater PR decrease than those 50 years or older (-7.1 ± 9.0 vs 0.7 ± 11.4 beats/min; P<.05). CONCLUSIONS: AD occurred not only in patients with lesions above T6, but also in those with lower lesion levels. Patients with higher injury level, continuous DSD, or a poorly compliant bladder had greater SBP changes during UD studies. During AD reactions, younger patients tended to have a greater PR decrease than older patients.

Comparing a transrectal ultrasound-guided with a cystoscopy-guided botulinum toxin a injection in treating detrusor external sphincter dyssynergia in spinal cord injury.

OBJECTIVE: The aim of this study was to compare the results of a transrectal ultrasound-guided botulinum toxin injection with those of a cystoscopy-guided method to the external urethral sphincter in treating detrusor external sphincter dyssynergia. DESIGN: A total of 18 suprasacral spinal cord-injured patients with detrusor external sphincter dyssynergia were included in the present study. A single dose of 100 IU botulinum toxin A was applied into the external urethral sphincter via a transrectal ultrasound-guided transperineal route. We retrospectively compared the outcome measurements with 20 suprasacral spinal cord-injured patients previously treated with the same dose of botulinum toxin through a cystoscopy-guided procedure. RESULTS: There were significant reductions in integrated electromyography and urethral pressure but not in detrusor pressure and leak point pressure after treatment. Postvoiding residuals were significantly decreased in the first, second, and third months in the cystoscopy group and in the first and second months in the transrectal ultrasound group. There were no significant differences between the groups in all of the outcome measures. CONCLUSIONS: This study demonstrates that transrectal ultrasound-guided transperineal botulinum toxin injection may be an alternative for a cystoscopy-guided injection. This alternative procedure provides clinicians with an innovative and less invasive method that is performed without requiring anesthesia or cystoscopy.

Transrectal ultrasound-guided transperineal botulinum toxin a injection to the external urethral sphincter for treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury.

OBJECTIVE: To evaluate the effects of a single transrectal ultrasound (TRUS)-guided transperineal injection of botulinum toxin A (BTX-A) to the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD). DESIGN: Descriptive study. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Patients (N=18) with suprasacral spinal cord injury who had DESD confirmed on video-urodynamic study. INTERVENTIONS: A single dose of 100U BTX-A was applied into the EUS via TRUS-guided transperineal route injection. MAIN OUTCOME MEASURES: Maximal detrusor pressure, detrusor leak-point pressure, integrated electromyography (iEMG), maximal pressure on static urethral pressure profilometry, and postvoiding residuals. RESULTS: There were significant reductions in iEMG (P=.008) and static (P=.012) and dynamic urethral pressure (P=.023), but not in detrusor pressure and detrusor leak-point pressure after treatment. Postvoiding residuals also significantly decreased in the first and second month after treatment (P<.012). CONCLUSIONS: TRUS-guided transperineal injection of BTX-A has beneficial effects in treating DESD.

Transperineal injection of botulinum toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance.

OBJECTIVE: To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI). DESIGN: A prospective, open-label trial. SETTING: A rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD. INTERVENTIONS: 100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy. MAIN OUTCOME MEASURES: (1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI). RESULTS: Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H2O, 45cm H2O, and 92cm H2O, respectively (all P values <.05). The mean QLI significantly improved from -0.68+/-0.27 to 0.66+/-0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters. CONCLUSION: With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.

Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury.

OBJECTIVE: To evaluate the effect of a single cystoscopic injection of botulinum toxin to the external urethral sphincter in treating detrusor external sphincter dyssynergia. DESIGN: An open treatment trial with pre- and post-treatment evaluations. SUBJECTS: A total of 20 suprasacral spinal cord injured patients with pure detrusor external sphincter dyssynergia. METHODS: A single dose of 100 IU botulinum toxin A was applied into the external urethral sphincter via cystoscopy. Outcome measurements included maximal detrusor pressure, maximal urethral pressure, detrusor leak point pressure, integrated electromyography, and maximal pressure on static urethral pressure profilometry obtained 4 weeks post-treatment. Post-voiding residuals were checked pre- and post-injection. RESULTS: There were significant reductions in integrated electro notmyography and static and maximal urethral pressure, but not in maximal detrusor pressure and detrusor leak point pressure after treatment. Post-voiding residuals were significantly decreased at all evaluation periods. In the sub-group analysis, patients who showed good effects of treatment had significantly lower baseline integrated electro-myography (p<0.05). CONCLUSION: This study demonstrates the effect of a single cystoscopic injection of botulinum toxin in detrusor external sphincter dyssynergia. Integrated electromyography is a good evaluation tool for the net effect and dosage of botulinum toxin. Patients with severe spasticity over the external urethral sphincter may require repeated injections or higher doses.

Urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia.

OBJECTIVE: To evaluate the urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia (DSD). DESIGN: Descriptive study. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Patients (N=36) with suprasacral spinal cord injury who had DSD confirmed on cystometrography. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Detrusor pressure, urethral pressure, and summated electromyogram of external urethral sphincter on cystometrography. RESULTS: The urodynamic responses to anal stretch were evaluated in the first half (time 1, 1-15s) and the second half (time 2, 16-30s) of the evaluation time period. The activity of external urethral sphincter was reduced significantly in both times 1 and 2 (P<0.5). The medians of reduction percentages were 33% and 35% for times 1 and 2, respectively. The change of detrusor pressure was not significant in either time 1 or time 2. CONCLUSIONS: Anal stretch can reduce the activity of external urethral sphincter without significant change in detrusor pressure.

Application of portable ultrasound scanners in the measurement of post-void residual urine.

The aims of the present study were to investigate the impact of research subjects' characteristics on the accuracy of the BladderScan when the latter is used to measure post-void residual urine volume, and to evaluate differences between BladderScan and catheterization in terms of the expenditure of time and of human and material resources. Subjects in the present study were 71 patients undergoing inpatient or outpatient rehabilitation therapy. Post-void residual urine was measured with the BladderScan BVI 3000, followed by intermittent catheterization. Repeated- measures ANOVA revealed no statistically significant difference between the post-void residual urine volume measured by the bladder ultrasound and that of catheterization, or among the factors: sex, diagnosis, body position, thickness of abdominal fat, bladder shape, urine volume, and time intervals between operations. The BladderScan averaged 45 seconds (range=17-119 seconds), while catheterization averaged 293 seconds (range=136-664 seconds); the time required for catheterization was 3 to 8 times that for the BladderScan. The BladderScan gave accurate measurements of post-void residual urine volume for all of the subjects. Using the BladderScan first to measure post-void residual urine volume can reduce the frequency of catheterization, and can save medical human resources costs as well.

Application of renal Doppler sonography in the diagnosis of obstructive uropathy in patients with spinal cord injury.

OBJECTIVES: To assess renal resistive index (RI) changes in patients with spinal cord injury (SCI) who have obstructive uropathy and to determine if an RI of 0.7 or more is useful in identifying such patients. DESIGN: Prospective cross-sectional study. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: A convenience sample of 99 kidneys of 51 SCI patients (38 men, 13 women; mean age, 38.8+/-14.0 y) with neuropathic bladder dysfunction. INTERVENTIONS: Ultrasonic examination to assess the degree of hydronephrosis, Doppler sonography to calculate renal vascular RIs, and radioisotopic renography to assess renal function and to determine excretory curves. Kidneys were assigned to control or obstructive uropathy groups, and RIs were compared for statistical significance (Student t test) and to assess whether an RI of 0.7 is a distinguishing criterion. MAIN OUTCOME MEASURES: RI and sensitivity. RESULTS: Average RIs were .58+/-.07 in the control group (71 kidneys) and .65+/-.08 in the uropathy group (28 kidneys) (P<.001). The sensitivity of using an RI of 0.7 or more to identify patients with obstructive uropathy was 39%. The c statistic of the receiver operating characteristic curve was .72. CONCLUSIONS: RIs increased in SCI patients with obstructive uropathy. In patients with SCI, urinary findings fit the chronic partial obstruction pattern. A renal RI of 0.7 or more was a poor indicator of obstructive uropathy in such patients.

Comparison of ultrasonographic renal excursion to fluoroscopic diaphragmatic excursion for the assessment of diaphragmatic function in patients with high cervical cord injury.

OBJECTIVE: To compare the renal excursion detected by ultrasonography with the diaphragmatic excursion recorded by fluoroscopy in estimating the diaphragmatic function in patients with high cervical cord injury. DESIGN: Prospective, blinded comparative study. SETTING: A rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Fifteen consecutively admitted patients with high cervical cord injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Chest radiographs, fluoroscopy of diaphragmatic motion, and ultrasonography of renal motion. RESULT: Of the 15 patients, 2 were diagnosed with hemidiaphragm paralysis using fluoroscopy and renal ultrasonography. The average diaphragmatic excursion was 59 mm (range, 30-83 mm) in 28 nonparalyzed hemidiaphragms. The average renal excursion was 49 mm (range, 28-61 mm). The correlation coefficient for fluoroscopic hemidiaphragm excursion and ultrasonographic renal excursion was .853. CONCLUSION: Ultrasonographic renal excursion and fluoroscopic diaphragmatic excursion correlated highly. With the fluoroscopy results as the criterion standard, the diagnostic sensitivity and specificity were both 100% for renal sonography. With the advantages of convenience of use, no radiation exposure, and high reproducibility, renal ultrasonography is recommended as a first-line screening and long-term follow-up tool for assessment of diaphragmatic function.

The accuracy of ultrasonic estimation of bladder volume: a comparison of portable and stationary equipment.

OBJECTIVE: To compare the accuracy of portable and stationary ultrasonography equipment in estimating residual bladder volume. DESIGN: A prospective study. SETTING: A rehabilitation hospital affiliated with a medical university in Taiwan. PARTICIPANTS: Sixty-four patients with voiding dysfunction. INTERVENTIONS: Each patient received both types of ultrasonography, plus catheterization (as the criterion standard for measuring bladder volume). MAIN OUTCOME MEASURES: The mean errors and mean percentage error resulting from use of the 2 types of equipment were recorded. RESULTS: Stationary real-time ultrasonography had a lower absolute error (21.9+/-25.0 mL vs 34.4+/-38.2 mL) and percentage error (13.1%+/-10.5% vs 36%+/-52.4%) than the portable ultrasonography (P<.05). CONCLUSION: Stationary ultrasonography provided a more accurate estimate of residual bladder volumes than did the portable device. However, portable ultrasonography is more convenient to use and has an acceptable accuracy for clinical use.

The relationship between sitting stability and functional performance in patients with paraplegia.

OBJECTIVES: To compare sitting stability between patients with high and low thoracic spinal cord injury (SCI), to determine the factors that can predict sitting stability, and to examine the relationship between sitting stability and functional performance. DESIGN: Cross-sectional assessment was performed on subjects with paraplegia. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Convenience sample of 30 adults with complete chronic thoracic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Postural sway during quiet sitting over 30 seconds was recorded as static sitting stability, and composite maximal weight-shift during leaning tasks over 30 seconds was measured as dynamic sitting stability; (2) age, body weight, trunk length, trunk strength, postonset duration, injury level, and presence of spasticity were examined as predictive variables for sitting stability; and (3) the time for completion of upper- and lower-body dressing and undressing and transfer was measured as functional performance. RESULTS: A significant difference in composite maximal weight-shift was found between high and low thoracic SCI subjects (t=2.90, P<.01). Injury level and trunk length were 2 important predictive factors for dynamic sitting stability, and they explained 43.5% of the variance. Only the completion time of upper-body dressing and undressing correlated significantly with static (r=.465, P=.01) and dynamic (r=-.377, P<.05) sitting stability. CONCLUSIONS: The subjects with low thoracic SCI showed better dynamic sitting stability than those with high thoracic SCI. Injury level and trunk length, not trunk flexion or extension strength, predicted the outcome of dynamic sitting stability. Measures were not precise enough to predict functional performance from the viewpoint of injury level and sitting stability. The underlying premise that a reduction or increase in trunk strength is indicative of poorer or better sitting stability in SCI individuals is questioned, and implications for problem identification and treatment planning are discussed.

Treatment of detrusor-sphincter dyssynergia by pudendal nerve block in patients with spinal cord injury.

OBJECTIVE: To study the effects of pudendal nerve block with phenol on detrusor-sphincter dyssynergia in patients with spinal cord injury (SCI). DESIGN: Before-after trial performed by using a consecutive sample. SETTING: Rehabilitation hospital affiliated with a medical school. PATIENTS: Twenty-two male SCI patients (mean age, 46.3+/-11.9y; mean duration postinjury, 2.7y) with voiding dysfunction resulting from external urethral sphincter hypertonicity. INTERVENTION: Pudendal nerve block with 5% phenol solution under the guidance of electric stimulator. MAIN OUTCOME MEASURES: Outcomes were measured using (1) postvoid residual volume, maximal detrusor pressure, leak point pressure, bladder volume at the first uninhibited contraction, maximal bladder capacity, and urethral pressure profile; (2) rectoanal rest and squeeze pressures; and (3) quality of life measures for urination, quantified by the Quality of Life Index (QLI). Changes in bowel habit or autonomic dysreflexia were recorded. RESULTS: The mean decrease in postvoid residual volume was 242.8mL (mean decrease, 66%) after treatment (P<.001). The mean reduction in leak point pressure and maximal detrusor pressure were 37.1cmH(2)O and 43.3cmH(2)O, respectively (P<.05). The mean QLI significantly improved from -.74+/-.38 to.42+/-.47 (P<.001). The rectoanal pressures showed no significant difference. No complaints of fecal incontinence or other complications were noted after treatment. CONCLUSION: Pudendal nerve block performed by using 5% phenol solution was safe, easy to perform, and effective as a treatment for detrusor-sphincter dyssynergia in selected patients with SCI.