Rehabilitation Outcomes in Spinal Abscess Patients With and Without a History of Intravenous Substance Abuse.

OBJECTIVE: The aim of the study was to compare functional outcomes of acute inpatient rehabilitation for spinal epidural abscess patients with and without history of intravenous substance abuse. DESIGN: This is a retrospective case series study in freestanding rehabilitation hospital. METHODS: Charts of 28 spinal epidural abscess patients admitted from January 2012 to September 2015: 13 with intravenous substance abuse and 15 without intravenous substance abuse were reviewed. Both groups received standard-of-care rehabilitation. Statistical analyses of Functional Independence Measure scores were conducted using individual 2 (substance use) × 2 (rehabilitation status) repeated measures analysis of variance. Functional outcomes were defined by total Functional Independence Measure scores as well as motor and cognitive subsets. Length of stay and morphine equivalents were also compared. RESULTS: There were no significant differences between the two groups. There was a significant main effect of treatment on total Functional Independence Measure scores (P < 0.001), Functional Independence Measure motor scores (P < 0.001), and Functional Independence Measure cognitive scores (P < 0.01) from admission to discharge. Subsequent Student's t tests revealed that the scores of both groups significantly improved on all Functional Independence Measure components. There were no group differences on length of stay and morphine equivalents at discharge. CONCLUSIONS: Acute inpatient rehabilitation can effectively improve functional outcomes in spinal epidural abscess patients with or without intravenous substance abuse, even though these two patient groups can vary in clinical factors.

Noninvasive evaluation of electrical stimulation impacts on muscle hemodynamics via integrating diffuse optical spectroscopies with muscle stimulator.

Technologies currently available for the monitoring of electrical stimulation (ES) in promoting blood circulation and tissue oxygenation are limited. This study integrated a muscle stimulator with a diffuse correlation spectroscopy (DCS) flow-oximeter to noninvasively quantify muscle blood flow and oxygenation responses during ES. Ten healthy subjects were tested using the integrated system. The muscle stimulator delivered biphasic electrical current to right leg quadriceps muscle, and a custom-made DCS flow-oximeter was used for simultaneous measurements of muscle blood flow and oxygenation in both legs. To minimize motion artifact of muscle fibers during ES, a novel gating algorithm was developed for data acquisition at the time when the muscle was relaxed. ES at 2, 10, and 50 Hz were applied for 20 min on each subject in three days sequentially. Results demonstrate that the 20-min ES at all frequencies promoted muscle blood flow significantly. However, only the ES at 10 Hz resulted in significant and persistent increases in oxy-hemoglobin concentration during and post ES. This pilot study supports the application of the integrated system to quantify tissue hemodynamic improvements for the optimization of ES treatment in patients suffering from diseases caused by poor blood circulation and low tissue oxygenation (e.g., pressure ulcer).

Trialing of intrathecal baclofen therapy for refractory stiff-person syndrome.

OBJECTIVE: Stiff-person syndrome (SPS) is a rare disorder of the central nervous system characterized by stiffness and muscle spasms that may be progressive in nature. When oral medication is inadequate to control muscle spasticity, intrathecal baclofen may be used. We report a patient with severe SPS and glutamate decarboxylase negative [GAD(-)] (note: GAD(-) indicates the patient has no antibodies to GAD), refractory to oral standard therapies. The patient was effectively trialed with an intrathecal catheter and subsequently treated with chronic intrathecal baclofen, which provided significant relief of spasticity symptoms. CASE REPORT: A 48-year-old white man with a history consistent with SPS presented to the clinic. His previous history showed that he met several diagnostic criteria for GAD(-) SPS and had a muscle biopsy positive for myositis. Oral medications were unable to control his muscle spasticity, preventing him from working. The patient received an intrathecal trial using a lumbar approach for placement of a thoracic catheter with an initial baclofen dose of 50 µg/d. Gradual titration to symptom relief was performed up to 150 µg/d. Functional evaluation by our physical therapist showed improved motor function, the temporary catheter was removed, and a permanent intrathecal pump placed for intrathecal baclofen infusion. The patient reported excellent symptom relief over the next 6 months and improved activity. CONCLUSIONS: Refractory SPS is difficult to treat and has few therapeutic options. We report a GAD(-) patient with SPS and resulting debilitating spasticity that was refractory to oral medications who underwent successful continuous intrathecal catheter trial of baclofen over 4 days and subsequently went on to implantation of intrathecal pump. The literature reports only 5 cases of GAD(-) SPS patients treated with intrathecal baclofen therapy, and these resulted in poor long-term success. Our patient completed a 4-day trial of intrathecal baclofen titrated to effect before pump implantation. We advocate continuous intrathecal trialing, as opposed to single-injection technique, to possibly better determine the effective therapeutic dose and ensure posttrialing successful therapy.

The long-term impact of physical and emotional trauma: the station nightclub fire.

BACKGROUND: Survivors of physical and emotional trauma experience enduring occupational, psychological and quality of life impairments. Examining survivors from a large fire provides a unique opportunity to distinguish the impact of physical and emotional trauma on long-term outcomes. The objective is to detail the multi-dimensional long-term effects of a large fire on its survivor population and assess differences in outcomes between survivors with and without physical injury. METHODS AND FINDINGS: This is a survey-based cross-sectional study of survivors of The Station fire on February 20, 2003. The relationships between functional outcomes and physical injury were evaluated with multivariate regression models adjusted for pre-injury characteristics and post-injury outcomes. Outcome measures include quality of life (Burn Specific Health Scale-Brief), employment (time off work), post-traumatic stress symptoms (Impact of Event Scale-Revised) and depression symptoms (Beck Depression Inventory). 104 fire survivors completed the survey; 47% experienced a burn injury. There was a 42% to 72% response rate range. Although depression and quality of life were associated with burn injury in univariate analyses (p<0.05), adjusted analyses showed no significant relationship between burn injury and these outcomes (p = 0.91; p = .51). Post-traumatic stress symptoms were not associated with burn injury in the univariate (p = 0.13) or adjusted analyses (p = 0.79). Time off work was the only outcome in which physical injury remained significant in the multivariate analysis (p = 0.03). CONCLUSIONS: Survivors of this large fire experienced significant life disruption, including occupational, psychological and quality of life sequelae. The findings suggest that quality of life, depression and post-traumatic stress outcomes are related to emotional trauma, not physical injury. However, physical injury is correlated with employment outcomes. The long-term impact of this traumatic event underscores the importance of longitudinal and mental health care for trauma survivors, with attention to those with and without physical injuries.

Increase in sensorimotor cortex response to somatosensory stimulation over subacute poststroke period correlates with motor recovery in hemiparetic patients.

BACKGROUND: . Somatosensory input to the motor cortex may play a critical role in motor relearning after hemiparetic stroke. OBJECTIVE: . The authors tested the hypothesis that motor recovery after hemiparetic stroke relates to changes in responsiveness of the sensorimotor cortex (SMC) to somatosensory input. METHODS: . A total of 10 hemiparetic stroke patients underwent serial functional magnetic resonance imaging (fMRI) during tactile stimulation and testing of sensorimotor function over 1 year-at early subacute, late subacute, and chronic poststroke time points. RESULTS: . Over the subacute poststroke period, increased responsiveness of the ipsilesional SMC to tactile stimulation of a stroke-affected digit correlated strongly with concurrent gains in motor function. Increased responsiveness of the ipsilesional and contralesional SMC over the subacute period also correlated strongly with motor recovery experienced over the first year poststroke. CONCLUSIONS: . These findings suggest that increased responsiveness of the SMC to somatosensory stimulation over the subacute poststroke period may contribute to motor recovery.

An introduction to trialing intrathecal baclofen in patients with hemiparetic spasticity: a description of 3 cases.

BACKGROUND: Intrathecal baclofen has been an effective therapy in the management of spasticity. As interventional pain physicians are rapidly becoming the experts in intrathecal drug delivery, they are now frequently asked to trial and implant intrathecal baclofen therapy. While some physicians might be very comfortable with the process of trialing and implanting, others will have next to no experience until the first consult appears on their desks. While uncomplicated lower extremity spasticity can usually be trialed with a single-shot bolus injection, more complicated cases of upper and lower extremities or hemiparetic spasticity need a more delicate approach. This is the first case series in the literature reporting a trial using an indwelling temporary catheter and inpatient admission. Moreover, while the technical aspects of intrathecal therapy trialing and implantation might be familiar for the interventional physician, we review the indications and goals of therapy, about which the physician may be less familiar. OBJECTIVE: To present a technique for trialing intrathecal baclofen in patients with severe upper and lower extremities spasticity complication for which a single shot technique may be inadequate. DESIGN: Case report of three patients. SETTING: Tertiary-care referral medical center. PATIENTS: A 30-year-old man with severe spasticity of the right upper and lower extremities with preserved left-sided function due to diffuse axonal injury. A 45-year-old woman with traumatic brain injury and severe spasticity of the left upper extremity with minimal dysfunction in the right upper extremity. A 34-year-old woman with Multiple Sclerosis and severe spasticity in the right upper extremity and bilateral lower extremities. INTERVENTION: Placement of a temporary intrathecal catheter and an inpatient trial of intrathecal baclofen. RESULTS: In all patients, there was significant improvement in spasticity as documented by decreased Modified Ashworth Scale scores while preserving motor strength and coordination in the unaffected extremities. LIMITATIONS: Retrospective review of 3 cases in a single center. CONCLUSIONS: Trialing for baclofen is usually performed as a single shot bolus. For patients with severe hemiparetic spasticity or in patients where weakness in the unaffected limb might significantly affect quality of life, this trialing technique may be inadequate. In these patients, placement of a temporary intrathecal catheter and inpatient admission may be a more effective trial method.

Inpatient rehabilitation after deep brain stimulator placement: a case series.

This case series describes the inpatient rehabilitation of two medically complex patients with Parkinson's disease (PD) who had undergone deep brain stimulator (DBS) placement. Most patients may not require inpatient rehabilitation. However, a short rehabilitation stay might be of use to patients who need to be weaned off medications or who need frequent adjustments of their deep brain stimulators. This is the first case series to describe the inpatient rehabilitation of patients with deep brain stimulators.

Clinical characteristics and rehabilitation outcomes of patients with posterior cerebral artery stroke.

OBJECTIVES: To describe the demographics, clinical profile, and functional outcomes in posterior cerebral artery (PCA) stroke and to identify factors associated with functional change during rehabilitation and discharge disposition. DESIGN: Retrospective study of patients with PCA stroke admitted to a rehabilitation hospital over an 8-year period. SETTING: Free-standing urban rehabilitation hospital in the United States. PARTICIPANTS: Eighty-nine consecutive patients with PCA stroke (48 men, 41 women; mean age, 71.5y) met inclusion criteria. INTERVENTION: Inpatient multidisciplinary comprehensive rehabilitation program. MAIN OUTCOME MEASURES: Demographic, clinical, and discharge disposition information were collected. Functional status was measured using the FIM instrument, recorded at admission and discharge. The main outcome measures were the discharge total FIM score, the change in total FIM score (DeltaFIM), and the discharge disposition. Multiple and logistic regression analyses were performed to identify factors associated with the main outcome measures. RESULTS: The most common impairments were motor paresis (65%), followed by visual field defects (54%) and confusion or agitation (43%). The mean discharge total FIM score +/- standard deviation was 88.3+/-28.2. The mean DeltaFIM was 23.3+/-16.4. Fifty-five (62%) patients were discharged home. On multiple regression analysis, higher admission total FIM score, longer length of stay (LOS), and a rehabilitation stay free of interruptions were associated with higher discharge total FIM score and greater DeltaFIM. Absence of diabetes mellitus and younger age were also associated with higher discharge total FIM scores, and male sex had greater DeltaFIM. On logistic regression analysis, younger patients, higher discharge FIM scores, presence of a caregiver, and the nonnecessity for 24-hour support were associated with a discharge to home. CONCLUSIONS: Motor, visual, and cognitive impairments are common in PCA stroke, and good functional gains are achievable after comprehensive rehabilitation. Higher admission FIM scores, longer LOS, and younger and male patients were associated with better functional outcomes. Most patients were discharged home, particularly those with caregivers and those for whom 24-hour support was not required. Further research should aim at the development of functional outcome measures of greater breadth and sensitivity to visual and cognitive deficits and should compare PCA stroke outcomes with outcomes of strokes in other vascular territories.

Data mining techniques to detect motor fluctuations in Parkinson's disease.

The purpose of this paper is to present preliminary evidence that data mining and artificial intelligence systems may allow one to recognize the presence and severity of motor fluctuations in patients with Parkinson's disease (PD). We hypothesize that movement disorders in late-stage PD present with identifiable and predictable features that can be derived from accelerometer (ACC) and surface electromyographic (EMG) signals recorded during the execution of a standardized set of motor assessment tasks. Although this paper focuses on a specific clinical application requiring advanced analysis techniques, the approach can be generalized to numerous applications in which data mining and other techniques can be used to analyze large data sets derived from wearable sensors.