A prediction model of military combat and training exposures on VA service-connected disability: a CENC study.

Background: Research has shown that number of and blast-related Traumatic Brain Injuries (TBI) are associated with higher levels of service-connected disability (SCD) among US veterans. This study builds and tests a prediction model of SCD based on combat and training exposures experienced during active military service.Methods: Based on 492 US service member and veteran data collected at four Department of Veterans Affairs (VA) sites, traditional and Machine Learning algorithms were used to identify a best set of predictors and model type for predicting %SCD ≥50, the cut-point that allows for veteran access to 0% co-pay for VA health-care services.Results: The final model of predicting %SCD ≥50 in veterans revealed that the best blast/injury exposure-related predictors while deployed or non-deployed were: 1) number of controlled detonations experienced, 2) total number of blast exposures (including controlled and uncontrolled), and 3) the total number of uncontrolled blast and impact exposures.Conclusions and Relevance: We found that the highest blast/injury exposure predictor of %SCD ≥50 was number of controlled detonations, followed by total blasts, controlled or uncontrolled, and occurring in deployment or non-deployment settings. Further research confirming repetitive controlled blast exposure as a mechanism of chronic brain insult should be considered.

The Chronic Effects of Neurotrauma Consortium (CENC) multi-centre observational study: Description of study and characteristics of early participants.

PRIMARY OBJECTIVES: To establish and comprehensively evaluate a large cohort of US veterans who served in recent military conflicts in order to better understand possible chronic and late-life effects of mild traumatic brain injury (mTBI), including those that may stem from neurodegeneration. RESEARCH DESIGN: Cross-sectional and prospective longitudinal. METHODS AND PROCEDURES: Inclusion criteria are prior combat exposure and deployment(s) in Operation Enduring Freedom, Operation Iraqi Freedom or one of their follow-on conflicts (collectively OEF/OIF). Effects of mTBI will be assessed by enrolling participants across the entire spectrum of mTBI, from entirely negative to many mTBIs. Longitudinal assessments consist of in-person comprehensive testing at least every 5 years, with interval annual telephonic testing. The primary outcome is the composite score on the NIH Toolbox neuropsychological test battery. Assessments also include structured interviews, questionnaires, traditional neuropsychological testing, motor, sensory and vestibular functions, neuroimaging, electrophysiology, genotypes and biomarkers. MAIN OUTCOMES AND RESULTS: The authors fully describe the study methods and measures and report demographic and exposure characteristics from the early portion of the cohort of OEF/OIF veterans. CONCLUSIONS: This centrepiece observational study of the Chronic Effects of Neurotrauma Consortium (CENC) is successfully launched and, within several years, should provide fertile data to begin investigating its aims.

Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury.

PRIMARY OBJECTIVES: To measure common psychiatric conditions after military deployment with blast exposure and test relationships to post-concussion syndrome (PCS) symptoms and mild traumatic brain injury (mTBI) history. RESEARCH DESIGN: Cross-sectional. METHODS AND PROCEDURES: Service members or Veterans (n = 107) within 2 years of blast exposure underwent structured interviews for mTBI, post-traumatic stress disorder (PTSD) and multiple mood and anxiety diagnoses. MAIN OUTCOMES AND RESULTS: MTBI history and active PTSD were both common, additionally 61% had at least one post-deployment mood or anxiety disorder episode. Psychiatric diagnoses had a high degree of comorbidity. Most dramatically, depression was 43-times (95% CI = 11-165) more likely if an individual had PTSD. PCS symptoms were greater in those with post-deployment PTSD or mood diagnosis. However, neither mTBI nor blast exposure history had an effect on the odds of having PTSD, mood or anxiety condition. CONCLUSIONS: These findings support that psychiatric conditions beyond PTSD are common after military combat deployment with blast exposure. They also highlight the non-specificity of post-concussion type symptoms. While some researchers have implicated mTBI history as a contributor to post-deployment mental health conditions, no clear association was found. This may partly be due to the more rigorous method of retrospective mTBI diagnosis determination.

Utility of post-traumatic amnesia in predicting 1-year productivity following traumatic brain injury: comparison of the Russell and Mississippi PTA classification intervals.

BACKGROUND: Duration of post-traumatic amnesia (PTA) correlates with global outcomes and functional disability. Russell proposed the use of PTA duration intervals as an index for classification of traumatic brain injury (TBI) severity. Alternative duration-based schemata have been recently proposed as better predictors of outcome to the commonly cited Russell intervals. OBJECTIVE: Validate a TBI severity classification model (Mississippi intervals) of PTA duration anchored to late productivity outcome, and compare sensitivity against the Russell intervals. METHODS: Prospective observational data on TBI Model System participants (n=3846) with known or imputed PTA duration during acute hospitalisation. Productivity status at 1-year postinjury was used to compare predicted outcomes using the Mississippi and Russell classification intervals. Logistic regression model-generated curves were used to compare the performance of the classification intervals by assessing the area under the curve (AUC); the highest AUC represented the best-performing model. RESULTS: All severity variables evaluated were individually associated with return to productivity at 1 year (RTP1). Age was significantly associated with RTP1; however, younger patients had a different association than older patients. After adjustment for individually significant variables, the odds of RTP1 decrease by 14% with every additional week of PTA duration (95% CI 12% to 17%; p<0.0001). The AUC for the Russell intervals was significantly smaller than the Mississippi intervals. CONCLUSIONS: PTA duration is an important predictor of late productivity outcome after TBI. The Mississippi PTA interval classification model is a valid predictor of productivity at 1 year postinjury and provides a more sensitive categorisation of PTA values than the Russell intervals.

A multicentre study on the clinical utility of post-traumatic amnesia duration in predicting global outcome after moderate-severe traumatic brain injury.

BACKGROUND: Past research shows that post-traumatic amnesia (PTA) duration is a particularly robust traumatic brain injury (TBI) outcome predictor, but low specificity limits its clinical utility. OBJECTIVES: The current study assessed the relationship between PTA duration and probability thresholds for Glasgow Outcome Scale (GOS) levels. METHODS: Data were prospectively collected in this multicentre observational study. The cohort was a consecutive sample of rehabilitation patients enrolled in the National Institute on Disability and Rehabilitation Research funded TBI Model Systems (n = 1332) that had documented finite PTA duration greater than 24 h, and 1-year and 2-year GOS. RESULTS: The cohort had proportionally more Good Recovery (44% vs 39%) and less Severe Disability (19% vs 23%) at year 2 than at year 1. Longer PTA resulted in an incremental decline in probability of Good Recovery and a corresponding increase in probability of Severe Disability. When PTA ended within 4 weeks, Severe Disability was unlikely (<15% chance) at year 1, and Good Recovery was the most likely GOS at year 2. When PTA lasted beyond 8 weeks, Good Recovery was highly unlikely (<10% chance) at year 1, and Severe Disability was equal to or more likely than Moderate Disability at year 2. CONCLUSIONS: Two PTA durations, 4 weeks and 8 weeks, emerged as particularly salient GOS probability thresholds that may aid prognostication after TBI.

Case report and rehabilitative management of a complete musculocutaneous nerve injury caused by shoulder dislocation.

Anterior shoulder dislocation can secondarily cause nerve injury and/or rotator cuff tear. An elderly male with a recent shoulder dislocation and multiple medical comorbidities was transferred to a rehabilitation inpatient service in order to maximize his functional status. Physical exam suggested a brachial plexus injury. Electrodiagnostic testing confirmed a complete musculocutaneous and a partial axillary nerve lesion. This specific combination of nerve lesions is a previously unreported complication of anterior shoulder dislocation. Prognosis and treatment are discussed, particularly the use of electrodiagnostic findings to tailor rehabilitation program design.

Return to work for patients with low back pain: two case studies.

Dismal return to work rates and mounting disability costs in the chronic low back pain (LBP) population imply the need for innovative re-employment strategies. The supported employment approach utilizes a vocational specialist under close physician supervision. It is more proactive, less biased, and more specialized than the more traditional case management approach used by many insurance companies. Supported employment has been used extensively at our institution in the brain injured population and we have recently begun exploring its use in LBP patients. Herein, we describe the successful use of supported employment in two individuals with chronic disabling LBP.

Silent cardiac ischemia in cervical spinal cord injury: case study.

The management of ischemic heart disease in patients with chronic spinal cord injury (SCI) will become an increasingly major concern as this population ages. Although silent ischemia has become an important topic in the medical literature, the relationship with cervical SCI has not been adequately explored. A literature search revealed no case reports of documented asymptomatic cardiac ischemia in SCI patients. This is a case report of a 65-year-old patient with chronic C7 incomplete SCI who had multiple risk factors for coronary artery disease and an abnormal electrocardiogram. Despite being completely asymptomatic, the patient was found to have significant myocardial ischemia induced by minimal stress using atrial paced thallium scintigraphy. This finding led to the cancellation of an elective surgical procedure. This case illustrates the importance of suspecting silent myocardial ischemia in cervical SCI patients.

Cardiopulmonary rehabilitation and cancer rehabilitation. 1. Cardiac rehabilitation.

UNLABELLED: This self-directed learning module highlights cardiac rehabilitation issues facing able-bodied populations. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on various aspects of the management of cardiac disease and rehabilitation, including medication, exercise, risk-factor modification, secondary prevention, and surgery. Topics discussed include myocardial infarction, coronary artery disease, cardiomyopathy, and angina. New advances covered in this article include the various phases of cardiac rehabilitation, data on lifestyle adaptations for cardiac disease, and recent surgical advances for the treatment of severe heart failure. OVERALL ARTICLE OBJECTIVE: To review aspects of the management of cardiac disease and rehabilitation, including medication, exercise, risk-factor modification, secondary prevention, and surgery.

Cardiopulmonary rehabilitation and cancer rehabilitation. 2. Cardiac rehabilitation in disabled populations.

UNLABELLED: This self-directed learning module highlights the clinical characteristics, medical treatment, and rehabilitation interventions of several cardiac scenarios encountered in physiatric practice. It is part of the chapter on cardiac rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses myocardial infarction during amputation, stroke as a result of cardiac surgery, myocardial perfusion defects in spinal cord injury, and heart murmur in Down syndrome. It also covers current medical management and the benefits of comprehensive rehabilitation and interventions for specific impairments seen in these conditions. OVERALL ARTICLE OBJECTIVE: To describe the clinical characteristics, medical treatment, and rehabilitation interventions of 4 cardiac scenarios encountered in physiatric practice.

Cardiopulmonary rehabilitation and cancer rehabilitation. 3. Pulmonary rehabilitation.

UNLABELLED: This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with pulmonary diseases and in the pulmonary management of neurologic disorders. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Topics reviewed in the rehabilitation of pulmonary diseases include interdisciplinary programming for patients with chronic obstructive pulmonary disease, the role of rehabilitation in lung transplantation and lung volume reduction surgery, and chest physiotherapy and other rehabilitation strategies for patients with cystic fibrosis. The pulmonary management of several neuromuscular disorders is discussed, with attention to the recognition of early pulmonary dysfunction, the role of ventilatory muscle training, and the indications and options for assisted ventilation. OVERALL ARTICLE OBJECTIVE: (a) To review the assessment and therapeutic options in the rehabilitation of patients with pulmonary diseases and (b) to describe the pulmonary management of neurologic disorders.

Level of care options for the low-functioning brain injury survivor.

During the early stages of recovery from severe brain injury many patients are comatose or minimally responsive. Rehabilitation for these low-functioning survivors traditionally includes acute medical care and transfer to a skilled nursing facility or acute rehabilitation. Concerns have been expressed that customary treatment options are ineffective, costly, or both. In response, 'intermediate'-level programmes designed to provide effective, cost-efficient rehabilitation have emerged. The purpose of this paper is to provide information regarding outcome of severe brain injury and the early rehabilitation needs of survivors. Common characteristics, advantages, and disadvantages of various intermediate programmes, including 'subacute' and 'transitional' rehabilitation, are discussed and contrasted.

Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions.

OBJECTIVE: To compare the effects of night-only to full-time splint wear instructions on symptoms, function, and impairment in carpal tunnel syndrome (CTS). DESIGN: Randomized clinical trial with 6-week follow-up. SETTING: Veterans Administration Medical Center, outpatient clinic. SUBJECTS: Outpatients with untreated CTS were consecutively recruited from our electrodiagnostics lab. Twenty-one patients (30 hands) were enrolled, and 17 patients (24 hands) completed the study. INTERVENTIONS: Thermoplastic, custom-molded, neutral wrist splints with subjects receiving either full-time or night-only wear instructions. OUTCOME MEASURES: Symptoms and functional deficits were measured by Levine's self-administered questionnaire, and physiologic impairment was measured by median nerve sensory and motor distal latency. COMPLIANCE AND CROSSOVER: Almost all (92%) of the combined sample reported frequent splint use, but their adherence to specific wearing instructions was limited. A majority (73%) of the full-time group reported splint wear less than one half of waking hours, and some (23%) of the night-only group reported occasional daytime wear. Despite this tendency for treatment crossover, the two treatment groups differed in daytime wear as intended (chi2 analysis, p = .004). RESULTS: The combined sample improved in three of four outcome measures: sensory distal latency (mean = .28msec, standard deviation [SD] = .37, p = .004), symptom severity (mean = .64, SD = .46, p = .0001), and functional deficits (mean = .49, SD = .51, p = .0001). Severity of CTS was a factor only in sensory distal latency improvement (more improvement in severe CTS). Subjects receiving full-time wear instructions showed superior distal latency improvement, both motor (.35 vs -.07msec, p = .04) and sensory (.46 vs . 13msec, p = .05) when compared with subjects receiving night-only wear instructions. CONCLUSIONS: This study provides added scientific evidence to support the efficacy of neutral wrist splints in CTS and suggests that physiologic improvement is best with full-time splint wear instructions.

Inpatient interdisciplinary rehabilitation after total hip arthroplasty surgery: a comparison of revision and primary total hip arthroplasty.

OBJECTIVES: To describe outcomes of revision total hip arthroplasty (THA) patients who underwent interdisciplinary inpatient rehabilitation, and to compare them with primary THA patients. DESIGN: Descriptive and case-control study. SETTING: Forty-bed, community-based, freestanding rehabilitation hospital. PATIENTS: Thirty-nine revision THA subjects, gender- and age-matched with 39 primary THA controls. INTERVENTION: Inpatient interdisciplinary rehabilitation. MAIN OUTCOME MEASURES: FIM instrument, length of stay, hospital charges, and disposition location. RESULTS: The average revision THA patient stayed 10.5 days, improved from an admission FIM score of 89 to a discharge FIM score of 110, and incurred a hospital charge of $10,600. Of the revision THA patients, 98% were discharged home, and orthopedic-related complications were uncommon. No significant differences existed between revision and primary THA patients in any outcome measures. A trend toward higher rehabilitation charges ($12,400 vs $9500, p =.07) was found in revision THA patients who wore a hip orthosis. Otherwise, no differences were found in outcome measures based on the type of revision surgery, the presence of weight-bearing restrictions, or the presence of orthopedic complications. CONCLUSIONS: THA patients selected for inpatient rehabilitation have favorable short-term functional outcomes. The type of THA (primary vs revision) is not an independent differentiating factor.

Functional assessment in patients with chronic pain: can physicians predict performance?

OBJECTIVES: To determine the appropriateness of using physicians to estimate the functional abilities of patients with chronic pain. Specific objectives included the following: (1) to compare the physician's predicted performance on functional assessment with actual performance, and (2) to compare the physician's predicted effort during functional assessment with an objective measure of effort. DESIGN: A total of 201 outpatients with chronic pain completed this prospective, multicenter, cohort study. Fifteen physicians, who were trained to administer the standardized evaluation, performed the evaluations and predicted performance and effort on functional assessment. Therapists, blinded to the physician's evaluation, administered a functional assessment (maximal and sustained lifts [n = 3 types]; repetitive activities [n = 4 types]) and a grip dynamometry test (effort measure) on each subject. RESULTS: Pearson's correlation testing demonstrated significant correlations between the physician's predicted performance and the observed performance for all lifting items and repetitive activities in both men (0.52, 0.50, 0.55) and women (0.36, 0.40, 0.18). Analysis of variance and post hoc t tests showed agreement between the physician's predicted effort and the dynamometry effort measure in only a small subset of patients (men were predicted to put forth absolutely no effort; n = 4). CONCLUSIONS: A trained physician, performing a standardized evaluation, can estimate with reasonable accuracy the work-related functional ability in patients with chronic pain. The prediction of effort seems to be more problematic.

Relation of electromyography-induced pain to type of recording electrodes.

Pain is an important consideration in the performance of needle electromyography (EMG). Prior investigations have suggested that pain is greater with a concentric needle electrode (CNE) than monopolar needle electrode (MNE). This prospective randomized study tested this hypothesis using improved methodology and disposable rather than reusable needle electrodes. Ninety consecutive outpatients were enrolled and randomized to CNE (diameter = 0.46 mm) or MNE (diameter = 0.41 mm) arms. Subjects underwent a standardized 4 limb-muscle needle EMG protocol during which pretest and posttest verbal analog pain scale (0-10) measures were obtained. As anticipated, EMG-induced pain was significantly higher (P < 0.001) than pre-EMG baseline pain. However, analysis of variance (ANOVA) revealed no significant differences in pain ratings between the CNE and MNE arms. Among other factors analyzed, only gender significantly influenced EMG-induced pain, with females reporting higher levels than males. Thus, pain is not an important selection criterion for type of disposable needle electrode.