A pilot study of pain management during rehabilitation for hip and knee arthroplasty.

UNLABELLED: {\it OBJECTIVE: } To evaluate the efficacy of pain management in a clinical pathway for rehabilitation after hip and knee arthroplasty, in which scheduled medications are rapidly tapered and prn medications are continued throughout the inpatient stay. {\it STUDY DESIGN: } A prospective cross-sectional study. {\it SETTING: } General rehabilitation unit of a regional acute rehabilitation center. {\it PATIENTS: } Twenty-nine patients admitted consecutively to the rehabilitation unit in three months. {\it OUTCOME MEASURES: } Number of pills/day of prn pain medication, pain scores at admission and discharge, frequency of constipation and nausea, Functional Independence Measure (FIM) gain, and length of stay (LOS). {\it RESULTS: } For all patients, prn pain medication use was 2.4 pills/day/patient; the mean FIM gain was 22.1; and the average LOS was 9.8 days. In comparison to the Vicodin group, patients on Darvocet N-100 had significantly fewer requests for prn pain medication each day (3.1 vs. 1.1, p < 0.01), significantly better FIM gains better (18.9 vs. 24.1, p < 0.05), and fewer side effects (nausea and constipation). {\it CONCLUSION: } Choosing the right pain medication is imperative for achieving optimal efficiency in clinical pathways for orthopedic rehabilitation. In this pilot study, Darvocet N-100 is the preferred narcotic over codeine and its derivatives.

Human immunodeficiency virus infection and diffuse polyneuropathy. Implications for rehabilitation medicine.

Patients at various stages of human immunodeficiency virus (HIV) infection require rehabilitation services. These patients present problems for each of the disciplines in a rehabilitation team, and all team members must confront the psychosocial and ethical issues involved with the disease. Patients with HIV infection may have polyneuropathy with multisystem involvement, including dysphagia, autonomic dysfunction, respiratory failure, bowel and bladder dysfunction, generalized weakness, a painful sensory neuropathy, and depression. Guidelines are presented for determining if inpatient rehabilitation or other settings are appropriate. Case management is a valuable strategy for the rehabilitation of patients with this complicated disorder.

Rehabilitative management of polyarteritis: a case report.

A 75-year-old woman with polyarteritis who developed polyneuropathy and quadriplegia underwent intensive rehabilitation that resulted in significant improvement. This report discusses various therapeutic strategies for the successful management of patients with severe polyarteritis. Strategies include orthotics for both upper and lower extremities, sensory reeducation, edema management, and the use of adaptive devices in retraining the patient with activities of daily living. The associated neurological, orthopedic, renal, and cardiac complications in the context of rehabilitation for this complex condition are discussed.

Delayed diagnosis of concomitant rotator cuff tear and brachial plexopathy in a patient with traumatic brain injury: a case report.

Traumatic brain injury (TBI) is often accompanied by additional trauma that can be obscured by cognitive dysfunction or multiple injuries in the same region of the body. This report describes the case of an unhelmeted motorcycle rider who collided with a telephone pole. He sustained a diffuse subarachnoid hemorrhage, bilateral subdural hematomas (right frontal and left temporal), diffuse axonal injury in the subcortical and periventricular white matter, and a left tibial fracture. After medical and surgical stabilization, he was transferred to a subacute rehabilitation facility and then to a rehabilitation center. He was evaluated for pain and limited range of motion in his right shoulder, where both a rotator cuff tear and a brachial plexopathy were diagnosed. This report discusses concomitant injuries that occur with TBI, and the management of rotator cuff tears and brachial plexopathy.

Midodrine for the management of orthostatic hypotension in patients with spinal cord injury: A case report.

A 21-year-old man sustained anterior displacement and a burst fracture of C7 in a motor vehicle crash. He underwent anterior corpectomy, decompression, fusion of C6-T1 vertebrae, and halo placement. The American Spinal Injury Association grade of his spinal cord injury (SCI) was C6 C tetraplegia. Severe orthostatic hypotension in the upright position complicated the patient's rehabilitation program. Midodrine was prescribed, and other medications with possible adverse effects were adjusted. Significant improvement after taking midodrine was reflected in the orthostatic vital signs and symptoms, as well as in FIM instrument scores. Staff noted improvements with therapy participation and functional status. The patient tolerated the midodrine well and had no significant side effects.

Common causes of knee effusions in spinal cord injury: a random study.

Patients with spinal cord injury are predisposed to knee effusions owing to osteoporosis, heterotopic ossification, trauma, and benign hydrarthrosis. This retrospective review discusses 11 patients with spinal cord injury and knee effusions seen during two years. One objective is to correlate the initial diagnosis based on clinical findings with the final diagnosis based on synovial fluid analysis and radiographic studies. Another is to describe the variety and complexity of clinical situations that involve knee effusions in spinal cord injury. The initial diagnosis was different from the final diagnosis in all of our cases. The final diagnoses were trauma (6 cases), pseudogout (2 cases), spasticity, fracture of the tibial plateau, septic joint, and tears of the anterior cruciate and lateral collateral ligaments. Knee effusions in this unique population must be carefully investigated to avoid erroneous diagnoses based on the initial clinical presentation, which can be complicated by multiple medical problems.

Pathological crying and laughing: treatment with sertraline.

OBJECTIVE: To evaluate the efficacy of sertraline for treating pathological laughing and crying after stroke. DESIGN: Case series. SETTING: Inpatient rehabilitation units of a community and a tertiary-care hospital. PATIENTS: One patient was a 62-year-old right-handed man who had two strokes approximately 2 years apart and had computed tomography consistent with a cerebral infarct involving the left middle cerebral artery branches in the left parietal lobe. A second patient was a 72-year-old right-handed man who had a right middle cerebral artery infarct. He had a questionable history of depression prior to the stroke. INTERVENTION: Both patients had poststroke labile affect that was interfering with their rehabilitation. Sertraline was prescribed. MAIN OUTCOME MEASURES: Pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. RESULTS: Both patients showed significant improvement after taking sertraline-improvement that was reflected in their pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. The staff noted improvements in sleeping, eating, social interaction, and therapy participation. Both patients tolerated the sertraline well and had no significant side effects.

Promoting smoking cessation in the rehabilitation setting.

Cigarette smoking is a known risk factor in patients with ischemic and hemorrhagic stroke. Smoking also increases the risk of cardiovascular disease, chronic bronchitis, emphysema, peptic ulcers, and cancer of several organs among middle-aged individuals and the elderly. In the elderly, smoking has also been associated with a general decline in physical functioning as a result of the increased incidence of chronic illnesses. The prevalence of smoking among community-dwelling adults aged 65 to 74 yr has been estimated to be 18% for men and 15% for women. More than 30% of Americans who are hospitalized each year are smokers. Although there are no published studies that have established the prevalence of smoking in a rehabilitation population, these data and our own clinical experience suggest that smoking continues to be a significant health problem for many persons who enter the inpatient rehabilitation setting. Because most hospitals have adopted a smoke-free policy, hospitalization itself may initiate a period of nonsmoking in patients who were smokers at the time of their admission. In addition, some smokers choose to quit smoking after stroke or other medical crisis caused by the health risks associated with cigarette smoking. However, research has also revealed a rather low-smoking cessation rate (30%) among smokers who have had a transient ischemic attack despite the health benefits associated with smoking cessation. Given the significant health risks associated with cigarette smoking, particularly in the elderly and those with cerebrovascular compromise, the effects of smoking on the patient's health should be discussed with the patient during inpatient rehabilitation. Unfortunately, given the current healthcare demands of reducing lengths of hospitalization and the focus on functional outcomes, health promotion issues, such as smoking cessation, nutrition, exercise, may not receive the attention that they deserve. Despite these constraints, we believe that the inpatient rehabilitation setting provides an opportunity for a "teachable moment" to introduce the idea of smoking cessation to the active smoker or to encourage continued smoking cessation and relapse prevention to those patients who have not smoked since their admission to the acute care hospital. If instituted in an effective manner, we believe that there could be significant healthcare benefits in establishing a formal smoking cessation or relapse prevention program in the rehabilitation setting.

The gastric emptying scan as a tool for surgical management of severe bowel dysfunction in spinal cord injury: 2 case reports.

We describe 2 patients with spinal cord injury (SCI) for whom the gastric emptying scan (GES) was crucial for determining the correct surgical approach in the therapeutic management of gastrointestinal complaints. Two men, ages 45 and 51 years, were admitted to a university hospital for delayed gastric complications from SCI. Both SCIs were traumatic, and the interval since injury was 18 months for the younger man and 6 months for the older man. Both men lacked voluntary motor and sensory function below the cord level of the lesion and had quadriplegia. Using GES, we measured motility (the cutoff for normal in this laboratory is 37%) and the time at which half the gastric contents were emptied (normal values are 45 +/- 8 min). Both patients had abnormal motility: residuals at 1 hour were above 50%. Half the gastric contents were emptied at 75 and 90 minutes, respectively. The therapeutic value of the GES was demonstrated for both patients, in combination with the history, physical examination, and abdominal radiographic studies. The first patient underwent ileostomy, and the second required a gastrostomy tube and a jejunostomy tube in addition to metoclopramide. The GES is a valuable diagnostic tool with an important role in the surgical management of patients with SCI.

Incidence of neurologic deficits and rehabilitation of patients with brain tumors.

OBJECTIVE: To report and discuss common neurologic problems in adults with brain tumors admitted for inpatient rehabilitation at an acute rehabilitation center. DESIGN: Retrospective, descriptive, case series of 51 consecutive adult patients (65% male), with a variety of tumor types (31.3% glioblastoma, 25.5% meningioma, and 25.5% metastatic). Outcome measures were the functional status as measured by the FIM scores, the length of rehabilitation stay, and discharge dispositions. RESULTS: The most common deficit was impaired cognition (80%), followed by weakness (78%), visual-perceptual deficit (53%), sensory loss (38%), and bowel and bladder dysfunction (37%). Less common problems, in decreasing incidence, were cranial nerve palsy, dysarthria, dysphagia, aphasia, ataxia, and diplopia. Thirty-eight (74.5%) patients had three or more concurrent neurologic deficits, and 20 (39.2%) patients had five or more deficits. Concurrent deficits among patients with hemi- and tetraparesis involved cognition (n = 29 patients), visual-perceptual function, sensation, cranial nerve palsy, and neurogenic bowel/bladder. The average admission FIM score of 67.2 increased to 87.1 at the time of discharge, with similar gains between patients with primary brain tumor and metastatic disease. Thirty-five patients were discharged home, seven to a nursing home, and one to hospice care; there were eight acute transfers. CONCLUSIONS: Impaired cognition, weakness, and visual-perceptual deficits were the most common problems in this study population. Our study supports the benefits of comprehensive and interdisciplinary rehabilitation for patients with primary as well as metastatic brain tumors.

Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series.

OBJECTIVE: To evaluate the efficacy of carbidopa L-dopa (Sinemet) in reducing left spatial neglect after stroke. DESIGN: Case series. SETTING: Inpatient neurorehabilitation unit in a regional rehabilitation center. PARTICIPANTS: A convenience sample of 4 women with right brain strokes and left neglect. INTERVENTION: A trial of carbidopa L-dopa to treat left neglect, if indicated by selected subtests of the Behavioral Inattention Test (BIT). MAIN OUTCOME MEASURES: Baseline and posttreatment evaluation with the modified BIT and the FIM instrument. RESULTS: Three of 4 subjects had significant improvements in their modified BIT scores (8%, 12%, 27%, respectively) and their functional status on the FIM. CONCLUSION: With further study, carbidopa L-dopa may be shown to reduce unilateral spatial neglect and thereby improve rehabilitation outcomes.