Christina M. Marciniak

Functional outcome following rehabilitation of the cancer patient

OBJECTIVE To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE Functional status as measured by the motor score of the Functional Independence Measure. RESULTS Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Literature review of the usefulness of repetitive nerve stimulation and single fiber EMG in the electrodiagnostic evaluation of patients with suspected myasthenia gravis or Lambert-Eaton myasthenic syndrome

A retrospective literature review of the electrodiagnosis of myasthenia gravis (MG) and Lambert–Eaton myasthenic syndrome (LEMS) through July 1998 was performed for the purpose of generating evidence‐based practice parameters. There were 545 articles identified, of which 13 articles met at least three of the six criteria set previously by the American Association of Electrodiagnostic Medicine (AAEM). An additional 21 articles were identified from review articles or the references of these first 13 articles leading to a total of 34 articles. Results of studies utilizing repetitive nerve stimulation (RNS) showed that a 10% decrement in amplitude from the first to fourth or fifth intravolley waveform while stimulating at 2–5 HZ is valid for the diagnosis of MG. The degree of increment needed for the diagnosis of LEMS is at least 25% but most accurate when greater than 100%. Abnormal jitter or impulse blocking are the appropriate criteria for diagnosis of neuromuscular junction (NMJ) disorders when using single fiber electromyography (SFEMG). SFEMG is more sensitive than RNS for the diagnosis of disorders of neuromuscular transmission, but may be less specific and may not be available. Therefore, RNS remains the preferred initial test for MG and LEMS.

Repeated dosing of botulinum toxin type A for upper limb spasticity following stroke

The authors evaluated the long-term efficacy and safety of botulinum toxin type A (BTX-A) in poststroke spasticity patients who completed a 12-week placebo-controlled study and received multiple open-label treatments with 200 to 240 U BTX-A for 42 weeks. Significant and sustained improvements were observed for Disability Assessment and Ashworth scores. Adverse events were generally mild. This extension of a double-blind study demonstrates that repeated treatments of BTX-A significantly improve function and tone in spasticity.

Wii Fit Balance Board Playing Improves Balance and Gait in Parkinson Disease

To assess the effect of exercise training by using the Nintendo Wii Fit video game and balance board system on balance and gait in adults with Parkinson disease (PD).

Practice parameter: Utility of electrodiagnostic techniques in evaluating patients with suspected peroneal neuropathy: An evidence-based review

An evidence‐based review of electrodiagnostic (EDX) techniques in the evaluation of peroneal neuropathy was conducted to determine whether these techniques are useful for diagnosis and prognostication in this disorder. A Medline search and a review of relevant sources were performed in 1999 and updated through July 2003 to identify articles describing the use of EDX in patients suspected to have peroneal neuropathy. From the 499 articles identified, 112 articles describing motor and sensory nerve conduction studies and needle electromyography in peroneal neuropathy were reviewed in detail; 11 articles met the predetermined literature inclusion criteria for the adequacy of EDX techniques employed. Six articles provided Class III evidence in support of a role for nerve conduction studies in making the diagnosis of peroneal neuropathy; five articles provided Class IV evidence. Implicit in making the diagnosis were normal EDX findings outside the distribution of the peroneal nerve. The current literature supports the use of EDX in patients with suspected peroneal neuropathy (Level C recommendation). Muscle Nerve, 2005

The use of botulinum toxin for spasticity after spinal cord injury.

Marciniak C, Rader L, Gagnon C: The use of botulinum toxin for spasticity after spinal cord injury. Am J Phys Med Rehabil 2008;87:312–320. Objective:To describe the use and effects of botulinum toxin (BTX) injections in persons with spinal cord injury (SCI) and focal spasticity. Design:Chart review of patients with SCI receiving their first injection of BTX for spasticity control at a freestanding urban rehabilitation hospital. Charts were reviewed for history and level of SCI, one of five self-identified goals (ambulation, positioning, upper-extremity function, hygiene, and pain control) before and after injection; site and doses of BTX used; and self-reported outcome on clinical follow-up. Results:Charts of 28 adults receiving BTX were reviewed. All patients received BTX type A. Dosages of BTX ranged from 10 to 119 units per muscle. Improvement was noted for 56% in ambulation and 71% in positioning. Overall, upper-extremity function improved in 78%, hygiene improved in 66.6%, and pain decreased in 83.3%. Early use of BTX injections (less than a year after onset of symptoms) vs. late use of BTX injections did not influence effectiveness. Conclusions:BTX seems to be an effective treatment for focal spasticity and for reducing disability in persons with SCI. Randomized trials are needed to confirm the value of this treatment in the setting of SCI.

Poststroke hypertonicity: upper limb assessment and treatment.

Abstract Hypertonicity is common in patients with upper limb dysfunction following hemiplegic stroke and is associated with greater impairment, worse function, and lower health-related quality of life. In addition to increased rest activity, abnormal patterns of muscle activation, such as spastic co-contraction, may contribute to disability. In the upper limb, flexor muscles are more commonly involved distally, and at the shoulder, spasticity of adductors, flexors, and internal rotators is most often observed. Prior to interventions, a history regarding prior interventions, comorbid diagnoses, and limitations imposed by abnormal tone should be elicited. Commonly used scales to assess hypertonicity include the Modified Ashworth, the Modified Tardieu, the Spasm Frequency, the Disability Assessment, the Fugl-Meyer, and the Motor Assessment Scales. Treatment interventions for upper limb hypertonicity include stretching, splinting, strengthening of antagonist muscles, oral medications, and focal injections (phenol or botulinum toxins). Intrathecal baclofen may also impact upper limb tone. For focal injections, correct identification of muscles contributing to problematic tone is evaluated by eliciting resistance to movement at rest and observation of patterns of tightness as the limb is used functionally. The botulinum toxins have been shown to decrease tone in stroke survivors and improve active and passive functioning. Because secondary changes such as contractures and weakness may occur with prolonged hypertonicity, therapy to improve range of motion, strengthen weakened muscles, and incorporate use of the limb should be considered following focal injections, oral medications, or intrathecal pump placement.

Long-term Intrathecal Baclofen: Outcomes After More than 10 Years of Treatment

To report outcomes of intrathecal baclofen (ITB) therapy for spasticity management in a cohort of patients who had received this treatment for at least 10 years.

Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: A case-control study

Marciniak C, Korutz AW, Lin E, Roth E, Welty L, Lovell L: Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study. Objective:To assess the association of selected clinical factors and specific medication use (proton pump inhibitors, H2 receptor antagonists [H2 blockers], and angiotensin-converting enzyme inhibitors) with presence of pneumonia in patients with stroke undergoing acute inpatient rehabilitation. Design:Matched case-control study in a freestanding urban academic inpatient acute rehabilitation hospital. Participants were 72 stroke survivors, consisting of 36 patients who developed pneumonia during rehabilitation hospitalization individually matched in order of decreasing priority on age, sex, stroke side, depth, and severity with 36 patients with stroke not developing pneumonia. Potential risk factors, including severe dysphagia, dietary interventions, presence of tracheostomy or feeding tube, and specific medications, were assessed for association with pneumonia during rehabilitation using separate univariate and multivariate analyses. Functional change was assessed using the functional independence measure. Results:Although pneumonia was associated with proton pump inhibitors or H2 blockers (odds ratio, 3.3; 95% confidence interval, 1.0–13.7), any feeding tube (odds ratio: 5.0; 95% confidence interval, 1.4–27.0), severe dysphagia (odds ratio: 15.0; 95% confidence interval, 2.3–631), and tracheostomy (odds ratio: 10; 95% confidence interval, 1.4–434.0) on univariate evaluation, none of these individual factors was significantly associated with pneumonia in a multivariate model. Risk factors were found to be highly related to each other. Odds of pneumonia did not significantly decrease with angiotensin-converting enzyme inhibitors (odds ratio: 0.9; 95% confidence interval, 0.2–3.0). Patients with pneumonia had a significantly lower functional independence measure score at discharge. Conclusions:A reduction in pneumonia was not found with the use of angiotensin-converting enzyme inhibitors. Although tracheostomies, feeding tubes, proton pump inhibitor or H2 blocker use, and the presence of dysphagia were identified as risk factors for pneumonia on univariate analyses, none of these factors demonstrated an independent association with pneumonia on multivariate analyses. It may be more that the underlying impairment, rather than the assessed interventions, may confer greater risk of pneumonia in the poststroke patient.

Functional outcomes of childhood dorsal rhizotomy in adults and adolescents with cerebral palsy: Clinical article

OBJECT In this descriptive study the authors evaluated medical outcomes, interventions, satisfaction with life, and subjective impressions about selective dorsal rhizotomy (SDR) in older adolescents and adults who had undergone the procedure as children. METHODS A survey was administered to older adolescents (16-20 years old) and adults with CP who had undergone SDR between 1986 and 2000 at two academic centers. The patients or their caregivers participated in telephone or clinic interviews. Subjective impressions about the SDR and a history of post-SDR medical interventions were obtained. Current functional status, history and ratings of pain, educational achievement, living situation, and subjective health status were also recorded. The Diener Satisfaction with Life Scale (SWLS) was administered. RESULTS Eighty-eight participants, mean age 25.6 ± 4.8 years (mean ± standard deviation), were interviewed at a mean of 19.6 ± 3.0 years after surgery. The distribution of current reported Gross Motor Function Classification System levels was as follows: I, 7%; II, 18%; III, 23%; IV, 36%; and V, 16%. Moreover, 56% of respondents were living with parents and 25% were living alone. Thirty-five percent were employed, and 39% were still in school. The mean overall SWLS score was 26.0 ± 7.3, indicating a high level of satisfaction with life. According to 65% of the patients, the SDR was helpful; 31% were uncertain about the procedures efficacy. Sixty-five percent would recommend the procedure to others. Fifty-eight percent reported excellent to very good health. Forty-four percent reported pain in the past week. Fifty-one percent reported chronic back pain in general. Logistic regression analysis suggested that an increased satisfaction with life was a predictor (p = 0.01) of an affirmative response to the question about recommending the procedure to others and that better overall health showed a trend toward being such a predictor (p = 0.08). Additional interventions were frequently performed after the SDR. Seventy-four percent of participants underwent orthopedic surgery. Thirty-eight percent were currently taking oral medications for tone, and 53% had received botulinum toxin injections for spasticity treatment. Thirteen patients (15%) had an intrathecal baclofen pump placed. CONCLUSIONS The majority of adults who had undergone SDR as children would recommend the procedure to others. Very few reported negative impressions of the procedure. Levels of satisfaction with life were generally high. Pain prevalence was similar to what has been reported in the literature for adults with cerebral palsy. Despite the SDR, further interventions, both surgical and nonsurgical, were used in the majority of patients.