Cindy B. Ivanhoe

Prediction of employment outcome one to three years following traumatic brain injury (TBI)

The current study investigated the relationship between age, education (EDUC), pre-injury productivity (PIP), Glasgow Coma Scale score, and a functional rating score at admittance and discharge from rehabilitation (Disability Rating Scale [DRS]) to employment status at one to three years following traumatic brain injury. EDUC, admit DRS, discharge DRS, and PIP all correlated significantly with follow-up employment status, 0.29, -0.32, -0.36, and 0.25 respectively. All possible combinations were then evaluated by Mallows Cp statistic. The best fitting model was then used in a discriminant function analysis. The discriminant function correctly classified 84% of the employed subjects, 66% of the unemployed, and 75% across both groups. The current results compare favourably with those obtained in previous studies.

Botulinum toxin in severe upper extremity spasticity among patients with traumatic brain injury An open-labeled trial

We studied the effect of botulinum toxin A (BTXA) among patients with traumatic brain injury (TBI) and severe spasticity unresponsive to conservative management.Twenty-one consecutive adult patients with severe spasticity involving the wrist and finger flexor musculature were treated with BTXA injection (20 to 40 units per muscle) under EMG guidance. After injection, patients received passive range of motion (ROM) exercise, with modalities and casting as clinically indicated. Outcome measures, including wrist ROM and the modified Ashworth Scale (MAS), were assessed 2 to 4 weeks after injection. Among the respective acute and chronic groups, mean ROM improved 42.9 (p = 0.001) and 36.2 degrees (p < 0.001). Mean MAS rating improved 1.5 (p = 0.01) and 1.47 (p = 0.002) points. There were no significant adverse effects. BTXA, in conjunction with conventional modalities, significantly improves spasticity and ROM in the distal upper extremity musculature of patients with TBI. NEUROLOGY 1996;47: 939-944

Spasticity: The misunderstood part of the upper motor neuron syndrome

Ivanhoe CB, Reistetter TA: Spasticity: The misunderstood part of the upper motor neuron syndrome. Am J Phys Med Rehabil 2004;83(suppl):S3–S9. Spasticity is a sensorimotor phenomenon related to the integration of the nervous system motor responses to sensory input. Although most commonly considered a velocity-dependent increase to tonic stretch, it is related to hypersensitivity of the reflex arc and changes that occur within the central nervous system, most notably, the spinal cord. Injury to the central nervous system results in loss of descending inhibition, allowing for the clinical manifestation of abnormal impulses. Muscle activity becomes overactive. This is mediated at several areas of the stretch-reflex pathway. Although spasticity is part of the upper motor neuron syndrome, it is frequently tied to the other presentations of the said syndrome. Contracture, hypertonia, weakness, and movement disorders can all coexist as a result of the upper motor neuron syndrome. Although basic science descriptions of spasticity are being elucidated, clinically, confusion exists.

Efficacy of early use of intrathecal baclofen therapy for treating spastic hypertonia due to acquired brain injury.

Objective. To determine the efficacy and safety of early (<1 year post-disease onset) use of intrathecal baclofen (ITB). Design. Consecutive case series of 14 individuals with spastic hypertonia due to trauma (5), anoxia (6) and stroke (3). Main outcome measures. Modified Ashworth (MAS) and Disability Rating (DRS) scales. Interventions. ITB pump placement within 1 year of onset, after inadequate response to other previous treatment modalities. Results. At follow-up after ITB pump implantation (mean = 13.9 months; mean daily dose = 591.5 µg per day), mean MAS scores improved from baseline by 1.0 and 2.1 points in the upper and lower limbs, respectively. DRS scores did not change significantly. Functional gains included decreased pain and improved gait speed and motor skills. The only complication was spinal leak in one subject. Conclusions. ITB therapy within 1 year of onset of acquired brain injury appears effective and safe in decreasing spastic hypertonia and does not appear to adversely affect recovery.

Bruxism after brain injury: Successful treatment with botulinum toxin-A

Bruxism, the rhythmic grinding of teeth--usually during sleep--is not an infrequent complication of traumatic brain injury. Its prevalence in the general population is 21%, but its incidence after brain injury is unknown. Untreated, bruxism causes masseter hypertrophy, headache, temporomandibular joint destruction, and total dental wear. We report a case of complete resolution of postanoxic bruxism after treatment with botulinum toxin-A (BTX-A). The patient was a 28-year-old man with no history of bruxism who sustained an anoxic brain injury secondary to cardiac arrest of unknown etiology. On admission to our rehabilitation unit 2 months after the injury, the patient presented with severe bruxism and heavy dental wear. The patient was injected with a total of 200 units of BTX-A to each masseter and temporalis. There was total resolution of bruxism 2 days after injection, with no complications. On follow-up 3 months after injection, the patient remained free of bruxism. We propose that botulinum toxin be considered as a treatment for bruxism secondary to anoxic brain injury. Further studies regarding muscle selection and medication dosage are warranted to elucidate the toxins efficacy in this condition.

Successful treatment of post-traumatic narcolepsy with methylphenidate: a case report.

Narcolepsy is a rare sequela of brain injury. We report the case of a 27-yr-old male with post-traumatic narcolepsy who was successfully treated with methylphenidate. This patient sustained moderate brain injury from a motorcycle accident. Subsequently, he manifested the classic tetrad of narcolepsy: cataplexy, excessive daytime sleepiness, sleep paralysis, and hypnogogic hallucinations. There was no premorbid seizure or sleep disorder. There was no family history of sleep disorders. Polysomnography and Multiple Sleep Latency Test confirmed the diagnosis of narcolepsy. Sleep latency (time to sleep onset), rapid eye movement sleep latency (time from sleep onset to rapid eye movement sleep onset), and mean multiple sleep latency were all pathologically shortened (2.5, 66, and 1.2 min, respectively). Twenty-four hour electroencephalographic monitoring and magnetic resonance imaging of the brain were normal, as were serum chemistries. Treatment with caffeine was unsuccessful. He was then started on methylphenidate, 10 mg twice daily, which was increased to 30 mg twice daily over a 4-mo period. Cataplexy and excessive daytime sleepiness started to improve 1 mo after adjustments in methylphenidate dosing. Six months after the initiation of methylphenidate therapy, the patient is completely asymptomatic.

Factors Affecting Hospital Length of Stay and Charges Following Traumatic Brain Injury

Objective:To examine the effect of Initial severity of traumatic brain injury (TBI), level of functional Independence at admission to rehabilitation, medical complications, mechanism of injury, and payer source on hospital length of stay (LOS) and charges. Design:Cohort analysis. Setting:Inpatient rehabilitation. Patients:525 subjects from the National Institute on Disability and Rehabilitation Research TBI Model Systems National Data Base with relatively mild to severe TBI, an average Glasgow Coma Scale (GCS) score of 8.5 (SD=3.9), and average duration of impaired consciousness (DIC) of 15.1 days (SD=40.6). Intervention:Inpatient rehabilitation. Main Outcome Measures:Hospital LOS, hospital charges. Results:Persons with lower initial GCS scores generally reached the rehabilitation setting later and stayed longer than persons with higher initial GCS scores. Within each GCS level, lower initial Functional Independence Measure (FIM) scores were associated with longer acute care and rehabilitation LOS. For persons admitted to rehabilitation with relatively high or medium FIM scores, greater severity of injury resulted in relatively modest increases in rehabilitation LOS. In contrast, low admission FIM scores were associated with much longer rehabilitation LOS for patients with severe injuries, compared with those with relatively mild injuries. Initial GCS score, DIC, admission FIM, and acute LOS accounted for 48% (adjusted 7?2) of the variance in rehabilitation LOS and 42% of the variance In rehabilitation hospital charges. Of the medical complications examined, only neurologic complications and intracranial operations added significantly to the model, explaining an additional 2% of the variance in rehabilitation LOS. The effect of payer source on LOS is complicated by age as well as by severity and mechanism of injury. Conclusions:Age, severity of Injury, and medical complications are powerful predictors of rehabilitation LOS and hospital charges. Other factors, such as functional independence at rehabilitation admission and length of acute hospitalization, explain additional variance. None of these factors in isolation is able to sufficiently predict rehabilitation LOS or charges. Multidimensional analysis of these factors is necessary to plan or administer the delivery of brain injury services

Clinical caveats on medical assessment and treatment of pain after TBI.

The diagnosis and management of pain in the patient with traumatic brain injury (TBI) can be difficult in light of the limitations imposed by the cognitive, language, and behavioral deficits. With patients in the acute rehabilitation setting, one must be vigilant for the often subtle signs and symptoms of pain. Causes more commonly seen in the population with TBI as a consequence of the injury itself include dysautonomia, neuropathic pain, spasticity, and heterotopic ossification. Headaches may be a consequence of TBI or associated with it for other reasons. Sources of pain associated with TBI include deep venous thrombosis and others. The reader is reminded that patients with TBI are subject to all the causes of pain that affect the general population.

Intrathecal baclofen therapy for spastic hypertonia in chronic traumatic brain injury

Objective: To describe the outcome of intrathecal baclofen (ITB) therapy in treating spastic hypertonia and its sequelae in individuals with chronic (>14 years) traumatic brain injuries (TBI). Design: Case series. Setting: Free-standing rehabilitation hospital. Participants: Three adult males who received a TBI 14, 17.1, and 19.9 years prior to receiving ITB pump. Outcome measures: Modified Ashworth Scale (MAS); Functional Independence Measure (FIM)-mobility scores; and informal functional evaluation. Intervention: ITB therapy. Results: MAS scores of the five most hypertonic muscles in the affected lower limbs improved following of ITB therapy. FIM-mobility scores did not change from baseline, but certain functional domains improved, such as gait, transfers, and sitting; decreased assistance for activities of daily living (ADL) and nursing care; decreased painful spasms; and increased community mobility and participation in recreational activities. Conclusion: ITB therapy is still beneficial even >14 years after TBI onset. In spite of the absence of improvement in FIM scores, functional enhancements in areas not measured by traditional scales can still be achieved. This suggests that in this patient population consideration for ITB therapy should not be based solely on conventional assessment scales.

Intrathecal Baclofen Therapy for Spasticity of Cerebral Origin: Cerebral Palsy and Brain Injury

Spasticity affects approximately 66% of individuals with cerebral palsy and 14% of the 100,000 individuals who, each year, experience brain injury in the US. This spasticity interferes with motor function and limits range of motion. It may cause pain and impede mobility, transfers, activities of daily living, sitting posture, and sleep. In addition, spasticity can contribute to the formation of pressure sores and joint contractures and make nursing or caregiving difficult. Several treatment options are available for intractable spasticity. For some diagnoses, oral medications are still the treatment of choice, while in other settings injection therapy may be more appropriate. If, however, they are ineffective or cause too many side effects, intrathecal baclofen therapy (ITB) may be a valuable alternative. ITB is effective, nondestructive, titratable, and reversible. In addition, it is associated with fewer CNS‐related side effects than oral Lioresal (Novartis Pharma AG, Basel, Switzerland). Intrathecal baclofen therapy may improve range of motion, facilitate movement, reduce the patients expenditure of energy, facilitate nursing, reduce the risk of developing contractures, and, in some cases, diminish pain resulting from spasticity and/or spasms. It also may improve speech, gait, upper extremity function, and activities of daily living, including communication, eating, dressing, hygiene, and other aspects of self‐care. A recent study shows that treatment with intrathecal baclofen reduces the need for corrective orthopedic surgeries. Patient selection should be done in a multidisciplinary spasticity setting, where the expertise for different treatment modalities is available. Patients must be screened for response to the drug prior to implantation of the drug delivery pump. Maintenance doses for intrathecal baclofen range from 22 to 1400 μg/day, with most patients adequately maintained on 90–703 μg/day. Complications, while rare, are most often related to the drug delivery catheter. Intrathecal baclofen treatment may be cost effective, primarily due to a reduced need for hospitalizations and treatment of adverse events related to uncontrolled spasticity, and may improve quality of life.