Daniel M. Clinchot

Defining sleep disturbance after brain injury.

Sleep disorders are a relatively common occurrence after brain injury. Sleep disturbances often result in a poor daytime performance and a poor individual sense of well-being. Unfortunately, there has been minimal attention paid to this common and often disabling sequela of brain injury. This study attempts to define and to correlate the incidence and type of sleep disturbances that occur after brain injury. Consecutive admissions to a rehabilitation unit were used to create a longitudinal database designed to predict long-term outcomes for individuals who suffered a brain injury. Fifty percent of subjects had difficulty sleeping. Sixty-four percent described waking up too early, 25% described sleeping more than usual, and 45% described problems falling asleep. Eighty percent of subjects reporting sleep problems also reported problems with fatigue. Logistic regression analysis revealed the following: the more severe the brain injury the less likely the subject would be to have a sleep disturbance; subjects who had sleep disturbances were more likely to have problems with fatigue; females were more likely to have trouble with sleep. This study demonstrates the substantial prevalence of sleep disturbances after brain injury. It underscores the relationship between sleep disorders and perception of fatigue. It also underscores the need for clinicians to strive for interventional studies to look at the treatment of sleep and fatigue problems after brain injury.

Systematic bias in outcome studies of persons with traumatic brain injury

OBJECTIVE (1) Examine systematic biases created by subjects lost at 1-year follow-up in samples of persons with traumatic brain injury; (2) identify potential threats to generalization of outcomes data. DESIGN A consecutive sample of admissions to acute rehabilitation studied 1 year following discharge. SETTING An inpatient brain injury rehabilitation unit in a large, academic medical center. SUBJECTS Eighty-eight patients with primary diagnosis of traumatic brain injury. MAIN OUTCOME MEASURES Subjects were considered lost to follow-up when phone calls, mail, clinic visits, and assistance from family failed to allow contact 1 year after discharge from acute rehabilitation. Potential effects of the biased follow-up sample were examined for seven suboptimal outcomes. RESULTS A total of 38.6% of subjects were lost to follow-up. Subjects intoxicated at time of injury and those with history of substance abuse were more-likely to be lost. Among subjects followed, the likelihood of working or being in school 1 year after discharge was significantly less for those intoxicated at time of injury and those with a history of substance abuse. CONCLUSIONS Systematic bias in longitudinal studies may result from subjects with substance use problems being lost to follow-up. Population estimates for return to work or school will be overestimated if those lost who have substance use problems resemble those followed.

Role of agitation in prediction of outcomes after traumatic brain injury.

Bogner JA, Corrigan JD, Fugate L, Mysiw WJ, Clinchot D: Role of Agitation in Prediction of Outcomes After Traumatic Brain Injury. Am J Phys Med Rehabil 2001;80:636–644. Objective: To determine the role of agitation in the prediction of traumatic brain injury rehabilitation outcomes. Design: A longitudinal study of 340 consecutive patients admitted to an acute traumatic brain injury rehabilitation unit was conducted. Outcomes under study included rehabilitation length of stay, discharge destination, functional independence at discharge (FIMTM instrument), productivity at 1-yr follow-up, and life satisfaction at 1-yr follow-up (Satisfaction with Life Scale). Results: Univariate analyses suggested that the presence of agitation in rehabilitation is predictive of a longer length of stay and decreased functional independence in the cognitive realm at discharge. In addition, individuals who exhibit agitation at any time during rehabilitation are less likely to be discharged to a private residence. However, multivariate analyses indicated that cognitive functioning at admission to rehabilitation (FIM cognitive) mediates the relationship between the presence of agitation and length of rehabilitation, as well as between agitation and FIM cognitive at discharge. Similar results were found when discharge residence was the dependent variable; however, agitation also contributed some unique variance to the prediction. Lower cognitive functioning at admission to rehabilitation was associated with the occurrence of agitation during rehabilitation, longer length of stay, lower cognitive functioning at discharge, and a decreased likelihood that an individual would be discharged to a private residence. Conclusions: The results of the multivariate analyses support the contention that agitation and cognition are intimately related, with the long-term effects of the former being at least partially driven by the latter. These findings support the importance of systematically monitoring both agitation and cognition when applying interventions to reduce agitation.

The impact of acute care medications on rehabilitation outcome after traumatic brain injury.

Objectives: To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation. Design: Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors. Methods: The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)). Main outcome and results: The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant. Conclusions: The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.

Autonomic hyperreflexia associated with recurrent cardiac arrest : Case Report

Autonomic hyperreflexia is a condition which may occur in individuals with spinal cord injuries above the splanchnic sympathetic outflow. Noxious stimuli can produce profound alterations in sympathetic pilomotor, sudomotor, and vasomotor activity, as well as disturbances in cardiac rhythm. A case of autonomic hyperreflexia in a patient with C6 tetraplegia with recurrent ventricular fibrillation and cardiac arrest illustrates the profound effects of massive paroxysmal sympathetic activity associated with this condition.

Surveillance With Duplex Ultrasound In Traumatic Spinal Cord Injury On Initial Admission To Rehabilitation

Abstract Objective: To determine the prevalence of deep vein thrombosis (DVT) by surveillance duplex ultrasound in the traumatic spinal cord injury (SCI) population on admission to rehabilitation. Design: Retrospective sequential case series. Setting: Midwest regional, university-based, Commission on Accreditation of Rehabilitation Facilities-accredited acute rehabilitation center. Methods: Charts of all patients with traumatic SCI admitted and discharged from january 1, 1996 through December 31, 1998 were reviewed. Preadmission data were collected on demographics, severity of injury, and DVT prophylaxis information, along with rehabilitation duplex ultrasound results and incidence of thromboembolic events. Results: Ninety-two participants met the inclusion criteria. There were 68 men and 24 women with a mean age on admission of 3 2.4 years. On admission, 45 participants (49%) were classified as tetraplegic and 47 (51%) were classified as paraplegic; 63 (69%) had motor-complete lesions and 29 (31 %) had motor-incomplete lesions. Of all the participants, 8 (8.7%) were found to have DVT on admission to rehabilitation. There were no statistically significant differences among participants with regard to age, sex, level of injury, or completeness of injury, when comparing those participants with DVT on admission, those without DVT on admission, and those with thromboembolic events diagnosed later in their hospitalization. Of the 84 participants who had negative duplex ultrasounds on admission, 4 individuals (4.8%) were found to have DVT and 4 (4.8%) had pulmonary emboli subsequently. In these 84 participants, DVT prophylaxis with low-molecular-weight heparin was found to be more effective than was adjusted-dose heparin in preventing thromboembolic phenomenon. Conclusion: Incidence of DVT remains high despite prophylaxis in traumatic SCI patients. Two thirds of DVT diagnosed in rehabilitation was identified on admission and one third was diagnosed later. Duplex ultrasound is an effective and valuable tool that assists in the diagnosis of asymptomatic DVT in patients with traumatic SCI who are initiating in -patient rehabilitation.

Cerebral aneurysms: analysis of rehabilitation outcomes.

OBJECTIVE To classify deficits after aneurysmal subarachnoid hemorrhage (SAH) and correlate rehabilitation outcomes with these findings. DESIGN A retrospective review of medical records. SETTING Institution-based rehabilitation hospital. PARTICIPANTS Eighty patients admitted to a rehabilitation facility after aneurysmal SAH. MAIN OUTCOME MEASURES For each subject, data were collected for time between surgery and admission, total inpatient days, time orientation at discharge, and level of supervision required at discharge. RESULTS Fifty-five percent of the subjects were women and 45% were men. The average age was 47 years. Sixty percent of the lesions were right-sided and 40% were left-sided. Aneurysms were localized, in decreasing order of frequency, in the anterior communicating artery, middle cerebral artery, posterior communicating artery, internal carotid artery, basilar artery, anterior cerebral artery, and posterior inferior cerebellar artery distribution. CONCLUSION Longer rehabilitation stays were associated with right-sided lesions (mean = 44.64 versus 33.93 days) and motor impairment (mean = 43.8 versus 31.53 days). A trend suggested that motor impairment also predicted the level of supervision required at discharge. The shorter the time between surgery and admission to rehabilitation, the more likely the patient will be oriented at the time of discharge (29.47 versus 43.29 days).

The association between deep venous thrombosis and heterotopic ossification in patients with acute traumatic spinal cord injury

The medical records of 209 patients with acute traumatic spinal cord injury (SCI) admitted to the SCI rehabilitation unit from 7/1/88 through 12/31/92 were reviewed. Whereas the incidence of heterotopic ossification (HO) and deep venous thrombosis (DVT) in this population were 16.7% and 14.3%, respectively, 36.6% of the individuals with DVT had HO. 31.4% of those with HO developed DVT at some time during their acute or rehabilitation hospitalization. The overall incidence of coexistent DVT and HO was 5.3%. The correlation between the occurrence of HO and DVT in this SCI population reached statistical significance (X2 = 9.97; p < 0.005). The results of this study suggest that there exists an association between the occurrence of DVT and HO following traumatic SCI. We hypothesize that venous compression from expanding heterotopic bone can result in lower limb DVT following traumatic SCI.

Sympathetic skin response in patients with reflex sympathetic dystrophy.

The sympathetic skin response (SSR) was recorded in four patients diagnosed with reflex sympathetic dystrophy (RSD) in one upper limb using Kozins clinical criteria in conjunction with a three-phase bone scan. All patients had sustained cerebral vascular accidents and were classified as Stage I RSD. The SSR was recorded in both hands after each of ten contralateral median nerve surface stimulations and in both feet after each of ten contralateral peroneal nerve surface stimulations. Amplitude, onset latency, and number of phases were recorded for all responses in each limb. Mean amplitude, onset latency, and the number of phases of the five largest potentials were then determined. In all patients, there was a statistically significant difference in the amplitude and latency of the SSR in the involved limb compared with the uninvolved limb; mean amplitude of the involved limb was greater than the mean amplitude of the uninvolved limb (P < 0.001), and latency to onset of the SSR in the involved limb was shorter than that of the uninvolved limb (P < 0.001). There was no statistically significant difference in mean amplitude and latency between the involved side and uninvolved side responses as measured at the feet.

Neurovascular complications of heterotopic ossification following spinal cord injury

Compression of neurovascular structures from heterotopic ossification can result in neurological and vascular sequelae. Three cases of neurovascular compression due to heterotopic ossification illustrate the potential for neurovascular compression resulting from this condition and underscore the importance of recognising this uncommon, but notable complication following spinal cord injury.