Darryl L. Kaelin

Methylphenidate effect on attention deficit in the acutely brain-injured adult

OBJECTIVES To determine the efficacy of methylphenidate in improving attention and functional outcome in acutely brain-injured adults. DESIGN Prospective multiple baseline design (A-A-B-A) utilized on a consecutive sample of patients. SETTING Acute brain injury rehabilitation unit in a large academic medical center. PATIENTS Eleven acutely brain-injured adults were included by performing below two standard deviations of the age equivalent norms on 4 of 5 neuropsychological tests for attentional capacity. One subject was withdrawn after developing tachycardia. INTERVENTION After a 1-week baseline assessment, subjects were placed on increasing doses of methylphenidate (Ritalin) so that on Day 7 all patients received a dose of 15 mg at 8 am and 12 pm. MAIN OUTCOME MEASURES Nine neuropsychological subtests measured attention on admission, at 1 week, while on methylphenidate, and 1 week after its discontinuation. Functional outcome was evaluated utilizing the Disability Rating Scale (DRS) at the same intervals. RESULTS Digit Span, Mental Control, and Symbol Search scores improved significantly (p < .05) on methylphenidate (A-B) as compared with the pre-methylphenidate (A-A) period. This advantage remained when the drug was removed. The mean improvement in DRS scores on methylphenidate approached a significant difference (p < .06) from that change in the DRS scores between baseline 1 and 2. CONCLUSIONS Use of methylphenidate in acutely brain-injured adults was well tolerated and demonstrated a significant improvement in attention compared to natural recovery in a rehabilitation setting. Methylphenidate also correlated with faster functional recovery as measured by the Disability Rating Scale although the improvement did not achieve statistical significance.

Deep venous thrombosis: Incidence on admission to a brain injury rehabilitation program

OBJECTIVE To determine the incidence of deep venous thrombosis (DVT) in brain injured individuals at time of admission to a brain injury (BI) rehabilitation program. DESIGN Prospective study, sequential case series. SETTING University tertiary care BI rehabilitation center. DATA SET Eighty-two traumatic brain injury (TBI) and 71 atraumatic brain injury (ABI) patients were consecutively admitted to our BI unit over a 12-month period and screened within 24 hours of admission for a lower extremity DVT with color flow duplex Doppler ultrasonography. All patients had been prophylaxed with either subcutaneous heparin anticoagulation therapy or intermittent compression devices, and all patients were within 2 months of the original BI. MAIN OUTCOME MEASURES Evidence of intrinsic venous occlusion by duplex Doppler. RESULTS DVTs were detected and treated prior to rehabilitation admission in three patients (2%), and these persisted at rehabilitation admission. New DVTs were detected at time of rehabilitation admission in 17 patients (11%). All were occult DVTs; none of the 17 patients had clinical findings indicative of acute DVT. No significant differences were noted in the TBI group when age, highest 24-hour Glasgow Coma Scale score, length of acute hospitalization, type of DVT prophylaxis, or presence of an extremity fracture were compared for individuals with and without DVT. No significant differences were noted in the ABI group when age, length of acute hospitalization, and type of DVT prophylaxis were compared for individuals with and without DVT. CONCLUSION The overall incidence of DVTs was 13% and the incidence of occult DVT was 11%. Individuals with TBI had an overall incidence of DVTs of 20% and an occult DVT incidence of 18%. Individuals with ABI had an overall incidence of DVTs of 6% and an occult DVT incidence of 4%. These findings indicate the importance of baseline screening for DVT in this patient population.

Zolpidem and restoration of consciousness.

Objective Zolpidem has been reported to cause temporary recovery of consciousness in vegetative and minimally conscious patients, but how often and why this occurs are unknown. The authors aimed to determine the frequency of this phenomenon and whether it can be predicted from demographic and clinical variables. Design This is a placebo-controlled, double-blind, single-dose, crossover study performed by caregivers and replicated by trained professionals, for naive participants. Four previously identified responders were also studied to further characterize the clinical drug response. Results Eighty-four participants with traumatic and nontraumatic disorders of consciousness of at least 4 mos’ duration were studied. Four “definite responders” were identified, but no demographic or clinical features were predictive of the response. Indicators of a drug response included increased movement, social interaction, command following, attempts at communication, and functional object use; typically lasted 1–2 hrs; and sometimes ended with increased somnolence. Adverse events were more common on zolpidem than placebo, but most were rated as mild. Conclusions Approximately 5% (4.8%) of the participants responded to zolpidem, but the responders could not be distinguished in advance from the nonresponders. Future research is needed to understand the mechanism of zolpidem in enhancing consciousness and its potential role in treatment and research.

Psychotropic medication use during inpatient rehabilitation for traumatic brain injury

OBJECTIVE To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. DESIGN Prospective observational cohort. SETTING Multiple acute inpatient rehabilitation units or hospitals. PARTICIPANTS Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. CONCLUSIONS Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.

Persisting impairment following rocky mountain spotted fever: A case report

A patient initially presented in the emergency room with fever, confusion, and a petechial rash. Rocky Mountain Spotted Fever (RMSF) was diagnosed and appropriate treatment was initiated. He subsequently became obtunded and required mechanical ventilation and temporary cardiac pacing. Four weeks later, he presented to our rehabilitation unit with ataxia, hyperreflexia and upper motor neuron signs, dysesthesias, sensorimotor axonopathy demonstrated by electrodiagnostic studies, and a global decrement in cognitive capability. Although he significantly improved in functional mobility and self-care, he exhibited little improvement in his cognitive impairment at 6-month follow-up. An understanding of the natural history of, and long-term impairments associated with, RMSF will be helpful to physiatrists in developing rehabilitation care plans and in assisting such patients with community re-entry.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Musculoskeletal disorders

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytrens disease.

Rehabilitation of orthopedic and rheumatologic disorders. 1. Osteoporosis.

This self-directed learning module reviews and summarizes recent literature on osteoporosis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The areas covered include pathophysiology of primary and secondary osteoporosis, effects of various pharmacologic treatments on bone metabolism, and the utility of available diagnostic tests. Management strategies for perimenopausal women as compared with postmenopausal women with established osteoporosis are discussed. This is followed by an evaluation and management plan for the older man with acute osteoporotic fracture.

Posttraumatic Stress Disorder Versus Traumatic Brain Injury

A 22-year-old right-handed male sergeant in the Afghanistan conflict worked as a gunner in an armed vehicle. Six months ago, his vehicle was hit with an improvised explosive device and subsequently ambushed by rocket-propelled grenade gunfire. The unit fought off the combatants with an ensuing gunfight. This young man was noted to experience no loss of consciousness but had several minutes of posttraumatic amnesia after each blast. The vehicle was filled with some smoke, and he experienced transient difficulty breathing. He sustained a nondisplaced left lateral ankle fracture that was treated with immobilization. His medical history is significant only for a single concussion sustained while playing high school football. Symptoms from this concussion appeared to last for 1 week. He also experienced a fractured radius as a child. He has no other significant medical history. Since his return to this country, his family claims he is different. He has difficulty sleeping, and he is hypervigilant at times, although this is improving. His memory is disturbed, and he has headaches. On physical examination, he does not have focal motor or sensory dysfunction. His memory is slightly impaired on clinical testing. He is also overtly anxious. His examination suggests a slight disturbance in higher-level balance, although formal balance testing has not been performed. Our experts are asked to comment on evaluation of this person, suggest metrics that could be used in the differential diagnosis of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), and provide an opinion regarding the diagnosis. Guest Discussants:

Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury – Evidence-based Recommendations for Clinicians

Psychiatric disorders frequently occur following a traumatic brain injury (TBI) and depression is the most common. When psychiatric diagnostic criteria are used, the prevalence of major depressive episode (MDE) in persons with moderate to severe TBI ranges from 26–36%. A recent study in the Journal Of the American Medical Association suggests that the first-year incidence of major depression (MD) following TBI may be as high as 50%. Despite the high incidence of depression reported in research studies, detecting and diagnosing MD following TBI can be challenging in the neurology clinic. Patients, family members, and examining clinicians often recognize the presence of typical indicators of a mood disturbance, such as feeling down or ‘blue’. Other diagnostic criteria for a MDE—such as poor concentration, trouble-making decisions, lability, sleep problems, decreased energy and activity, and restlessness—may also be due to TBI sequelae, other psychiatric disorders, neuroendocrine dysfunction, preinjury functioning, or medication side-effects.

Rehabilitation of orthopedic and rheumatologic disorders. 3. Degenerative joint disease

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with osteoarthritis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include updates on conservative and operative treatment of lumbar spinal stenosis and pediatric hip diseases, prophylactic therapy for thromboembolic disease after lower limb joint replacement, new therapies for osteoarthritis, and the impact of exercise on outcome following hip replacement in active persons.