David Crandell

Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systems the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

Best Practice Guidelines on Surgical Response in Disasters and Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

A systematic review of functional and quality of life assessment after major lower extremity amputation.

BACKGROUND When judging the success or failure of major lower extremity (MLE) amputation, the assessment of appropriate functional and quality of life (QOL) outcomes is paramount. The heterogeneity of the scales and tests in the current literature is confusing and makes it difficult to compare results. We provide a primer for outcome assessment after amputation and assess the need for the additional development of novel instruments. METHODS MEDLINE, EMBASE, and Google Scholar were searched for all studies using functional and QOL instruments after MLE amputation. Assessment instruments were divided into functional and QOL categories. Within each category, they were subdivided into global and amputation-specific instruments. An overall assessment of instrument quality was obtained. RESULTS The initial search revealed 746 potential studies. After a review of abstracts, 102 were selected for full review, and 40 studies were then included in this review. From the studies, 21 different assessment instruments were used 63 times. There were 14 (67%) functional measures and 7 (33%) QOL measures identified. Five (36%) of the functional instruments and 3 (43%) of the QOL measures were specific for MLE amputees. Sixteen instruments were used >1 time, but only 5 instruments were used >3 times. An additional 5 instruments were included that were deemed important by expert opinion. The 26 assessment instruments were rated. Fourteen of the best-rated instruments were then described. CONCLUSIONS The heterogeneity of instruments used to measure both functional and QOL outcomes make it difficult to compare MLE amputation outcome studies. Future researchers should seek to use high-quality instruments. Clinical and research societies should endorse the best validated instruments for future use in order to strengthen overall research in the field.

Optimizing Rehabilitation for Phantom Limb Pain Using Mirror Therapy and Transcranial Direct Current Stimulation: A Randomized, Double–Blind Clinical Trial Study Protocol

BACKGROUND Despite the multiple available pharmacological and behavioral therapies for the management of chronic phantom limb pain (PLP) in lower limb amputees, treatment for this condition is still a major challenge and the results are mixed. Given that PLP is associated with maladaptive brain plasticity, interventions that promote cortical reorganization such as non-invasive brain stimulation and behavioral methods including transcranial direct current stimulation (tDCS) and mirror therapy (MT), respectively, may prove to be beneficial to control pain in PLP. Due to its complementary effects, a combination of tDCS and MT may result in synergistic effects in PLP. OBJECTIVE The objective of this study is to evaluate the efficacy of tDCS and MT as a rehabilitative tool for the management of PLP in unilateral lower limb amputees. METHODS A prospective, randomized, placebo-controlled, double-blind, factorial, superiority clinical trial will be carried out. Participants will be eligible if they meet the following inclusion criteria: lower limb unilateral traumatic amputees that present PLP for at least 3 months after the amputated limb has completely healed. Participants (N=132) will be randomly allocated to the following groups: (1) active tDCS and active MT, (2) sham tDCS and active MT, (3) active tDCS and sham MT, and (4) sham tDCS and sham MT. tDCS will be applied with the anodal electrode placed over the primary motor cortex (M1) contralateral to the amputation side and the cathode over the contralateral supraorbital area. Stimulation will be applied at the same time of the MT protocol with the parameters 2 mA for 20 minutes. Pain outcome assessments will be performed at baseline, before and after each intervention session, at the end of MT, and in 2 follow-up visits. In order to assess cortical reorganization and correlate with clinical outcomes, participants will undergo functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) before and after the intervention. RESULTS This clinical trial received institutional review board (IRB) approval in July of 2015 and enrollment started in December of 2015. To date 2 participants have been enrolled. The estimate enrollment rate is about 30 to 35 patients per year; thus we expect to complete enrollment in 4 years. CONCLUSIONS This factorial design will provide relevant data to evaluate whether tDCS combined with MT is more effective than each therapy alone, as well as with no intervention (sham/sham) in patients with chronic PLP after unilateral lower limb amputation. In addition, this randomized clinical trial will help to investigate the neurophysiological mechanisms underlying the disease, which could potentially provide relevant findings for further management of this chronic condition and also help to optimize the use of this novel intervention. TRIAL REGISTRATION Clinicaltrials.gov NCT02487966; https://clinicaltrials.gov/ct2/show/NCT02487966 (Archived by WebCite at http://www.webcitation.org/6i3GrKMyf).

The effect of social integration on outcomes after major lower extremity amputation.

OBJECTIVE Major lower extremity (MLE) amputation is a common procedure that results in a profound change in a patients life. We sought to determine the association between social support and outcomes after amputation. We hypothesized that patients with greater social support will have better post amputation outcomes. METHODS From November 2011 to May 2013, we conducted a cross-sectional, observational, multicenter study. Social integration was measured by the social integration subset of the Short Form Craig Handicap Assessment and Reporting Technique. Systemic social support was assessed by comparing a United States and Tanzanian population. Walking function was measured using the 6-minute walk test and quality of life (QoL) was measured using the EuroQol-5D. RESULTS We recruited 102 MLE amputees. Sixty-three patients were enrolled in the United States with a mean age of 58.0. Forty-two (67%) were male. Patients with low social integration were more likely to be unable to ambulate (no walk 39% vs slow walk 23% vs fast walk 10%; P = .01) and those with high social integration were more likely to be fast walkers (no walk 10% vs slow walk 59% vs fast walk 74%; P = .01). This relationship persisted in a multivariable analysis. Increasing social integration scores were also positively associated with increasing QoL scores in a multivariable analysis (β, .002; standard error, 0.0008; P = .02). In comparing the United States population with the Tanzanian cohort (39 subjects), there were no differences between functional or QoL outcomes in the systemic social support analysis. CONCLUSIONS In the United States population, increased social integration is associated with both improved function and QoL outcomes among MLE amputees. Systemic social support, as measured by comparing the United States population with a Tanzanian population, was not associated with improved function or QoL outcomes. In the United States, steps should be taken to identify and aid amputees with poor social integration.

Pharmacokinetics of Extended-Release Dipyridamole following Administration through a Gastrostomy Tube: An Open-Label, Case-Control, Two-Centre Study

AbstractBackground: Many stroke survivors have severe dysphagia and are unable to take antithrombotic medications orally. Objective: To evaluate whether dipyridamole concentrations achieved in the plasma of patients taking an extended-release formulation of the medication through a gastrostomy tube (G-tube) are therapeutic and similar to those achieved in the plasma of patients who receive the drug orally. Methods: This was an open-label, case-control, two-centre study conducted in two academic centres in a metropolitan area. Patients included were those admitted following an acute cerebral infarction, with an indication for anti-platelet therapy for secondary prevention. Twelve patients with severe dysphagia requiring G-tube placement were cases, and 12 patients who were able to swallow safely served as controls. The components of Aggrenox® (extended-release dipyridamole/aspirin [acetylsalicylic acid]), suspended in water, were administered twice daily for 5 days through the G-tube. The 12 control patients without dysphagia took the medication orally. Dipyridamole plasma concentrations were compared between the groups at three different timepoints on the fifth day: 2, 6 and 12 hours after administration. The main outcome measure was dipyridamole plasma concentrations on day 5 at all three timepoints. Results: No significant difference in dipyridamole plasma concentrations between the groups was found at 2 hours (p = 0.18), 6 hours (p = 0.92) or 12 hours (p = 0.69). Conclusion: Dipyridamole plasma concentrations obtained following administration of extended-release dipyridamole through a G-tube in dysphagic patients achieved similar therapeutic levels to those obtained in patients taking the medication orally.

Poster 252: Hypoesthesia and Weakness of Legs After Heller Myotomy for Achalasia: A Case Report

hospital 13 days post-op, then re-admitted 2 days later for uncontrollable choreiform movements in all four extremities and slurred speech. Physical examination was most notable for proximal ballistic and distal choreiform movements, along with dystonic posturing of the trunk and bilateral upper extremities. Setting: Acute rehabilitation unit within a tertiary hospital Results: MRI of the brain was performed, revealing a symmetric bilateral increase of T1 signal intensity in caudate head, globus pallidus and putamen with no evidence of acute infarction. Presentation and imaging were consistent with post-pump chorea (PPC), a rare disorder seen more often in children than adults, which develops after cardiac surgery. Discussion: PPC is an acquired movement disorder related to prolonged circulatory arrest duration, time on extracorporeal circulation, hypothermia, and/or hypoxia. Patients often have no risk factor for movement disorders. FDCG-PET scans in a prior case report of this disease showed bilateral basal ganglia deep hypometabolism, which resolved within 6 months. The patient in our report had a history of two prior major surgical procedures, however no previously reported episodes of choreiform movements. As in other reported cases, this patient had no detectable morphological brain changes, thus PPC diagnosis remains a diagnosis of exclusion. Conclusions: PPC is a very rare but potentially severe complication of cardiac surgery. The exact pathophysiological process responsible for choreoathetosis following heart surgery is still unknown. Treatment included neuroleptic medication in addition to weights placed on extremities and torso to improve motor control. Level of Evidence: Level V

The Specialty of Hope: How Physiatry Made Boston Strong

The 5-year anniversary of the Boston Marathon Bombings (BMB) was April 15, 2018. It is hard to believe that this amount of time has passed, and yet, Boston has been joined by other cities and communities that have experienced mass casualty events in the time since. Unfortunately, there are no clear strategies to insure prevention, and so we as a community of caring individuals must learn to react and respond. In being invited to present the 2017 Zeiter Lecture at the American Academy of Physical Medicine and Rehabilitation Annual Assembly as well as this Invited Perspective, I have been given the opportunity to reflect on my personal and professional experience working with many of the most severely injured in the BMB through my inpatient and outpatient work at Spaulding Rehabilitation Hospital (SRH) in Boston. The rehabilitation respondersdphysical medicine and rehabilitation (PM&R) attendings and residents, along with nursing and therapy staff, mental health providers, and administration leadersdall played instrumental and powerful roles in the recovery of the many individuals, families, and the community as a whole in 2013 and the months, and now years, that followed. The 2-word motto “Boston Strong” quickly “became an early shorthand for defiance, solidarity, and caring” [1]. It also became a way to herald the heroic actions of both professional and untrained first responders, hospital trauma teams, and now “the last responders,” the rehabilitation professionals who helped the survivors find their strength as part of their recovery. Not being a Massachusetts native, I had to learn a few things when I arrived in Boston for my PM&R residency and fellowship at Tufts New England Medical Center in 1990, for example, the markdown system at the original Filene’s Basement, how to negotiate rotaries, and several new holidays, which serve as a reminder of the role that Massachusetts played in the American Revolution. Bunker Hill Day, June 17, marks the anniversary of the Battle of Bunker Hill. This battle, which occurred in 1775, was part of the Siege of Boston. Evacuation Day, March 17, celebrates the date when the British troops

Strategies to enhance recruitment methods in phantom limb pain clinical trials

Phantom Limp Pain (PLP) was first described in 1551. To date, its mechanisms and novel interventions remain mostly untested. Only limited conclusions can be drawn from few and small randomized clinical trials (RCTs) on PLP. In this scenario, recruitment strategies are crucial in order to overcome inherent challenges to recruit PLP subjects for clinical trials. Although there are many methods to enhance recruitment and also retention, in this article we discuss these methods based on a common topic: dissemination. We summarize and discuss 10 strategies of recruitment related to the dissemination of information based on the notion that an increase in trial awareness may lead to both increased recruitment and also increased external generalizability. In addition, in our discussion we included insights based on our experience recruiting PLP patients for our large NIH-sponsored clinical trial. Although specific regulatory considerations need to be considered when choosing the methods of recruitment, which may vary across different countries and Institutional Review Boards (IRBs), these strategies may be applicable to most of research settings.

Poster 81 Heart of the Matter. Atypical Mechanisms of Amputation in Young Adults. A Review of Two Case Reports.

Objective: Traditional methods of increasing Vitamin D are not optimal and absorption is often a challenge. This study tested a novel patchless delivery (TransEpi technology) to increase Vitamin D levels in subjects with Vitamin D insufficiency (25(OH)D) Design: Open label, single-arm study. Setting: University diagnostic center tested and verified serum analyses (Screening, Baseline, Days 35, 42 and 56) on subjects (n1⁄46). Safety and tolerability were assessed by serum levels and investigator assessed ordinal scale. Participants: Healthy male/female adults. Interventions: Technology containing Vitamin D3 was applied for 35 days with other sources of Vitamin D controlled or restricted (no oral supplements, SPF30+ sunscreen required, no change in pre-study lifestyle). Main Outcome Measures: Numerically significant increases in 25(OH) D serum levels and safety/ tolerability. Results: Overall 40%-50% increases (mean 44.5%) in Vitamin D insufficient subjects after 35 days application including a Cystic Fibrosis (CF) subject (+51% increase) who achieved normalized Vitamin D (35.3 ng/mL) and was previously unable for several years to normalize Vitamin D on oral supplements (2,000 IU/b.i.d.). Vitamin D insufficiency in CF patients is >90% despite oral supplementation. There were no adverse events and tolerability was good. Conclusions: Adequate levels of Vitamin D improves performance and muscle strength and decreases the risk of fractures, osteoporosis, cancers, cardiovascular/metabolic and respiratory disorders. TransEpi technology appears to be an effective delivery to increase Vitamin D levels in patients with malabsorption issues without exposure to UVA/UVB and/or when accompanied by sun-protecting ingredients. Further studies of the technology are ongoing. Level of Evidence: Level II