Frederick S. Frost

Intramuscular electrical stimulation for hemiplegic shoulder pain: a 12-month follow-up of a multiple-center, randomized clinical trial.

Chae J, Yu DT, Walker ME, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Frost FS, Grill JH, Fang ZP: Intramuscular electrical stimulation for hemiplegic shoulder pain: A 12-month follow-up of a multiple-center, randomized clinical trial. Am J Phys Med Rehabil 2005;84:832–842. Objective:Assess the effectiveness of intramuscular electrical stimulation in reducing hemiplegic shoulder pain at 12 mos posttreatment. Design:A total of 61 chronic stroke survivors with shoulder pain and subluxation participated in this multiple-center, single-blinded, randomized clinical trial. Treatment subjects received intramuscular electrical stimulation to the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius for 6 hrs/day for 6 wks. Control subjects were treated with a cuff-type sling for 6 wks. Brief Pain Inventory question 12, an 11-point numeric rating scale was administered in a blinded manner at baseline, end of treatment, and at 3, 6, and 12 mos posttreatment. Treatment success was defined as a minimum 2-point reduction in Brief Pain Inventory question 12 at all posttreatment assessments. Secondary measures included pain-related quality of life (Brief Pain Inventory question 23), subluxation, motor impairment, range of motion, spasticity, and activity limitation. Results:The electrical stimulation group exhibited a significantly higher success rate than controls (63% vs. 21%, P = 0.001). Repeated-measure analysis of variance revealed significant treatment effects on posttreatment Brief Pain Inventory question 12 (F = 21.2, P < 0.001) and Brief Pain Inventory question 23 (F = 8.3, P < 0.001). Treatment effects on other secondary measures were not significant. Conclusions:Intramuscular electrical stimulation reduces hemiplegic shoulder pain, and the effect is maintained for ≥12 mos posttreatment.

Social and personal consequences of acquired bowel dysfunction for persons with spinal cord injury

Abstract Background: Traditional literature regarding acquired bowel dysfunction for persons with spinal cord injury (SCI) has focused on clinical assessments of bowel dysfunction and bowel management programs. These studies make reference to the effects of bowel dysfunction on quality of life (QOL), but none systematically study the relationship. This study develops 4 scales that measure impediment to community integration (ICI) due to bowel dysfunction and then examines the relationship between bowel dysfunction, ICI, and QOL. Methods: A structured telephone survey was conducted with a convenience sample of 103 SCI consumers. Survey questions documented bowel dysfunction (ie, severity and number of accidents), bowel management (ie, how often bowels are evacuated), ICI , and satisfaction with 4 life domains. Results: Correlation analyses showed that subjective bowel dysfunction severity and number of days per month a respondent had to stay home because of lack of bowel control were associated with barriers to personal relationships, feelings about self, and home life. Also, the number of bowel accidents per month was associated with feelings about self. ICI scales were shown to be related to lower levels of satisfaction with free time, friendships. family life, and life in general. No statistically significant relationships were found between bowel dysfunction and satisfaction with life. Conclusion: Bowel dysfunction is a barrier to community integration and is related to low leve ls of life satisfaction. Also , it is possible to quantify ICI related to bowel dysfunction. Educational programs can reduce the stigma associated with bowel dysfunction. Further research into the intricate relationships between bowel problems, barriers to participation in the community, and life satisfaction is needed.

Self-Inflicted Finger Injury in Individuals With Spinal Cord Injury: An Analysis of 5 Cases

Abstract Objective: To describe the occurrence of finger autophagia in 5 persons with traumatic spinal cord injury and to present a discussion of putative causes and potential treatments. Background: Minor self-mutilating actions, such as nail biting and hair pulling, are common in humans and usually benign. In some circumstances, these behaviors are associated with obsessive-compulsive personality traits. In humans, self-injurious biting behaviors are well described in the setting of mental retardation and psychosis and in persons with Lesch-Nyhan syndrome. Rare cases of human autophagia in persons with intact cognition have been reported, most commonly in the setting of acquired nervous system lesions. After spinal cord injury, it has been suggested that this behavior constitutes a human variant of animal autotomy and a response to neuropathic pain. Design: Case presentation narrative. Main Outcome Measures: Photographic and radiological study, administration of Yale-Brown Obsessive- Compulsive Scale (YBOCS). Findings: In 5 patients with complete tetraplegia, pain in the hands was present in only one instance. The severity of autoamputation varied from minor to extreme. In all cases, damage was confined to analgesic body parts. In 3 cases, autophagia behavior was discovered in progress. Treatments included pharmacotherapy, counseling, and behavioral therapy, with mixed results. All patients were intelligent, willing to discuss their issues, and able to identify conditions of stress and isolation in their lives. Mild preinjury obsessive-compulsive behaviors, such as nail biting, were universal. On the YBOCS, only 1 patient scored in a range indicative of mild obsessive-compulsive symptomatology. Conclusions: This group exhibited heterogeneous medical, social, and cultural characteristics. A link between pain and self-injurious behavior could not be demonstrated. This behavior may be viewed as an extreme variant of nail biting, with potential ominous complications. Treatment strategies have been employed with mixed results.

Why can't I move, Doc? Ethical dilemmas in treating conversion disorders.

p o U D I first encountered a patient with conversion disorder about 20 years ago. I was a new attending physician, and the woman was admitted to my inpatient rehabilitation service with a diagnosis simply of “quadriplegia.” The diagnosis of an underlying conversion disorder was ingeniously cinched by a video that documented normal movement during sleep. But, during her waking hours, she was as disabled as if she had had a spinal cord injury, that is, she was unable to move, she was dependent in her self–care, and she was still subject to the problems of immobility. What to do? On the one hand, I understood that conversion disorder was a physical manifestation of an unconscious psychological conflict. The longer the condition persisted, the less likely it was to improve. On the other hand, without treating and resolving the underlying psychiatric conflict, “curing” her condition was also unlikely. Yet psychiatric treatment requires the active and willful engagement of the patient, and she (like many patients with conversion disorder) was not amenable to psychotherapy. Psychiatric inpatient units also tend to be uncomfortable with accepting patients who have significant physical disabilities. Did rehabilitation have a legitimate role to play? What should she be told about her condition and treatment plan? How likely was it to be successful? When Geoffrey Smith, MD, from the University of Virginia, brought the ethical issues that underlie the care of patients with conversion disorder forward, it was not difficult to decide to pursue an ethics column on the topic. Indeed, the issues that he raises remain controversial and unresolved. What follows is his presentation of a woman with conversion disorder with whom he had direct care responsibilities as a resident. After the case presentation are several questions raised for discussion by our invited commentators (see below). The column concludes with an epilogue by Dr Smith about how the case was resolved, and his reflections years later. As always, we welcome your comments and reactions, or suggestions for future columns!

High resolution real-time ultrasound for the diagnosis of venous thrombosis in the rehabilitation setting

Accurate, noninvasive testing for deep venous thrombosis (DVT) by conventional methods is often not possible in the rehabilitation patient. Lower extremity amputation, a cast or bandage, or skin problems present obstacles to standard diagnostic methods. This report describes the use of duplex ultrasound (US) scanning for noninvasive diagnosis of DVT in a seventy-year-old man with a below-knee amputation, on whom Doppler and plethysmography examinations could not be performed. As experience is gained with this technique, the use of venography for diagnosis of DVT becomes more difficult to rationalize.

Transcranial direct current stimulation (tDCS) paired with massed practice training to promote adaptive plasticity and motor recovery in chronic incomplete tetraplegia: A pilot study

Objective: Our goal was to determine if pairing transcranial direct current stimulation (tDCS) with rehabilitation for two weeks could augment adaptive plasticity offered by these residual pathways to elicit longer-lasting improvements in motor function in incomplete spinal cord injury (iSCI). Design: Longitudinal, randomized, controlled, double-blinded cohort study. Setting: Cleveland Clinic Foundation, Cleveland, Ohio, USA. Participants: Eight male subjects with chronic incomplete motor tetraplegia. Interventions: Massed practice (MP) training with or without tDCS for 2 hrs, 5 times a week. Outcome Measures: We assessed neurophysiologic and functional outcomes before, after and three months following intervention. Neurophysiologic measures were collected with transcranial magnetic stimulation (TMS). TMS measures included excitability, representational volume, area and distribution of a weaker and stronger muscle motor map. Functional assessments included a manual muscle test (MMT), upper extremity motor score (UEMS), action research arm test (ARAT) and nine hole peg test (NHPT). Results: We observed that subjects receiving training paired with tDCS had more increased strength of weak proximal (15% vs 10%), wrist (22% vs 10%) and hand (39% vs. 16%) muscles immediately and three months after intervention compared to the sham group. Our observed changes in muscle strength were related to decreases in strong muscle map volume (r=0.851), reduced weak muscle excitability (r=0.808), a more focused weak muscle motor map (r=0.675) and movement of weak muscle motor map (r=0.935). Conclusion: Overall, our results encourage the establishment of larger clinical trials to confirm the potential benefit of pairing tDCS with training to improve the effectiveness of rehabilitation interventions for individuals with SCI. Trial Registration: NCT01539109

Poster 29: Functional outcomes of liver transplant patients treated in an acute rehabilitation setting1

Abstract Objective: To determine associations between categorical and continuous variables that characterize liver transplant patients and outcome variables measuring resource utilization and functional gains during inpatient rehabilitation. Design: Retrospective review. Setting: Inpatient acute rehabilitation unit and community follow-up. Participants: 13 liver transplant patients undergoing initial acute rehabilitation. Interventions: ≥3h/d of acute multidisciplinary rehabilitation treatment. Main Outcome Measures: Rasch-converted FIM™ instrument scores, and categorical and continuous clinical variables. Results: Patients of a mean age of 52±12.35 years were admitted at a mean of 34.77±18.27 days after transplant. 9 of 13 patients were discharged to a residential setting, with mean rehabilitation length of stay (LOS) of 15.9±13.1 days. The median hospital charge was

Opportunities in Community Placement: An Innovative Personal Care Assistant Training Program in the Inner City

21,500 (range,

The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain

7137–

Failed Removal of Indwelling Urinary Catheters in Patients With Acute Stroke: Incidence and Risk Factors

107,568). These patients had a mean Model for End-Stage Liver Disease (MELD) score of 24.17±11.26 and serum ammonia averaged 104.46±73.08μmol/L. The Wilcoxon signed-rank assessment of paired t tests for differences between time points (admission, discharge, follow-up) showed that motor scores ( P P P =.01), while cognitive function correlated with low levels of total protein (Spearman P =.014) and low globulin (Spearman P =.059). Despite this, these patients did not differ in the degree of cognitive or motor gains across their stay. Subgroups characterized by other clinical characteristics (eg, alcoholism, gender, cigarette use, diabetes) did not differ in rehabilitation outcomes, although LOS varied by group. Conclusion: Patients with end-stage liver disease are among the most medically complex and debilitated in the hospital. Despite this, we found that liver transplantation patients demonstrated significant reduction in motor disabilities when rehabilitation was provided in an inpatient rehabilitation unit setting. Cognition did not improve during the study period.